Although epidemiologic studies suggest that blood pressure higher than 115/75 mmHg is associated with progressive increases in CVD events and mortality in people with diabetes, randomized clinical trials have not demonstrated that lowering blood pressure to less than 140/80 mmHg provides a significant clinical benefit in type 2 diabetes. The United Kingdom Prospective Diabetes Study (UKPDS) found that blood pressure control that targeted less than 150/85 mmHg (achieved 144/82 mmHg) significantly reduced risk for diabetes-related deaths, stroke, heart failure, microvascular disease, retinopathy progression, and deterioration of vision in people with type 2 diabetes compared to a target of 180/105 mmHg. 2 The Hypertension Optimal Treatment (HOT) trial found a 51 percent reduction in major CVD events in people with diabetes at a diastolic goal of 80 mmHg compared with 90 mmHg. 3
The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial found no substantial advantage in lowering systolic blood pressure to less than 120 mmHg compared to less than 140 mmHg in people with type 2 diabetes, and found a higher risk of serious adverse events with lower blood pressure targets. 4 A meta-analysis of randomized trials in adults with type 2 diabetes found that the use of intensive blood pressure targets (upper limit of 130 mmHg systolic and 80 mmHg diastolic) was associated with a small but significant reduction in stroke but no significant decrease in mortality or myocardial infarction. 5
The Systolic Hypertension in the Elderly Program (SHEP) study found that diuretics reduced CVD death in people with diabetes by 31 percent. 6 Angiotensin converting enzyme (ACE) inhibitors have been shown to provide substantial benefits, including reduced risk of heart attack, stroke, and CVD death 7, 8 and prevention of progression of nephropathy. 9 The Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE) study assessed the effects of the routine administration of an ACE inhibitor-diuretic combination in people with diabetes and found a significant reduction in relative risk of major macrovascular or microvascular events, death from CVD, and death from any cause. 10
Blood pressure management
- Blood pressure should be measured at every routine medical visit.
- Consider home blood pressure monitoring when office/clinic measurements are borderline or elevated.
- The following strategies may have antihypertensive effects similar to pharmacologic monotherapy:
- Reduce sodium intake by selecting low-sodium foods, not adding sodium to food, and limiting processed foods.
- Reduce excess body weight by increasing consumption of fruits, vegetables, and low-fat dairy products; avoiding excessive alcohol consumption; and increasing activity levels.
- Follow the Dietary Approaches to Stop Hypertension (DASH) Eating Plan. (See Resources.)
- Engage in 40 minutes of aerobic physical activity at a moderate to vigorous intensity, at least 3 days a week. 11
- Referral to a registered dietitian/registered dietitian nutritionist can also be helpful.
- People with a systolic blood pressure of 130 to 139 mmHg or a diastolic blood pressure of 80 to 89 mmHg may initially be treated with lifestyle therapy alone. Overweight people with higher blood pressure should receive both pharmacologic and lifestyle therapy at the time of diagnosis of hypertension.
- The primary goal of therapy is systolic blood pressure less than 140/90 mmHg. Lower blood pressure targets can be individualized, based upon shared decision making that addresses factors such as the level of CVD risk, presence of kidney disease, and burden of therapy.
- ACE inhibitors and angiotensin II receptor blockers (ARBs) are contraindicated in pregnancy.
Consider initial therapy with a thiazide, calcium channel blocker, ACE inhibitor, or an ARB. Multi-drug therapy (two or more agents at maximal doses) usually is required to achieve and maintain blood pressure targets. An ACE inhibitor or an ARB reduces progression of chronic kidney disease in people with albuminuria. Individualize further medication choices according to patient characteristics such as age, race, and response to therapy. Measure blood pressure at every health visit and adjust treatment as necessary.
Resources for blood pressure management