Blood Pressure Goal for Cardiovascular Disease Prevention in Diabetes, Hypertension, and CKD
The blood pressure goal for this 55-year-old woman with diabetes, hypertension, and CKD (eGFR 50 mL/min) should be <130/80 mmHg to prevent cardiovascular disease, making answer C (<135/80) the closest correct option among the choices provided. 1, 2
Guideline-Based Recommendations
The most recent high-quality guidelines establish clear targets for this specific patient population:
The American College of Cardiology/American Heart Association (ACC/AHA) recommends a blood pressure goal of <130/80 mmHg for all adults with chronic kidney disease and hypertension, regardless of diabetes status. 2 This patient meets criteria for high-risk atherosclerotic cardiovascular disease given the combination of diabetes and CKD. 2
The European Society of Cardiology similarly recommends systolic <130 mmHg and diastolic <80 mmHg for patients with diabetes and chronic kidney disease, specifically targeting reduction of both microvascular and macrovascular complications. 1
The 2018 American Diabetes Association Standards of Care state that blood pressure levels <140/90 mmHg are generally recommended, but lower targets (e.g., <130/80 mmHg) may be appropriate for patients at highest cardiovascular risk, which includes those with both diabetes and CKD. 3
Supporting Evidence from Clinical Trials
The most recent and highest quality observational study directly addresses this question:
A 2025 Korean nationwide cohort study of 373,966 adults with both diabetes and CKD demonstrated that systolic BP <130 mmHg and diastolic BP <80 mmHg were each associated with reduced cardiovascular disease risk in a log-linear pattern. 4 Using systolic BP 130-140 mmHg as reference, those with systolic BP <120 mmHg had a hazard ratio of 0.77 (95% CI 0.74-0.80) for cardiovascular events, while those with 120-130 mmHg had HR 0.89 (95% CI 0.87-0.91). 4
The SPRINT trial demonstrated cardiovascular benefit with intensive systolic blood pressure lowering (target <120 mmHg) in the CKD subgroup, showing hazard ratio 0.72 (95% CI 0.53-0.99) for death. 2 However, SPRINT explicitly excluded patients with diabetes, limiting direct applicability. 1
Critical Safety Boundaries
Avoid lowering systolic blood pressure below 120 mmHg, as this may increase risk of hypoperfusion in patients with chronic kidney disease. 1 Similarly, diastolic blood pressure should not be lowered below 70 mmHg, as this increases cardiovascular risk, particularly coronary events. 1, 2
Medication Selection Priority
For this patient with CKD stage 3a (eGFR 50 mL/min):
An ACE inhibitor or ARB should be first-line therapy, particularly given the combination of diabetes and CKD. 1, 2 The ACC/AHA gives this a Class IIa recommendation (Level of Evidence B-R) for slowing kidney disease progression. 2
Combination therapy with a calcium channel blocker or thiazide/thiazide-like diuretic is typically required to achieve target blood pressure in CKD patients. 1
Check serum creatinine and potassium within 2-4 weeks after initiating or titrating ACE inhibitors or ARBs. 2
Reconciling Older Guidelines
Earlier guidelines recommended less aggressive targets:
The 2003 JNC-7 guideline recommended <130/80 mmHg specifically for patients with diabetes or chronic kidney disease. 3 This represented the standard for nearly two decades.
However, more recent evidence and the 2025 Korean study provide stronger support for the <130/80 mmHg target specifically for cardiovascular disease prevention in this high-risk population. 4
Answer to Multiple Choice Question
Among the provided options, answer C (<135/80 mmHg) is the closest to the evidence-based target of <130/80 mmHg and represents the most appropriate choice for preventing cardiovascular disease in this patient. 1, 2, 4 Options A and B are too permissive and would not provide adequate cardiovascular protection. 4 Option D (<125/70 mmHg) risks excessive diastolic lowering below the safe threshold of 70 mmHg. 1, 2