Pillars of Blood Pressure Management in Patients with Type 2 Diabetes Mellitus: Insights from Recent Trials and Emerging Perspectives
Abstract
:1. Introduction
2. Methods and Research Design
3. Target Blood Pressure in Hypertensive Patients with Type 2 Diabetes Mellitus
4. The Pillars of Blood Pressure Management in Patients with T2DM
4.1. The First Pillar–Measuring and Confirming BP
4.2. The Second Pillar–Assessing CVD Risk and Comorbidities
4.3. The Third Pillar–Lifestyle and Pharmacological Treatment
4.4. The Fourth Pillar–Assessing Resistant or Uncontrolled HTN
4.5. The Fifth Pillar–Diabetic Treatment with Protective Cardiovascular and Renal Effects, Effective for HTN Control
5. Areas of Uncertainty
- Lack of consensus on BP targets: Different clinical trials and professional guidelines suggest varying BP targets for diabetic patients, with discrepancies between studies like ACCORD BP, SPRINT, and others. These trials yield conflicting results regarding the benefits of intensive BP control, especially concerning cardiovascular outcomes and adverse events.
- Conflicting evidence from trials: While some trials (e.g., SPRINT, BPROAD) support intensive BP control (<120 mmHg) for cardiovascular benefits, others (e.g., ACCORD BP) show no significant reduction in cardiovascular mortality, indicating that intensive control may not be universally beneficial for all T2DM patients.
- Potential risks of intensive BP control: Intensive BP lowering, particularly below 120 mmHg, has been linked to increased adverse events like hypotension, electrolyte imbalances, and kidney dysfunction, raising concerns about the safety of aggressive treatment strategies in certain patient groups.
- Generalizability of trial results: Some studies, such as the BPROAD trial, were conducted among specific populations (e.g., East Asians), and their findings may not be applicable to broader or more diverse groups, adding to the uncertainty regarding universal treatment guidelines.
- Changes in guidelines over time: There has been a shift in BP targets in clinical guidelines (e.g., from <140/90 mmHg to <130/80 mmHg), yet the supporting evidence is often based on a limited number of trials, leaving the question of an optimal target still open.
6. Strengths and Limitations
7. Future Directions
8. Conclusions
- Intensive BP control (<130/80 mmHg or lower if tolerated) reduces CV events in T2DM but must be balanced against the risk of adverse effects.
- Individualized treatment based on CV risk, organ damage, and patient tolerance remains crucial.
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Trial | Year | BP Target | Key Outcome |
---|---|---|---|
UKPDS 38 [10] | 1998 | <150/85 mmHg | Reduced stroke and microvascular complications; limited effect on major CV events. |
HOT [11] | 1998 | ≤80 mmHg (DBP) | Lower CV events in diabetic patients. |
ADVANCE BP [12] | 2008 | <130/80 mmHg | Reduced major CV events and kidney disease progression. |
INVEST [13] | 2010 | <130/85 mmHg vs. 130–139/<90 mmHg | No CV benefits with intensive control; increased mortality in some. |
ACCORD BP [14] | 2010 | <120 mmHg vs. <140 mmHg | No reduction in major CV events; more adverse events. |
ACCORD BP Substudy [15] | 2011 | <120 mmHg vs. <140 mmHg | Reduced stroke and HF hospitalizations; riskier in older patients. |
SPRINT [16] | 2015 | <120 mmHg | Reduced CV events and mortality (non-T2DM). |
STEP [21] | 2019 | <120 mmHg | Lowered stroke and HF risk; not specific to T2DM. |
ESPRIT [22] | 2024 | <120 mmHg vs. <140 mmHg | Reduced CV death, MI, stroke, and HF hospitalization; greater benefit in T2DM. |
BPROAD [23] | 2024 | <120 mmHg vs. <140 mmHg | Lower incidence of MACE, non-fatal stroke, non-fatal MI, HF hospitalization, cardiovascular death in overweight and diabetic patients. |
Guideline | Office BP Target | Key Notes |
---|---|---|
ESC 2024 [25] | 120–129/70–79 mmHg | Same BP targets for DM and non-DM if feasible and tolerated. |
ADA 2022 [24] | <140/90 mmHg (general); <130/80 mmHg (high ASCVD risk) | Individualized based on age, CVD, CKD, risk factors. |
ESC Prevention 2021 [26] | 120–130/<80 mmHg | SBP 130 mmHg if tolerated; DBP <80 mmHg. |
ESC/ESH 2018 [2] | <130/80 mmHg | 130–139/<80 mmHg for patients ≥65 years. |
AHA/ACC 2017 [15] | <130/80 mmHg | Universal target for DM patients. |
ADA 2017 [27] | <140/80 mmHg; <130/80 mmHg (high CVD risk) | Based on CVD risk. |
JNC 8—2014 [8] | <140/90 mmHg | Same for general and diabetic populations. |
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Pop, C.; Petriş, A.O.; Pop, L.; David, L.E. Pillars of Blood Pressure Management in Patients with Type 2 Diabetes Mellitus: Insights from Recent Trials and Emerging Perspectives. J. Clin. Med. 2025, 14, 3269. https://doi.org/10.3390/jcm14103269
Pop C, Petriş AO, Pop L, David LE. Pillars of Blood Pressure Management in Patients with Type 2 Diabetes Mellitus: Insights from Recent Trials and Emerging Perspectives. Journal of Clinical Medicine. 2025; 14(10):3269. https://doi.org/10.3390/jcm14103269
Chicago/Turabian StylePop, Călin, Antoniu Octavian Petriş, Lavinia Pop, and Liliana Elisabeta David. 2025. "Pillars of Blood Pressure Management in Patients with Type 2 Diabetes Mellitus: Insights from Recent Trials and Emerging Perspectives" Journal of Clinical Medicine 14, no. 10: 3269. https://doi.org/10.3390/jcm14103269
APA StylePop, C., Petriş, A. O., Pop, L., & David, L. E. (2025). Pillars of Blood Pressure Management in Patients with Type 2 Diabetes Mellitus: Insights from Recent Trials and Emerging Perspectives. Journal of Clinical Medicine, 14(10), 3269. https://doi.org/10.3390/jcm14103269