Cholesterol, BP Control Does Little Good for Diabetics

 

Cholesterol, BP Control Does Little Good for Diabetics

ABC News - Crystal PhendPeggy Peck - ‎27 minutes ago‎
Research findings released today have dashed doctors' hopes that intensive blood pressure and blood fat management could drive down diabetics' higher risks of heart problems.

 

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Title: Effects of Intensive Blood-Pressure Control in Type 2 Diabetes Mellitus
Topic: Prevention/Vascular
Date Posted: 3/14/2010
Author(s): The ACCORD Study Group.
Citation: N Engl J Med 2010;Mar 14:[Epub ahead of print].
Clinical Trial: yes
Study Question: Does lowering systolic blood pressure (SBP) to <120 mm Hg reduce risk for cardiovascular disease (CVD) in patients with type 2 diabetes?
Methods: The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial was designed to examine the effects of intensive blood glucose control and either blood pressure or plasma lipid control on cardiovascular outcomes. The trial includes 10,251 diabetics from 77 sites in the United States and Canada. In the ACCORD BP study, 4,733 subjects were randomized to intensive therapy for a goal SBP <120 mm Hg or standard therapy for a goal SBP of <140 mm Hg. All subjects had type 2 diabetes defined as glycated hemoglobin ≥7.5%, and were at high risk for CVD (defined as evidence of clinical CVD (age 40-79 years) or two additional risk factors (age range 55-79 years). Exclusion criteria included a body mass index >45, a serum creatinine of 1.5 mg/dl or greater, or protein excretion rate of <1.0 g. Baseline SPB had to be between 130 and 180 mm Hg on three or fewer antihypertensives. The primary outcomes of interest were nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death. The secondary outcomes included the combination of the primary outcomes and revascularization or hospitalization for congestive heart failure. Mean follow-up was 4.7 years. Clinic visits were monthly for the first 4 months, then every 2 months thereafter.
Results: Mean age was 62 years for this study population, with 47.7% women and 37% having a history of CVD. After 1 year, the on-treatment SBP was 119.3 mm Hg in the intensive therapy group and 133.5 mm Hg in the standard therapy group. The annual rate of primary outcome events was 1.8% in the intensive therapy group and 2.09% in the standard therapy group (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.73-1.06; p = 0.20). The annual rate of all-cause mortality was 1.28% for the intensive therapy group and 1.19% for the standard therapy group (HR, 1.07; 95% CI, 0.85-1.35; p = 0.55). The annual rate of stroke was 0.32% in the intensive therapy group and 0.53% in the standard therapy group (HR, 0.59; 95% CI, 0.39-0.89; p = 0.01). Reduced rates of nonfatal stroke were observed for the intensive therapy group (HR, 0.63; 95% CI, 0.41-0.96; p = 0.03). No significant differences were noted for major CVD events (fatal coronary events, nonfatal myocardial infarction, and unstable angina) (HR, 0.94; 95% CI, 0.79-1.12; p = 0.50) and fatal or nonfatal heart failure (HR, 0.94; 95% CI, 0.70-1.26; p = 0.67). Serious adverse events attributed to the antihypertensive treatment occurred in 3.3% of the intensive treatment group and 1.3% of the standard treatment group (p < 0.001).
Conclusions: The investigators concluded that among patients with type 2 diabetes who are at high risk for cardiovascular events, lowering SBP to <120 mm Hg did not reduce rates of fatal or nonfatal major cardiovascular events compared to a goal of SBP of <140 mm Hg.
Perspective: This landmark study adds to our understanding of management goals for high-risk diabetics and does not support aggressive lowering of SBP in high-risk diabetics. However, whether a blood pressure goal of <130 mm Hg provides significant benefit as compared to <140 mm Hg remains unanswered.  Elizabeth A. Jackson, M.D., F.A.C.C.

 

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