Blood Pressure Goal for Cardiovascular Disease Prevention
For this 55-year-old woman with diabetes, hypertension, and CKD (eGFR 50 mL/min), the blood pressure goal should be <130/80 mmHg (answer c) to prevent cardiovascular disease. 1, 2
Guideline-Based Recommendation
The American College of Cardiology/American Heart Association (ACC/AHA) explicitly recommends a blood pressure target of <130/80 mmHg for all adults with chronic kidney disease and hypertension, regardless of diabetes status. 1, 2 This patient meets criteria for high-risk atherosclerotic cardiovascular disease (ASCVD) category due to having both diabetes and hypertension, which mandates pharmacologic treatment at 130/80 mmHg or higher. 1, 2
Supporting Clinical Trial Evidence
The SPRINT trial provides the strongest contemporary evidence for intensive blood pressure control in CKD patients, demonstrating:
- In the CKD subgroup (eGFR 20-60 mL/min), targeting systolic BP <120 mmHg reduced cardiovascular events with a hazard ratio of 0.81 (95% CI, 0.63-1.05) 3
- All-cause mortality was reduced with HR 0.72 (95% CI, 0.53-0.99) 3, 1
- The intensive target (<120 mmHg achieved) showed 25% reduction in composite cardiovascular outcomes compared to standard target (<140 mmHg) 3
The ACCORD BP trial specifically studied patients with type 2 diabetes and found that while the primary composite endpoint was not significantly reduced, stroke risk was reduced by 41% with intensive control (target <120 mmHg vs. 130-140 mmHg). 3
Why Other Targets Are Inadequate
- <155/100 mmHg (option a): This is far too permissive and would expose the patient to unacceptably high cardiovascular risk 3
- <145/90 mmHg (option b): While the older JNC-8 guideline suggested <140/90 mmHg for CKD patients 1, this has been superseded by more recent evidence showing benefit from lower targets 1, 2
- <125/70 mmHg (option d): While some data support systolic BP <120 mmHg, diastolic BP <70 mmHg increases cardiovascular risk, particularly coronary events 1, 2
Medication Strategy
ACE inhibitors should be the cornerstone of therapy in this patient with diabetes and CKD (eGFR 50 mL/min). 3, 1 The ACC/AHA guideline provides a Class IIa recommendation (Level of Evidence B-R) for ACE inhibitors to slow kidney disease progression in CKD stage 3 or higher. 1
If ACE inhibitors are not tolerated, angiotensin receptor blockers (ARBs) serve as an alternative (Class IIb recommendation). 1, 2
Critical Implementation Points
Gradual blood pressure reduction over weeks to months is essential to minimize risk of acute kidney injury from hypoperfusion in CKD patients. 1, 2
Avoid excessive diastolic lowering below 70 mmHg, as this increases cardiovascular risk. 1, 2 The European Society of Cardiology specifically recommends diastolic BP <80 mmHg but not <70 mmHg. 2
Laboratory monitoring is mandatory: Check basic metabolic panel (serum creatinine, potassium) within 2-4 weeks after initiating or titrating ACE inhibitors or ARBs. 1, 2
Recent Observational Data
A 2025 Korean nationwide 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, with multivariable-adjusted HR of 0.89 (95% CI, 0.87-0.91) for systolic BP 120 to <130 mmHg compared to 130 to <140 mmHg. 4