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Call for tighter blood pressure targets in patients with diabetes

Researchers have called for an urgent review of recommended blood pressure levels for people with diabetes, after finding even patients within current ‘safe’ levels benefited from having their blood pressure lowered.

The team’s analysis included 40 randomised clinical trials, and found a 27% reduction in the risk of stroke and 11% reduced risk of coronary heart disease events among patients who achieved a 10mmHg reduction in systolic levels.

Overall mortality was also 13% lower with a 10mmHg reduction, relative to higher systolic pressures, while retinopathy and albuminuria risks were reduced by 13% and 17%, respectively.

The researchers said this showed treatment goals for blood pressure in current guidelines are too slack.

European guidelines were recently revised - bringing them nore closely in line with NICE guidelines - to relax maximum blood pressure levels for high-risk patients, such as those with diabetes, to the 140/90mmHg threshold recommended for other patients with hypertension.

NICE recommends patients with type 2 diabetes have blood pressure levels kept below 140/90 mmHg, or 130/80 mmHg if they have kidney, eye or cerebrovascular disease.

Study author Professor Kazem Rahimi, a cardiologist and deputy director of the George Institute at the University of Oxford, said: ‘Our review shows that people with diabetes who reached a systolic blood pressure below 130mmHg had about a 25% lower stroke risk compared with those with higher blood pressure levels.’

He added: ‘Unfortunately, recent US and EU changes to the guidelines will negatively impact the treatment options for people with diabetes in the UK. We urgently call for these recent changes to guidelines to be modified and for all guidelines around the world to consistently reflect the evidence.’

Hypertension expert Professor Neil Poulter, from Imperial College London, who was not involved in the study, backed the researchers’ call for a change in guidelines.

Professor Poulter said: ‘I expect this study to influence guidelines for the treatment of people with diabetes, and for this to translate to appreciable effects on the health of people with diabetes.

‘I have been increasingly concerned about the trend to advocate higher blood pressure targets as reflected by recent changes to guidelines in Europe and the US; this study provides the evidence needed to reconsider this.’

But Professor Bryan Williams, professor of at University College London, said GPs should not wait for guidelines to change but consider taking a ‘bolder’ approach to tackling high blood pressure in younger patients in particular.

Writing in a related editorial, Professor Williams said: ‘It would seem reasonable to consider a bolder approach to blood pressure treatment in younger patients with diabetes and especially those with albuminuria or other early manifestations of microvascular or macrovascular disease than currently advocated in guidelines.’

JAMA 2015; available online 12 February

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Readers' comments (3)

  • Vinci Ho

    I think academics need to make up their mind . The practicality of getting systolic BP under 130mmHg with or without side effects need to be weighted properly.
    I suppose one can also look into sub-profiling these patients with systolic BP under 130, 140 and 150mmHg and label with an absolute risk of stroke or MI.

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  • The problem is that although tighter BP control is of benefit the practicalities of achieving this outside trial conditions is challenging. We deal with real patients with conflicting priorities in their life and multiple medical and psychosocial morbidity. We are supposed to respect patient autonomy and practice patient centred medication as well as being aware of the risks of polypharmacy in frail elderly people. How many of these studies reflect 'real' patients where the patients enrolled accurately reflect a primary care population without selection bias and exclusion of patients in the above groups??

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  • Samuel Lewis

    the ARRs for benefits per 10mmHg reduction were of the order of 3 per 1000 patient-years.

    thats an NNT of about 333 i think.

    pretty slim chance of benefit, but i guess it beats an NNT of 800 quoted for mildly hypertensive non-diabetic men !!!

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