What is the target blood pressure (BP) for diabetic patients?

Target Blood Pressure for Diabetic Patients

For diabetic patients, blood pressure targets should be individualized based on cardiovascular risk: <130/80 mmHg for those with high cardiovascular risk (existing ASCVD or 10-year ASCVD risk ≥15%) and <140/90 mmHg for those with lower cardiovascular risk (10-year ASCVD risk <15%). 1

Risk-Based Blood Pressure Targets

High Cardiovascular Risk Patients (Target <130/80 mmHg)

• Appropriate for diabetic patients with existing atherosclerotic cardiovascular disease (ASCVD) or 10-year ASCVD risk ≥15% 1
• This lower target may reduce risk of stroke, which was significantly reduced in the ACCORD BP trial 1
• This approach aligns with American College of Cardiology/American Heart Association guidelines that advocate for a blood pressure target <130/80 mmHg 1
• Should only be implemented if it can be safely attained without significant adverse effects 1

Lower Cardiovascular Risk Patients (Target <140/90 mmHg)

• Appropriate for diabetic patients with 10-year ASCVD risk <15% 1
• Strong evidence supports that treatment to this threshold reduces cardiovascular events and microvascular complications 1
• This target is supported by multiple randomized clinical trials showing unequivocal benefit 1
• More conservative target helps minimize potential adverse effects of intensive blood pressure control 1

Evidence Behind These Recommendations

• The ACCORD BP trial found that intensive blood pressure control (target systolic <120 mmHg) did not reduce total major atherosclerotic cardiovascular events compared to standard control (target systolic <140 mmHg), but did reduce stroke risk 1
• Meta-analyses show antihypertensive treatment is beneficial when mean baseline blood pressure is ≥140/90 mmHg or mean attained intensive blood pressure is ≥130/80 mmHg 1
• Among trials with lower baseline or attained blood pressure, treatment reduced risk of stroke, retinopathy, and albuminuria, but effects on other ASCVD outcomes were not evident 1
• The 2022 American Diabetes Association standards of care support this risk-stratified approach 1

Special Considerations

Potential Adverse Effects

• Intensive blood pressure control may increase risks of:
  • Hypotension and syncope 1
  • Falls, particularly in elderly patients 2
  • Acute kidney injury and electrolyte abnormalities 1
• Patients with older age, chronic kidney disease, and frailty have higher risk of adverse effects from intensive control 1

Pregnancy

• For pregnant patients with diabetes and preexisting hypertension, a blood pressure target of 110–135/85 mmHg is recommended to reduce risk of maternal hypertension and minimize impaired fetal growth 1

Implementation Approach

Measurement and Monitoring

• Blood pressure should be measured at every routine clinical visit 1
• Elevated readings should be confirmed using multiple readings, including measurements on a separate day 1
• All hypertensive patients with diabetes should monitor their blood pressure at home 1

Treatment Strategy

• For patients with blood pressure >120/80 mmHg, lifestyle interventions are recommended:

  • Weight loss when indicated 1
  • DASH-style eating pattern with reduced sodium and increased potassium 1
  • Moderation of alcohol intake 1
  • Increased physical activity 1

• For pharmacological therapy:

  • ACE inhibitors or ARBs are preferred first-line agents, particularly in patients with albuminuria or renal insufficiency 1
  • Thiazide diuretics are particularly effective in African-American patients 1
  • Multiple agents are often required to achieve target blood pressure 3

Clinical Pitfalls to Avoid

• Treating to excessively low targets in elderly patients, which may increase risk of falls and adverse events 2
• Not accounting for white coat hypertension or masked hypertension 2
• Ignoring orthostatic blood pressure changes, which may indicate autonomic neuropathy and require adjustment of targets 1
• Failing to use appropriate cuff size, which can lead to inaccurate measurements 2