Intensive blood pressure treatment reduces cardiovascular risk in people with Type 2 diabetes

An intensive treatment approach to lowering high systolic blood pressure in people with Type 2 diabetes led to a reduced risk of heart attack, stroke, heart failure and death due to cardiovascular disease when compared to a standard treatment approach, according to late-breaking science presented today at the American Heart Association's Scientific Sessions 2024. The meeting, Nov. 16-18, 2024, in Chicago, is a premier global exchange of the latest scientific advancements, research and evidence-based clinical practice updates in cardiovascular science.

We found that for most people with Type 2 diabetes, lowering systolic blood pressure to less than 120 mm Hg reduced the risk of major cardiovascular events. These findings provide strong support for a more intensive systolic blood pressure target in people with Type 2 diabetes for the prevention of major cardiovascular events."

Guang Ning, M.D., Ph.D., lead study author, elected member of the Chinese Academy of Engineering and professor at Ruijin Hospital at Shanghai Jiao Tong University School of Medicine in Shanghai, China

A person living with Type 2 diabetes is twice as likely to have high blood pressure than someone without Type 2 diabetes. Elevated blood sugar levels can cause damage to blood vessels and impair kidney function, leading to elevated blood pressure. Almost three-fourths of adults with Type 2 diabetes are estimated to also have high blood pressure, according to the U.S. Centers for Disease Control and Prevention data, and when blood pressure levels are consistently elevated, lifestyle modification and medication are recommended. If unmanaged, high blood pressure can cause damage over time and increase the risk of heart attack, stroke, heart failure, kidney problems and more.

The goal of the BPROAD study was to determine whether an intensive systolic blood pressure reduction approach to a target of lower than 120 mm Hg was more effective in reducing the risk of major cardiovascular events, including non-fatal stroke, non-fatal myocardial infarction, treated or hospitalized heart failure, and cardiovascular death than a standard systolic blood pressure reduction approach to a target of lower than 140 mm Hg among people with Type 2 diabetes.

The BPROAD study included 12,821 adults at 145 study sites located in 25 provinces or municipalities across mainland China were enrolled in the study. All participants had Type 2 diabetes, elevated systolic blood pressure and an increased risk of cardiovascular disease. In this study, the criteria for elevated systolic blood pressure was ≥140 mm Hg without antihypertensive medications or ≥130 mm Hg and taking at least one anti-hypertensive medication.

The results found:

• The mean systolic blood pressure levels of the participants at the four-year visit was 120.6 mm Hg in the intensive treatment group and 132.1 mm Hg in the standard treatment group.
• The people who received the intensive treatment had a 21% lower relative risk of major cardiovascular events, compared with those who received the standard treatment during the follow-up period.
• Non-fatal stroke, non-fatal heart attack, hospitalization or treatment for heart failure, or cardiovascular deaths occurred in 393 participants (1.65% per year) in the intensive treatment group and 492 participants (2.09% per year) in the standard treatment group.
• Serious adverse events such as hospitalization were generally similar between the two treatment groups. However, blood pressure levels that were too low with symptoms (symptomatic hypotension) and high potassium levels (hyperkalemia) occurred more frequently among participants in the intensive treatment group.

"Our study results are consistent with another study of patients with hypertension but without diabetes, which found a significantly 27% reduction in the incidence of cardiovascular diseases," said Ning. "Future clinical practice guidelines will hopefully consider these results when making recommendations for blood pressure targets for people with Type 2 diabetes. Beneficial future research could focus on profiling those with the largest benefit and the lowest harm in an intensive blood pressure treatment group."

Study background and details:

• The average age of participants was 64 years old.
• About 45% of the study participants were women, and 55% were men, with 22.5% having a history of cardiovascular disease, which was self-reported.
• The participants all had similar baseline characteristics at enrollment, including blood pressure levels, body mass index measurements, smoking status, HbA1c levels, cholesterol levels, kidney function, duration of Type 2 diabetes and other key health factors.
• The study enrollment period was from February 2019 until December 2021, with follow-up lasting up to five years.
• About half (6,414) of the participants were enrolled in the intensive treatment group, and half (6,407) of the participants were enrolled in the standard treatment group.
• The study was conducted within the framework of the National Clinical Research Center for Metabolic Diseases and the Metabolic Management Center (MMC).

The study had several limitations, including that the participants and study physicians were not blinded, however, other cardiovascular risk factors during follow-up were similar between treatment groups. In addition, telephone interviews were used when participants were not able to come to the clinics, especially during the COVID-19 pandemic lockdown. During the lockdown, participants used standard home blood pressure monitoring to self-report their blood pressure levels if they were unable to come to the clinics in person. Also, the findings may not be generalizable to people of other ethnic populations or to populations with characteristics different from the participants.

Blood pressure is measured using two numbers: systolic blood pressure (the first number) indicates the force of the blood against the artery walls when the heart beats, and diastolic blood pressure (the second number) measures the pressure of the blood between beats. The American Heart Association defines elevated blood pressure as a systolic blood pressure measurement of 120-129 mm Hg and a diastolic blood pressure <80 mm Hg, and high blood pressure, or hypertension, is defined as a systolic blood pressure ≥130 mm Hg and a diastolic blood pressure ≥80 mm Hg. While a higher than normal reading of either number can be used to diagnose high blood pressure, high systolic blood pressure may be more indicative of risk factors for heart disease.