Speaker highlights concordance of studies, BP guidelines in diabetes
CHICAGO — Data from multiple trials show a similar effect of systolic BP lowering on CV outcomes between patients with diabetes and those without diabetes, according to a presentation at the American Heart Association Scientific Sessions.
Paul K. Whelton, MB, MD, MSc, Show Chwan Health System Endowed Chair in Global Public Health at Tulane University, also pointed out similarities between BP guidelines of the American College of Cardiology and AHA — which recommend hypertension treatment for patients with diabetes and BP of 130/80 mm Hg or higher — and those of other groups.
“I think for the most part, guidelines are looking at pretty much the same and data are coming to pretty much the same conclusions,” he said. “We see a similar antihypertensive effect on CV outcomes in diabetics and nondiabetics in most trials.”
During his presentation, Whelton said the comparable response between diabetic and non-diabetic groups occurs regardless of the medication, and that network meta-analyses of trials over the years have shown lower levels of BP result in better clinical outcomes. He noted that results from SPRINT — which compared the CV effects of targeting systolic BP to a goal of less than 140 mm Hg vs. a goal of less than 120 mm Hg in patients at high CV risk — were similar for the primary endpoint of composite CV outcome and for all-cause death between patients with pre-diabetes and those with normoglycemia. Similarly, patients in SPRINT had good BP reduction and maintained the change in BP over time.
“At the end of the day, the primary outcome was not significantly reduced but when you looked at it, it had a wide confidence interval and most of that confidence interval was below 1,” Whelton said. “If you were a betting person, you would say, ‘Well the likelihood there is a benefit is probably greater than the likelihood that there is not.’”
He said post-hoc analyses of the trial indicate interactions between interventions and underpowering, which may account for this lack of significance.
“The ACCORD results are consistent with SPRINT and post hoc analyses would suggest that there was an interaction between the glycemic intervention and BP control intervention,” he said. “I think that, probably to a large extent, explains the lack of significance and there’s some effect of power as well.”
Regarding recommendations for BP targets, Whelton noted the ACC/AHA guideline somewhat differs from the American Diabetes Association position statement, which recommends therapy for all patients with diabetes who have BP of 140/90 mm Hg or higher, and for those with BP of 130/80 mm Hg who are at high risk for CVD.
“When you look at diabetics who have high BP, they are almost all at high risk,” Whelton said. “It is unusual to find someone at low risk, unless they are very young.”
“When you compare these two recommendations...the concordance is extraordinarily high,” he added. “I’m sure we will continue to see people focus on differences, but I would say let’s focus on commonalities.”
BP guidelines in Europe and Canada are also similar, according to Whelton. To lower BP, Whelton said most patients with diabetes can receive diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers.
“We specifically recommend combinations for those who are starting a higher-level BP medication and in all African Americans with high BP,” he said. – by Gina Brockenbrough, MA.
Whelton PK. Blood pressure target in adults with hypertension and diabetes. Presented at: American Heart Association Scientific Sessions; Nov. 10-12, 2018; Chicago.
Disclosure: Whelton reports no relevant financial disclosures.