Action Points
- In patients along with diabetes mellitus and systolic blood stress (SBP) > 140 mmHg, antihypertensive treatment reduces the risk of mortality and cardio morbidity, according to a large meta-analysis.
- In patients along with diabetes and SBP < 140 mm Hg, further treatment is associated along with a significantly increased risk of cardio death, and a tendency to increased risk of all-trigger mortality, along with no observed benefit.
For patients along with diabetes and moderately elevated blood pressure, aggressive antihypertensive therapy might do a lot more harm compared to good, according to a meta-analysis published in The BMJ.
In diabetic patients along with systolic blood stress (SBP) much less compared to 140 mm Hg at baseline, added antihypertensive treatment increased the risk of cardio mortality by 15%, reported co-authors Mattias Brunström, a doctoral student, and Bo Carlberg, MD, of Umeå University in Sweden.
Cardiovascular mortality was low once baseline SBP was higher compared to 150 mm Hg. once baseline SBP was 140-150 mm Hg, the effect of treatment on cardio mortality was not significant, Brunström and Carlberg said.
“This systematic review and meta-analyses included a large quantity of previously unpublished data, thereby increasing precision compared along with previous research,” Brunström and Carlberg said.
The study authors added that “our results, combined along with those from the SPRINT trial, suggest that blood stress treatment targets ought to be much less aggressive in individuals along with diabetes compared to free of diabetes. This review strongly supports blood stress treatment in individuals along with diabetes mellitus if SBP is a lot more compared to 140 mm Hg. If SBP is already much less compared to 140 mm Hg, however, adding added agents could be harmful.”
But an independent expert told MedPage Today that these data were not enough to transform practice.
“Based on exactly what I enjoyed in this study, this will certainly probably not adjustment the method clinicians manage patients,” said Tom Giles, MD, of Tulane University in Brand-new Orleans. “I believe clinicians will certainly take advantage of every one of the short article available to them and conclude that lesser BPs are much better — if they accommodate comorbidities and unwanted medical effects.”
Study Details
The meta-analysis covered 49 clinical trials involving a lot more compared to 73,000 patients. The investigators included randomized controlled trials of antihypertensive therapy along with a mean follow-up of 12 months or a lot more and at least 100 patients along with diabetes. The mean follow-up was 3.7 years, and most of the patients had type 2 diabetes.
Included trials had to compare any sort of antihypertensive agent versus placebo, any sort of two agents versus one, or any sort of blood stress target versus another. The investigators excluded strictly comparative trials, evaluating one agent versus another, too as trials along with combined interventions. For 12 of the studies, Brunström and Carlberg obtained unpublished data by contacting study authors, pharmaceutical companies, or relevant authorities. Vital outcomes included the following:
If baseline SBP was much less compared to 140 mm Hg, further treatment increased the risk of cardio mortality (relative risk 1.15; 95% CI 1.00-1.32), along with a tendency toward an increased risk of all-trigger mortality (RR 1.05; 95% CI 0.95-1.16).
If baseline SBP was 140-150 mm Hg, added treatment low the risk of all-trigger mortality (RR 0.87; 95% CI 0.78-0.98), myocardial infarction (RR 0.84; 95 CI 0.76-0.93), and heart failure (RR 0.80; 95% CI 0.66-0.97). Yet the risk reduction along with cardio mortality was not statistically substantial (RR 0.87; 95% CI 0.71-1.05).
If baseline SBP was higher compared to 150 mm Hg, antihypertensive treatment low the risk of all-trigger mortality (RR 0.89; 95% CI 0.80-0.99), cardio mortality (RR 0.75; 95% CI 0.57-0.99), myocardial infarction (RR 0.74; 95% CI 0.63-0.87), stroke (RR 0.77; 95% CI 0.65-0.91), and end stage renal health problem (RR 0.82; 95% CI 0.71-0.94).
Speculation and Caveats
“The most most likely biological explanation for our findings is that intensive treatment impairs blood flow to end organs, leading to ischemia,” Brunström and Carlberg said. “In arterial stiffening, usually present in individuals along with diabetes, myocardial perfusion is increasingly dependent on SBP. This could, at least partly, explain the association between reasonable SBP and even worse treatment effect in our analyses.”
“one more potential explanation for our findings is that reasonable blood stress leads to much less coronary collateral circulation,” they said. “This could explain not just an increased lot of events along with treatment Yet additionally a even worse prognosis once having an event, as reflected by the feasible boost in case fatality suggested by our analyses.”
“Lots of treatment guidelines, the 2 Swedish and international, will certainly be redrawn in the next couple of years,” Brunström said in a statement. “It has actually been discussed to recommend even lesser blood stress levels for individuals along with diabetes — maybe as reasonable as 130. We are hoping that our study, which shows potential risks of such aggressive blood stress lowering treatment, will certainly come to influence these guidelines.”
However, he added, “In practice, it is vital to remember that undertreatment of higher blood stress is a bigger problem compared to overtreatment.”
Giles said an vital limitation of the meta-analysis is that the blood stress data was obtained primarily by office measurements, which increasing evidence suggests is unreliable. The very same problem plagued hypertension trials such as SPRINT and ACCORD, said Giles, that recently authored an editorial in Hypertension advocating ambulatory blood stress monitoring to confirm office measurements.
SPRINT and ACCORD yielded conflicting results. SPRINT reported improved outcomes along with a lot more aggressive hypertension treatment in high-risk patients, excluding those along with diabetes. ACCORD reported just a nonsignificant trend toward improvement along with aggressive treatment in patients along with diabetes.
Clinicians ought to be wary of changing their clinical technique based on meta-analyses such as the one by Brunström and Carlberg, Giles cautioned. “It’s every one of smoke and mirrors,” he scoffed. “It’s not research, it’s sitting at a computer dredging through data.”
The study was funded by the Västerbotten County Council of Sweden.
No researchers disclosed financial relationships along with industry.
Giles is a speaker or consultant for Allergan, AstraZeneca, and Boehringer Ingelheim.
