Therefore, the presence of low diastolic blood pressure is not necessarily a contraindication to more intensive blood pressure management in the context of otherwise standard care. However, in ACCORD BP, it was found that intensive blood pressure lowering decreased the risk of cardiovascular events irrespective of baseline diastolic blood pressure in patients who also received standard glycemic control ( 43). In addition, patients with orthostatic hypotension, substantial comorbidity, functional limitations, or polypharmacy may be at high risk of adverse effects, and some patients may prefer higher blood pressure targets to enhance quality of life. Patients with older age, chronic kidney disease, and frailty have been shown to be at higher risk of adverse effects of intensive blood pressure control ( 42). Potential adverse effects of antihypertensive therapy (e.g., hypotension, syncope, falls, acute kidney injury, and electrolyte abnormalities) should also be taken into account ( 29, 36, 41, 42). Notably, ACCORD BP and SPRINT measured blood pressure using automated office blood pressure measurement, which yields values that are generally lower than typical office blood pressure readings by approximately 5–10 mmHg ( 31), suggesting that implementing the ACCORD BP or SPRINT protocols in an outpatient clinic might require a systolic blood pressure target higher than <120 mmHg, such as <130 mmHg. The Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation–Blood Pressure (ADVANCE BP) trial did not explicitly test blood pressure targets ( 30) the achieved blood pressure in the intervention group was higher than that achieved in the ACCORD BP intensive arm and would be consistent with a target blood pressure of <140/90 mmHg. Intensive therapy increased risks of electrolyte abnormalities and AKIĪdditional studies, such as the Systolic Blood Pressure Intervention Trial (SPRINT) and the Hypertension Optimal Treatment (HOT) trial, also examined effects of intensive versus standard control ( Table 10.1), though the relevance of their results to people with diabetes is less clear.Intensive target reduced risk of death 27%. Intensive SBP target lowered risk of the primary composite outcome 25% (MI, ACS, stroke, heart failure, and death due to CVD).In the subpopulation with diabetes, an intensive DBP target was associated with a significantly reduced risk (51%) of CVD events.In the overall trial, there was no cardiovascular benefit with more intensive targets.6-year observational follow-up found reduction in risk of death in intervention group attenuated but still significant ( 198)ġ8,790 participants, including 1,501 with diabetesĭBP target: ≤80 mmHg Achieved (mean): 81.1 mmHg, ≤80 group 85.2 mmHg, ≤90 group.Intervention reduced risk of primary composite end point of major macrovascular and microvascular events (9%), death from any cause (14%), and death from CVD (18%).Intervention: a single-pill, fixed-dose combination of perindopril and indapamide Adverse events more common in intensive group, particularly elevated serum creatinine and electrolyte abnormalitiesġ1,140 participants with T2D aged 55 years and older with prior evidence of CVD or multiple cardiovascular risk factors.Stroke risk reduced 41% with intensive control, not sustained through follow-up beyond the period of active treatment.No benefit in primary end point: composite of nonfatal MI, nonfatal stroke, and CVD death.adults with diabetes have improved significantly over the past decade ( 2) and that ASCVD morbidity and mortality have decreased ( 3, 4).Ĥ,733 participants with T2D aged 40–79 years with prior evidence of CVD or multiple cardiovascular risk factors Under the current paradigm of aggressive risk factor modification in patients with diabetes, there is evidence that measures of 10-year coronary heart disease (CHD) risk among U.S. Furthermore, large benefits are seen when multiple cardiovascular risk factors are addressed simultaneously. Numerous studies have shown the efficacy of controlling individual cardiovascular risk factors in preventing or slowing ASCVD in people with diabetes. Common conditions coexisting with type 2 diabetes (e.g., hypertension and dyslipidemia) are clear risk factors for ASCVD, and diabetes itself confers independent risk. Atherosclerotic cardiovascular disease (ASCVD)-defined as coronary heart disease (CHD), cerebrovascular disease, or peripheral arterial disease presumed to be of atherosclerotic origin-is the leading cause of morbidity and mortality for individuals with diabetes and results in an estimated $37.3 billion in cardiovascular-related spending per year associated with diabetes ( 1).
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