Conference Coverage
Hypertension Guideline Lowers Threshold to 130/80 mm Hg
ANAHEIM, CA—Thirty million Americans became hypertensive overnight with the introduction of a new high blood pressure guideline from the American...
LOS ANGELES—Current guidelines can help physicians prevent stroke in patients with diabetes, according to a lecture delivered at the International Stroke Conference 2018. The prevalence of diabetes is expected to approximately double by 2050, and 16% of patients with diabetes die from stroke, said Philip B. Gorelick, MD, MPH, Professor of Translational Science and Molecular Medicine at Michigan State University College of Human Medicine in Grand Rapids. Patients with diabetes and ischemic stroke tend to have hypertension, thus controlling blood pressure in these patients could improve public health.
Philip B. Gorelick, MD, MPH
The ACC/AHA 2017 Hypertension Guideline
The 2017 hypertension guideline published by the American College of Cardiology (ACC) and the American Heart Association (AHA) recommends antihypertensive therapy for patients with diabetes and blood pressure of 130/80 mm Hg or higher. The treatment goal is blood pressure lower than 130/80 mm Hg. First-line treatment options include thiazide-like diuretics, ACE inhibitors, angiotensin receptor blockers (ARBs), and calcium-channel blockers. For patients with albuminuria, physicians may consider treatment with an ACE inhibitor or an ARB.
The ADA Position Statement
The American Diabetes Association (ADA) published an updated position statement on diabetes and hypertension in Diabetes Care in September 2017. One of its important recommendations is that orthostatic measurement of blood pressure be performed during the initial evaluation of hypertension and periodically at follow-up, said Dr. Gorelick. “Many of us are not doing that, I suspect,” he added.
Unlike the ACC and AHA, the ADA recommends a blood pressure target of less than 140/90 mm Hg and adds that lower blood pressure targets may be indicated for patients at high risk of cardiovascular disease. For patients with blood pressure greater than 120/80 mm Hg, the ADA recommends lifestyle management such as weight loss, the Dietary Approaches to Stop Hypertension diet, increased consumption of fruits and vegetables, moderate alcohol consumption, and increased physical activity.
Furthermore, the ADA recommends timely titration of pharmacologic therapy plus lifestyle management for patients with diabetes and blood pressure of 140/90 mm Hg or greater. For patients with blood pressure of 160/100 mm Hg or greater, the statement recommends prompt initiation and timely titration of two drugs or a single-pill combination, plus lifestyle intervention. Appropriate therapies include ACE inhibitors, ARBs, thiazide-like diuretics, and calcium-channel blockers, according to the statement. An ACE inhibitor or ARB is recommended for patients with a high ratio of urine albumin to creatinine.
AHA/ASA 2014 Guidelines
The ADA’s recommendations are similar to those of the guidelines for primary stroke prevention that the AHA and the American Stroke Association (ASA) issued in 2014. The latter guidance recommends control of blood pressure to a target of less than 140/90 mm Hg for patients with type 1 or type 2 diabetes. The associations recommend statin therapy to lower the risk of a first stroke and suggest that aspirin be considered for primary stroke prevention in patients with diabetes and a high 10-year risk of cardiovascular disease. Finally, the AHA and ASA recommend that physicians use the ADA’s guidance for glycemic control and management of cardiovascular risk factors.
Evidence That Informed Guidelines
The abovementioned guidelines incorporate evidence from various trials that examined the effect of antihypertensive treatment on stroke risk in patients with and without diabetes. One such trial is the Secondary Prevention of Small Subcortical Strokes study, the results of which were published by Benavente et al in 2013. They found that treatment to a target systolic blood pressure of less than 130 mm Hg reduced the risk of recurrent stroke by about 20%, compared with a target of between 130 mm Hg and 149 mm Hg, but the difference was not statistically significant. Treatment to the lower blood pressure target did, however, significantly reduce the risk of intracranial hemorrhage by about two-thirds.
In the ACCORD trial, which was published in 2010, investigators randomized participants with type 2 diabetes to intensive therapy (ie, a target systolic blood pressure of less than 120 mm Hg) or standard therapy (ie, a target systolic blood pressure of less than 140 mm Hg). Although intensive therapy did not reduce the composite risk of fatal and nonfatal major cardiovascular events, compared with standard therapy, it did reduce the risk of stroke.
—Erik Greb
Suggested Reading
ACCORD Study Group, Cushman WC, Evans GW, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362(17):1575-1585.
de Boer IH, Bangalore S, Benetos A, et al. Diabetes and hypertension: A position statement by the American Diabetes Association. Diabetes Care. 2017;40(9):1273-1284.
Meschia JF, Bushnell C, Boden-Albala B, et al. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(12):3754-3832.
SPS3 Study Group, Benavente OR, Coffey CS, et al. Blood-pressure targets in patients with recent lacunar stroke: the SPS3 randomised trial. Lancet. 2013;382(9891):507-515.
Whelton PK, Carey RM. The 2017 American College of Cardiology/American Heart Association clinical practice guideline for high blood pressure in adults. JAMA Cardiol. 2018 Feb 21 [Epub ahead of print].