What is the ideal blood pressure target for a patient with type 2 diabetes (T2D)?

Ideal Blood Pressure Target for Type 2 Diabetes

For most patients with type 2 diabetes and hypertension, target a blood pressure of <140/90 mmHg, but if the patient has existing cardiovascular disease or a 10-year ASCVD risk ≥15%, target <130/80 mmHg if it can be safely achieved. 1

Risk-Stratified Blood Pressure Targets

Higher Cardiovascular Risk Patients (ASCVD risk ≥15% or existing CVD)

• Target: <130/80 mmHg 1, 2
• This includes patients with prior myocardial infarction, stroke, coronary revascularization, or documented atherosclerotic disease 1
• The American Diabetes Association explicitly supports this lower target for high-risk patients, though acknowledging it should only be pursued if safely attainable 1

Lower Cardiovascular Risk Patients (ASCVD risk <15%)

• Target: <140/90 mmHg 1
• This is the minimum target supported by unequivocal evidence from randomized trials showing reduction in both macrovascular and microvascular complications 1

Evidence Base and Key Trial Findings

Why Not More Aggressive Targets for Everyone?

The ACCORD BP trial provides the strongest direct evidence in type 2 diabetes patients and fundamentally shaped current recommendations 1:

• 4,733 patients with type 2 diabetes were randomized to intensive (<120 mmHg systolic) versus standard (<140 mmHg systolic) blood pressure control 1
• Achieved blood pressures: 119/64 mmHg (intensive) versus 133-135/70 mmHg (standard) 1
• Primary composite outcome (MI, stroke, CV death): No significant reduction with intensive control 1
• Stroke reduction: 41% reduction with intensive control, but this benefit was not sustained after the trial ended 1
• Adverse events: Significantly more common with intensive control, particularly elevated creatinine, electrolyte abnormalities, hypotension, and syncope 1

Supporting Evidence for <130/80 mmHg in High-Risk Patients

While SPRINT excluded diabetes patients, it provides supportive evidence for lower targets in high cardiovascular risk populations 1:

• 25% reduction in the composite outcome of MI, acute coronary syndromes, stroke, heart failure, and cardiovascular death with systolic target <120 mmHg 1
• 27% reduction in all-cause mortality 1
• Achieved blood pressures were 121 mmHg versus 136 mmHg 1

The more recent STEP trial (2021) reinforced these findings with a 26% reduction in cardiovascular events targeting 110-130 mmHg versus 130-150 mmHg, with 19% of participants having type 2 diabetes 1

Critical Implementation Considerations

Blood Pressure Measurement Method Matters

• ACCORD BP and SPRINT used automated office blood pressure measurement, which yields values approximately 5-10 mmHg lower than typical office readings 1
• In clinical practice: If using standard office measurement, a target of <130 mmHg may actually correspond to the ACCORD intensive arm target 1
• Home blood pressure monitoring is recommended for all hypertensive patients with diabetes 1

The J-Curve Phenomenon

• Avoid diastolic blood pressure <60 mmHg, particularly in patients with coronary artery disease, as this may compromise coronary perfusion 3
• Meta-regression analysis shows stroke risk continues to decline to systolic <120 mmHg, but serious adverse events increase by 40% below 130 mmHg with no benefit for other outcomes 4

Individualization Factors

Pursue more aggressive targets (<130/80 mmHg) when: 1

• Existing ASCVD or 10-year ASCVD risk ≥15%
• Patient can tolerate treatment without significant adverse effects
• Patient understands and accepts increased treatment burden

Use less aggressive targets (<140/90 mmHg) when: 1

• Lower cardiovascular risk (10-year ASCVD risk <15%)
• Elderly patients with limited life expectancy
• Severe coronary artery disease where diastolic hypotension is concerning 3
• History of adverse effects from intensive blood pressure lowering
• Patient preference after shared decision-making

Common Pitfalls to Avoid

• Therapeutic inertia: The most dangerous error is leaving diabetic patients with blood pressure ≥140/90 mmHg untreated, which leads to unacceptable cardiovascular and microvascular complications 5
• Over-aggressive lowering: Targeting <120/70 mmHg in most diabetic patients increases adverse events without additional cardiovascular benefit beyond stroke reduction 1, 4
• Ignoring measurement technique: Failing to account for the difference between automated and manual blood pressure measurement can lead to inappropriate targets 1
• One-size-fits-all approach: Not stratifying by cardiovascular risk misses the opportunity to provide more intensive treatment to those most likely to benefit 1