Consider patient risk when targeting BP in diabetes
PHILADELPHIA — A debate continues over the optimal target for blood pressure management in type 2 diabetes with comorbid hypertension, with some experts pushing for a lower goal whenever possible, whereas others prefer a more individualized, patient-centered approach, according to two speakers here.
For most adults, treating to the American Heart Association and American College of Cardiology’s revised target for hypertension, defined as lower than 130/80 mm Hg, results in no incremental benefit in cardiovascular risk reduction vs. a goal of lower than 140/90 mm Hg, but could lead to potential incidental harms, George L. Bakris, MD, FAHA, professor of medicine and director of the Comprehensive Hypertension Center at University of Chicago Medicine and Endocrine Today Editorial Board Member, said during a debate on high vs. lower blood pressure goals at the second annual Heart in Diabetes Clinical Education Conference.
“Everybody should not be [treated to a BP of] 130/80 mm Hg,” Bakris said. “In a perfect world, maybe, but not in this world.”
However, clinicians should not be so immobilized by the possibility of an adverse event related to a lower systolic BP goal that they fail to treat people who could benefit, argued Paul K. Whelton, MB, MD, MSc, the Show Twan chair of global public health at Tulane University School of Public Health and Tropical Medicine. In all adults, including those with diabetes and hypertension, the AHA/ACC recommended treatment target of less than 130/80 mm Hg is appropriate, Whelton said.
“You can have a reasonably good expectation that an adult with high blood pressure and diabetes is very likely to be at high risk [for a CV event], and if they’re not, they’re just a little bit younger waiting to get there, or, they’re slightly below the cut point,” Whelton said.
The AHA/ACC revised guideline, released in November, has been a source of debate since its publication, Whelton acknowledged; however, the new targets reflect a reality that must be acknowledged, he said.
“We knew this [revised guideline] would have a big impact on prevalence,” said Whelton, who served on the AHA/ACC guideline committee. “We knew there would be people who said, ‘Are you crazy? You’re medicalizing half the population.’ Unfortunately, we live in a population where we’re not very healthy. You can be mad with me or the guideline group, but we didn’t make people unhealthy, and we have to just be honest about it.”
“We felt it’s more important that people in this category know that they are higher risk and that there are solutions to help get them to lower risk,” Whelton said. “We’ve been accused in blogs that the pharmaceutical industry is driving this [lower threshold]. Well, unfortunately for the pharmaceutical industry ... we didn’t actually increase the recommendations for drug therapy very much, but we think we captured the people most likely to benefit.”
In September, guidelines issued by the American Diabetes Association included the more relaxed BP goal of less than 140 mm Hg/90 mm Hg for most people with diabetes and emphasized the need to individualize specific BP targets for each patient. Bakris, who served on the ADA guideline committee, argued that “one size does not fit all” when it comes to optimal BP targets in diabetes; people are highly variable, and flexibility is needed when defining a shared goal between the clinician and the patient.
“Everybody gets hung up on numbers,” Bakris said. “I don’t hear anybody talking about risk. I hear them talking about the numbers, and the numbers are relevant in the context of risk.”
Bakris said it is important to distinguish BP thresholds used to diagnose hypertension from thresholds used as treatment targets, just as clinicians do with HbA1c level.
“There is no real good rationale to lower [BP] to 130/80 mm Hg for everyone who is hypertensive, and 140/90 mm Hg is quite good,” Bakris said.
Additionally, studies suggest that patients with type 2 diabetes without prior history of CVD who were treated to an aggressive systolic BP goal of less than 120 mm Hg experienced increased risk for death, Bakris said. Further, a new analysis that will soon be published in Diabetes Care suggests that the ADA guideline and the AHA/ACC guideline are in agreement 75.2% of the time when it comes to antihypertensive medication initiation recommendations, and 95.7% of the time when it comes to additional intensification for patients not meeting a recommended BP goal, Bakris said.
“I would hardly call that a major argument,” Bakris said. “You have to define each patient ... what kind of [CV] risk do they have over 10 years? If that risk is high — certainly if the risk is 15% or more — then they need to be below 130/80 mm Hg, if you can get them there. If they will allow you to get them there. You need to explain this to them.”
“The assumption is everybody is going to do better [with a lower BP target], and everybody is not going to do better,” Bakris said.
Whelton agreed that there are similarities between the two guidelines that should be highlighted more often.
“We have some differences in how to diagnose, but when it comes to treatment, to a large extent, we are pretty similar,” Whelton said. “We have a lot of commonality, and I’m someone who likes to understand how we can come together. Can we get everyone under the same tent and how can we stop writing papers that nitpick differences? It confuses clinicians and confuses the public.”
“Our two recommendations are much more similar than they are different,” Whelton said. “The key for us is to get people on treatment.” – by Regina Schaffer
Bakris GL; Whelton PK. HTN in DM and CVD — the great debate. Presented at: Presented at: Heart in Diabetes Clinical Education Conference; July 14-16, 2018; Philadelphia.
Disclosures: Bakris reports he is a principal investigator for studies for Bayer, a steering committee member for trials sponsored by Janssen and Vascular Dynamics and a consultant for Merck, Relypsa and Vascular Dynamics. Welton reports no relevant financial disclosures.