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care.diabetesjournals.

org Cardiovascular Disease and Risk Management S77

and indapamide) showed a signicant Systolic Blood Pressure without diabetes and has shown antihy-
reduction in the risk of the primary com- The evidence that SBP .140 mmHg is pertensive effects similar to those of phar-
posite end point (major macrovascular harmful is irrefutable, suggesting that macologic monotherapy.
or microvascular event) and signicant clinicians promptly initiate and ti- Lifestyle therapy consists of reduc-
reductions in the risk of death from any trate therapy to achieve and maintain ing excess body weight through caloric
cause and of death from cardiovascular SBP ,140 mmHg in most patients. For restriction, restricting sodium intake
causes (15). The baseline blood pres- some patients, lower SBP targets closer (,2,300 mg/day), increasing consump-
sure among the study subjects was to 130 mmHg are appropriate. A recent tion of fruits and vegetables (810 serv-
145/81 mmHg. Compared with the pla- systematic review and meta-analysis ings per day) and low-fat dairy products
cebo group, the patients treated with a evaluating SBP lowering in adults with (23 servings per day), avoiding exces-
single-pill, xed-dose combination of type 2 diabetes showed that each sive alcohol consumption (no more than
perindopril and indapamide experienced 10 mmHg reduction of SBP was associ- 2 servings per day in men and no more
an average reduction of 5.6 mmHg in ated with signicantly lower risk of than 1 serving per day in women) (21),
SBP and 2.2 mmHg in DBP. The nal mortality, cardiovascular events, CHD, and increasing activity levels (11).
blood pressure in the treated group was stroke, albuminuria, and retinopathy. These lifestyle (nonpharmacologic)
136/73 mmHg, not quite the intensive or However, when trials were stratied by strategies may also positively affect gly-
tight control achieved in ACCORD. The mean baseline SBP $140 mmHg or cemia and lipid control and should be
recently published 6-year follow-up of ,140 mmHg, blood pressurelowering encouraged in those with even mildly
the ADVANCE trial, the ADVANCEPost- treatment was associated with lower elevated blood pressure, although the
Trial Observational Study (ADVANCE-ON), risks of stroke and albuminuria, regard- impact of lifestyle therapy on cardiovas-
reported that the reductions in the risk of less of initial SBP (9). Therefore, indivi- cular events has not been established.
death from any cause and of death from duals in whom cardiovascular disease Nonpharmacologic therapy is reasonable
cardiovascular causes in the intervention risk, particularly stroke, is a concern in individuals with diabetes and mildly el-
group were attenuated but remained sig- may, as part of shared decision making, evated blood pressure (SBP .120 mmHg
nicant (16). have lower systolic targets than 140 or DBP .80 mmHg). If the blood pressure
mmHg. This is especially true if lower is conrmed to be $140 mmHg systolic
HOT. The Hypertension Optimal Treat- blood pressure can be achieved with
ment (HOT) trial included patients with and/or $90 mmHg diastolic, pharma-
few drugs and without side effects of
and without diabetes and compared cologic therapy should be initiated
therapy. For older adults, treating to
DBP targets of #90, #85, and #80 an SBP of ,130 mmHg has not been
along with nonpharmacologic therapy
mmHg. Post hoc analyses found cardio- (11). A lifestyle therapy plan should be
shown to improve cardiovascular out-
vascular benet with more intensive developed in collaboration with the pa-
comes (19).
targets in the subpopulation with dia- tient and discussed as part of diabetes
Diastolic Blood Pressure management.
betes (17). The HOT trial results, taken
together with the higher quality data Similarly, strong evidence from random-
Pharmacologic Interventions
from ACCORD and ADVANCE, support ized clinical trials supports DBP targets
Lowering of blood pressure with regimens
the current recommendation to achieve of ,90 mmHg. These targets are in har-
based on a variety of antihypertensive
blood pressure levels ,140/90 mmHg, mony with the Eighth Joint National
agents, including ACE inhibitors, angioten-
with lower targets in selected patients. Committee (JNC 8) recommendation
sin receptor blockers (ARBs), diuretics, and
of a DBP threshold of ,90 mmHg for
SPRINT. The Systolic Blood Pressure In- calcium channel blockers has been shown
individuals over 18 years of age with di-
tervention Trial (SPRINT) was a multi- to be effective in reducing cardiovascular
abetes (11). A DBP of ,80 mmHg may
center, randomized controlled trial events (9,22).
still be appropriate for patients with
that compared two strategies for treat- In people with diabetes and albumin-
long life expectancy, chronic kidney dis-
ing SBP with either the standard target uria, ACE inhibitors or ARBs may have
ease, elevated urinary albumin excretion,
of ,140 mmHg or an intensive target evidence of cardiovascular disease, or unique advantages for initial or early
of ,120 mmHg; primary outcomes additional risk factors such as dyslipidemia, treatment of hypertension. In a trial of
were MI, ACS, stroke, heart failure, smoking, or obesity (17). In older adults, individuals at high risk for ASCVD,
and death due to cardiovascular dis- treating to a DBP of ,70 mmHg has been including a large subset with diabetes,
ease. Patients assigned to the intensive associated with a greater risk of mortality an ACE inhibitor reduced ASCVD out-
SBP target of ,120 mmHg, compared (20). comes and the development of albumin-
with a target SBP of 140 mmHg, had uria when compared with placebo, even
reduced RR of cardiovascular events Treatment Strategies after adjustment for differences in
by almost a third and of death by almost Lifestyle Intervention blood pressure, an effect that has been
a quarter, though risks of electrolyte ab- Although there are no well-controlled termed a blood pressure independent
normalities and acute kidney injury were studies of diet and exercise in the treat- effect (23). In patients with congestive
increased (18). Of note, patients with di- ment of elevated blood pressure or hy- heart failure, including subgroups with
abetes were excluded from participating pertension in individuals with diabetes, diabetes, ARBs have been shown to re-
in this trial, so the results have no direct the Dietary Approaches to Stop Hyperten- duce major ASCVD outcomes (2426).
implications for blood pressure manage- sion (DASH) study evaluated the impact of Among patients with type 2 diabetes,
ment in patients with diabetes. healthy dietary patterns in individuals urine albumintocreatinine ratio (UACR)