Intensive BP control benefits diabetic patients at high CV risk
Intensive Versus Standard Blood Pressure Control in SPRINT-Eligible Participants of the ACCORD-BP TrialLiterature - Buckley LF, Dixon DL, Wohlford IV GF, et al. - Diabetes Care 2017; published online ahead of print
In the ACCORD-BP study, an SBP of <120 mmHg did not significantly reduce the composite of CVD death, non-fatal MI, and non-fatal stroke compared with a standard SBP goal of <140 mmHg . In the SPRINT study however, a significant reduction was seen in the number of CVD events with intensive BP control to a target SBP of <120 mmHg, although T2DM patients were excluded . The discrepancy might be explained by the different non-DM risk profiles of patients enrolled in the 2 studies.
In this analysis, patients from the ACCORD-BP study with CVD risk factors that would have been eligible for the SPRINT study were identified, and the hypothesis was tested that intensive BP control reduces CVD risk in these patients. For this purpose, the SPRINT inclusion criteria were applied to the ACCORD-BP cohort. This led to a SPRINT-eligible ACCORD-BP population of 2592 participants with the following characteristics:
- Clinical or subclinical CVD (n=2592)
- Chronic kidney disease (n=403)
- Age at least 75 years (n=254)
- Framingham 10-year risk at least 15% (n=1349)
Subsequently, ACCORD-BP participants in the intensive glucose control arm were excluded from the analysis, because they had an HbA1c goal of <6.0%, which is not recommended by current guidelines as standard of care . Ultimately, 652 participants were left in the intensive BP control arm and 632 participants were left in the standard BP control arm.
- Intensive BP control significantly reduced the risk of the composite of CVD death, non-fatal MI, non-fatal stroke, any revascularization, or HF by 21% in SPRINT-eligible ACCORD-BP participants (3.48%/year vs. 4.22%/year; HR: 0.79; 95% CI: 0.65 – 0.96; P = 0.02).
- Intensive BP control also significantly reduced the risk of the ACCORD-BP primary end point of CVD death, non-fatal MI, or non-fatal stroke (1.26%/year vs. 1.79%/year; HR: 0.69; 95% CI: 0.51 – 0.93; P = 0.01).
- The risks of non-fatal MI, non-fatal stroke, and HF were favorably influenced by intensive BP control compared with standard BP control, although statistical significance was not reached.
- Treatment-related serious adverse events among SPRINT-eligible ACCORD-BP patients occurred more frequently in intensive BP control participants compared with standard BP control participants (4.1% vs. 2.1%; P = 0.003).
- After pooling the original SPRINT participants with SPRINT-eligible ACCORD-BP participants, there was no evidence of heterogeneity in the effect of intensive BP control between participants with and without T2DM with respect to the composite of CVD death, non-fatal MI, non-fatal stroke, any revascularization, or HF (P = 0.76 for interaction); or the composite of CVD death, non-fatal MI, or non-fatal stroke (P = 0.62 for interaction).
In an SPRINT-eligible ACCORD-BP population, a high-risk cohort of diabetic patients, intensive BP control reduced CVD outcomes. These results support the rational use of an intensive BP control strategy in select, high-risk T2DM patients.