Blood Pressure Goal for Cardiovascular Disease Prevention in DM, HTN, and CKD
The goal blood pressure is <130/80 mmHg (answer: 135/80 is closest) for this 55-year-old woman with diabetes, hypertension, and CKD (eGFR 50 ml/min) to prevent cardiovascular disease. 1, 2
Rationale for <130/80 mmHg Target
The 2019 ACC/AHA Primary Prevention Guideline and 2017 ACC/AHA Hypertension Guideline both explicitly recommend initiating antihypertensive therapy at BP ≥130/80 mmHg with a treatment goal of <130/80 mmHg for patients with CKD. 1
The vast majority of patients with CKD have a 10-year ASCVD risk ≥10%, automatically placing them in the high-risk category that requires this lower BP target. 1
Patients with both diabetes and CKD fall into this high-risk category, making the <130/80 mmHg goal appropriate for both cardiovascular protection and renal preservation. 1, 2
Evidence Supporting This Target
The SPRINT trial demonstrated that intensive BP lowering (SBP target <120 mmHg) in CKD patients (including those with eGFR 20-60) reduced cardiovascular events and all-cause mortality compared to standard therapy (SBP target <140 mmHg), with a hazard ratio of 0.81 for CV events and 0.72 for death. 1
Meta-analyses show that achieving an additional 10 mmHg reduction in SBP reduces CVD risk across multiple BP ranges, including when lowering from 134/79 to 125/76 mmHg, and these analyses specifically included patients with diabetes and CKD. 1
For patients with diabetes specifically, meta-analyses demonstrated that a target BP of 133/76 mmHg provided significant benefit compared with 140/81 mmHg for major cardiovascular events, MI, stroke, albuminuria, and retinopathy progression. 1
Why Not More Aggressive Targets?
While SPRINT showed benefit with SBP <120 mmHg, the ACCORD trial in diabetic patients found that lowering BP to SBP <120 mmHg did not reduce major cardiovascular events and was associated with greater risk of adverse events including hypotension and reduction in eGFR. 1
The consensus target of <130/80 mmHg balances cardiovascular benefit with safety, avoiding the increased adverse events seen with more aggressive targets in diabetic patients. 1, 2
Treatment Approach
Initiate therapy with an ACE inhibitor or ARB as first-line agents, as these provide both BP control and renoprotection, particularly important given the CKD. 1, 2
Most patients with diabetes and CKD require multiple antihypertensive agents (typically 2-3 medications) to achieve the <130/80 mmHg goal. 1, 2
Add a thiazide-like diuretic or calcium channel blocker as second-line therapy to reach target BP. 1, 2
Monitoring Considerations
Check basic metabolic panel within 2-4 weeks after initiating or titrating ACE inhibitors/ARBs to monitor for hyperkalemia and acute changes in renal function. 2
A 10-25% increase in serum creatinine may occur with ACE inhibitor/ARB therapy and is generally acceptable as a hemodynamic effect. 1
Avoid lowering systolic BP below 110 mmHg or diastolic BP below 70 mmHg, as excessive lowering increases cardiovascular risk and adverse events. 1, 2
Use home BP monitoring to confirm office readings and avoid white coat effect or excessive lowering. 2
Critical Pitfalls to Avoid
Do not use the older target of <140/90 mmHg for this patient—this is outdated for high-risk patients with diabetes and CKD. 1
Do not aggressively lower BP during acute illness or volume depletion, as this increases risk of acute kidney injury from hypoperfusion. 2
Monitor carefully for orthostatic hypotension, especially when using multiple agents or in older patients. 2