Pushing BP levels to lower targets better for cardioprotection in T2D

Intensive systolic blood pressure (BP)-lowering treatment to reach target levels of less than 120 mm Hg is more beneficial than standard treatment in terms of reducing the risk of major cardiovascular events in Chinese patients with type 2 diabetes (T2D) and elevated BP, according to data from the BPROAD* trial.

Over a median follow-up of 4.2 years, the primary outcome of a composite of nonfatal stroke, nonfatal myocardial infarction, treatment or hospitalization for heart failure, or death from cardiovascular causes occurred with significantly less frequency with intensive treatment than with standard treatment (incidence rate, 1.65 vs 2.09 events per 100 person-years; hazard ratio [HR], 0.79, 95 percent confidence interval [CI], 0.69?0.90; p<0.001). [New Engl J Med 2024;doi:10.1056/NEJMoa2412006]

The observed difference was primarily due to a lower incidence rate of fatal or nonfatal stroke in the intensive-treatment group (1.19 vs 1.50 events per 100 person-years; HR, 0.79, 95 percent CI, 0.67?0.92), said one of the authors Dr Guang Ning from the Shanghai Jiaotong University School of Medicine, Shanghai, China, who presented the results in a late-breaking science session at AHA 2024.

“The benefits of intensive treatment were consistent across all prespecified subgroups,” Ning added.

In terms of safety, the percentage of patients who had serious adverse events was similar between the two treatment groups (HR, 1.00, 95 percent CI, 0.94?1.06; p=0.96). However, intensive treatment was associated with a higher incidence of symptomatic hypotension (0.1 percent vs <0.1 percent; p=0.05) and hyperkalemia (>5.5 mmol/L: 2.8 percent vs 2.0 percent; p=0.003) compared with standard treatment.

Of note, incident albuminuria was less common among patients who underwent intensive treatment (11.29 vs 13.84 events per 100 person-years; HR, 0.87, 95 percent CI, 0.77?0.97).

According to Ning, the findings are consistent with those of two other trials in which the benefit of lowering BP to a target of less than 120 mm Hg as opposed to a target of less than 140 mm Hg. Specifically, when compared with standard treatment, intensive treatment reduced the risk of major cardiovascular disease events by 27 percent in high-risk patients without diabetes in SPRINT, as well as the risk of major vascular events by 12 percent in high-risk patients with hypertension, regardless of the status of diabetes or history of stroke, in ESPRIT. [N Engl J Med 2021;384:1921-1930; Lancet 2024;404:245-255]

“Our trial has important implications for BP management in clinical practice,” given that evidence supporting the recommendation of most guidelines to lower systolic BP to less than 130 mm Hg in patients with diabetes is lacking, Ning said. [J Am Coll Cardiol 2018;71:e127-e248; Diabetes Care 2024;47:S179-S218; J Hypertens 2023;41:1874-2071; Eur Heart J 2024;45:3912-4018]

“Our results with respect to the primary outcome provide support for more intensive systolic BP control in patients with diabetes for the prevention of major cardiovascular disease events,” he added.

However, Ning emphasized that patients undergoing intensive BP targets must be monitored for hypotension, especially during the initiation of treatment, and for hyperkalemia.

BPROAD included 12,821 patients with diabetes who were at least 50 years of age (mean 63.8 years, 45.3 percent female), had elevated systolic BP levels, and at increased risk of cardiovascular disease. These patients were randomly assigned to receive intensive treatment that targeted a systolic BP of less than 120 mm Hg (n=6,414) or standard treatment that targeted a systolic BP of less than 140 mm Hg (n=6,407) for up to 5 years.

At 1 year of follow-up, the mean systolic BP was 121.6 mm Hg in the intensive-treatment group and 133.2 mm Hg in the standard-treatment group.

*Blood Pressure Control Target in Diabetes