As the leading cause of diabetes-related death, cardiovascular disease (CVD) continues to be a major threat in patients with type 2 diabetes.1 Numerous facets regarding the pathology of type 2 diabetes are also independent factors of a patient’s cardiovascular risk, such as hypertension. These risk factors continue to be targeted in efforts to reduce the incidence of related cardiovascular events. Hypertension is nearly twice as frequent in patients with diabetes, and the coexistence of these two common chronic diseases markedly increases a person’s CVD risk compared with either one alone.1
With data suggesting up to 75% of CVD in diabetics is attributable to hypertension,1 the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) continues to recommend more aggressive blood pressure control as the current standard of practice in patients with diabetes. Specifically, diabetic patients with a systolic blood pressure (BP) of 130 mmHg or higher should begin drug therapy to achieve a BP treatment goal of below 130 mmHg.2 There is limited evidence from randomized control trials to support this BP goal,2,3 leading practitioners to question whether the current treatment strategy of “lower-is-better” is legitimate.
In the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Blood Pressure Study, Cushman and colleagues4 sought to answer whether therapy targeting an intensive systolic BP of 120 mmHg or less compared with standard therapy targeting a systolic BP of less than 140 mmHg reduces major cardiovascular events among high-risk patients with diabetes. Patient eligibility included type 2 diabetes, a glycated hemoglobin level of ≥ 7.5%, and ≥ 40 years of age with established CVD or ≥ 55 years of age with anatomical evidence of a substantial amount of atherosclerosis, albuminuria, left ventricular hypertrophy, or at least two additional risk factors for CVD (dyslipidemia, hypertension, smoking, or obesity). Additionally, patients participated in the simultaneous glycemic control trial.5 The ACCORD-BP trial evaluated an explicit treatment goal, rather than a certain drug regimen. All antihypertensive regimens were to include drug classes that had previously been shown to result in a reduction in cardiovascular events among diabetic patients.4
In all, 4733 patients with type 2 diabetes were randomly assigned to the intensive antihypertensive therapy arm (n = 2362) or the standard therapy arm (n = 2371), and the mean follow-up was 4.7 years. The primary composite outcome consisted of the first occurrence of a major cardiovascular event, defined as the composite of nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death. The pre-specified secondary outcomes included the combination of the primary outcome in addition to revascularization or hospitalization for congestive heart failure, major coronary disease events, nonfatal myocardial infarction, fatal or nonfatal stroke, death from any cause, death from cardiovascular causes, and hospitalization or death due to heart failure.4
After a year of follow-up, investigators found that although the mean systolic BP achieved was 119.3 mmHg in the intensive therapy arm and 133.5 mmHg in the standard therapy arm, the ...