The importance of lower blood pressure targets

//The importance of lower blood pressure targets
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Do you know what hypertension means?

Although it might sound like it refers to someone who is very, very tense, it is actually just the medical term for high blood pressure (BP).  The current standards of diabetes care from the American Diabetes Association indicate that for people with diabetes and hypertension, the goal is:

  • Systolic (top number) BP less than 140
  • Diastolic (bottom number) BP less than 90 (typically indicated as 140/90).

For some people with diabetes who have additional risk, a BP goal less than 130/80 might be appropriate.

  • Previous versions of the standards of care gave a goal of less than 130/80 for all with diabetes, so the current recommendation actually represents a relaxation of the BP goals.

Towards the end of 2015, results from the SPRINT trial were released.

SPRINT stands for Systolic Blood Pressure Intervention Trial, and it was published in the New England Journal of Medicine The results from this show that a lower systolic BP of less than 120 was associated with lower rates of death and adverse cardiovascular events in high-risk patients.  High blood pressure is very common, and there has long been a strong relationship between blood pressure and cardiovascular risk.  We know that lowering an elevated blood pressure reduces risk, and yet the big question is how low should we try to get the BP?  The SPRINT trial looked at the effect of lowering BP more than what is recommended by most current guidelines.

The trial included:

  • 9,361 participants
  • Age – minimum of 50 years old
  • Participants had treated or untreated systolic BP of 130-180
  • Participants had at least one additional cardiovascular risk factor
    • Additional risk factors included: cardiovascular disease, chronic kidney disease, a Framingham Risk Score of at least 15% for 10-year cardiovascular disease risk, or an age of at least 75 years.
    • People with diabetes or previous stroke were excluded from the study.

Participants were randomly assigned to one of two groups.
  • The intensive treatment group had a target systolic BP of less than 120
  • The standard treatment group had a target systolic BP of less than 140

The trial was expected to last for four to six years.  It was stopped after a follow-up of 3.26 years because the researchers saw significant benefits WITH intensive treatment.

Positive Results:
  • After 1 year, systolic BP was about 15 points lower in the intensive treatment arm compared to the standard treatment arm of the trial.
  • The participants in the intensive group needed only one additional BP medication to achieve the BP target.
  • A very impressive effect for reduction in all causes of death as a result of intensive treatment.
  • Significantly lower rate of serious outcomes in the intensive treatment group versus the higher rate seen in the standard treatment group.

Adverse Outcomes:
  • The research did NOT show any significance in between-group difference for the composite outcome of a decrease in a measure of kidney function, or the development of end-stage renal disease in the participants who DID have chronic kidney disease (defined as a decrease in eGFR {a test that measures kidney function} of at least 50%).  This was very good news.
  • In participants who did NOT have chronic kidney disease, the researchers used a lower threshold, which they defined as a decrease in eGFR of at least 30%. The incidence of this problem was higher in the intensive treatment group than in the standard treatment group.  The reason for this is not known, and further follow up is needed.
  • There were higher rates of serious adverse events in the intensive treatment group:
    • BP that was too low, fainting, electrolyte disturbances (labs like sodium, potassium, and chloride being out of target), acute injury to the kidneys or kidney failure.

Overall, the researchers found significant benefits to intensive treatment, as compared to standard treatment.  The trial was, after all, stopped early because such clear benefit was seen in the intensive treatment arm of the study.  The incidence of the primary outcomes of heart attack, acute coronary syndromes, stroke, heart failure, and cardiovascular death were reduced by 25%, and all causes of death were reduced by 27%.  There were, though, some adverse events that were more common in the intensive treatment group, and that needs to be followed.  But the bottom line of SPRINT was that they felt the benefits far outweighed the potential for risk.

This gives us a lot of food for thought, but the fact that people with diabetes were excluded from the study means that we can’t assume that this applies WITH diabetes.  It does make us question whether perhaps our current BP goals when living with diabetes are more lax than might be desirable, given the high risk for cardiovascular disease that goes along with a diabetes diagnosis.  High BP is called “the silent killer” because generally there are no symptoms of hypertension unless the BP is dangerously high.  At minimum, this is a nice reminder that we do need to pay attention to our BP on an ongoing basis, and to have conversations about our level of control and our risk with our doctors.

Be proactive and talk to your doctor about what you might need to do to reduce your risk!

By | 2016-12-08T23:26:43+00:00 May 3rd, 2016|Thinking Like A Pancreas Blog|0 Comments

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Integrated Diabetes Services is the worldwide leader in one-on-one consulting for people who use insulin. Diabetes “coaching” services are available in-person and remotely via phone and the internet for children and adults.

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