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New ADA Guidelines Ease Blood Pressure Target

Posted: Monday, January 07, 2013

The ADA's Clinical Practice Recommendations, revised on an annual basis, include the association's major position statement along with additional position statements on a range of diabetes-management-related topics.

Dr. Richard Grant (Kaiser Permanente Division of Research, Oakland, CA), incoming chair of the ADA Professional Practice Committee, stated that the revisions reflect the increasing use of evidence-based recommendations in addition to the recognition that the population-based evidence derived from studies needs to be tailored to the individual patient, and commented, "The changes reflect a broader trend in ADA standards and also how we take care of patients with type 2 diabetes."

The new ADA guidelines raise the target for systolic blood pressure from <130 mm Hg to <140 mm Hg based on evidence that there is not a great deal of additional value in aiming for the lower target, but there is an increase in risk in pushing systolic pressure lower than 140 mm Hg, Grant explained.

The primary data for that recommendation came from a meta-analysis that demonstrated that although the use of intensive vs standard blood-pressure targets in patients with type 2 diabetes was associated with a small reduction in the risk for stroke, there was no evidence for decreased mortality or MI, but an increased risk for hypotension and other adverse events.

The previous target of <130 mm Hg had not been derived from randomized, controlled trials, but from observational studies that seemed to suggest lower is better for blood pressure in those with diabetes. However, the new ADA recommendations do say that a target <130 mm Hg might be appropriate for certain individuals, such as younger patients, as long as it can be achieved "without undue treatment burden." Grant stressed that raising the systolic threshold should not be interpreted to mean that blood-pressure control is not important.

"We really tried to communicate that it's crucially important that everyone with type 2 diabetes have a [systolic] blood pressure down to 140mm Hg," he said. "It's a very important threshold. Changing the recommendation is not meant to imply that excellent blood-pressure control is not as much of a priority as it was." However, Dr. Yehuda Handelsman (Metabolic Institute of America, Tarzana, CA) said he is concerned about just that. "I believe the headline sends the wrong message. This will be interpreted that's its less important to get to a more intensive goal."

There have been no new prospective data in the past year to merit the change, said Handelsman, immediate past president and chair of the Diabetes Scientific Committee of the American Association of Clinical Endocrinologists (AACE).

"There are no new studies, only meta-analyses, which are for generating hypotheses that need to be tested," said Handelsman.

Regarding adverse events, Handelsman pointed out that in the Action to Control Cardiovascular Risk in Diabetes [ACCORD] trial, the average blood pressure achieved in the standard group, which had a target of <140 mm Hg, was 133.5 mm Hg compared with 119.3 mm Hg in the intensive treatment group, which had a target blood pressure of <120 mm Hg.

In ACCORD, the annual stroke rates were 0.32% vs 0.53% in the intensive and standard BP-control groups, respectively (hazard ratio [HR] 0.59, 95% CI 0.39-0.89, p=0.01), whereas adverse events such as syncope and dizziness occurred in 1.3% vs 3.3% in the intensive and standard groups, respectively.

"Based on this trial, to say that a systolic blood pressure of 130 [mmHg] is dangerous is wrong," said Handelsman.

He added that he believes that what the ADA should have advised (and did, in fact, do so, but only secondarily) is that "if you can get to <130 [mm Hg] and do it safely, you should do it."

Handelsman noted that he was voicing his own views and not those of the AACE. 

Source:, Clinical Practice Recommendations, Diabetes Care Supplement Jan 2013.

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