The prevalence of hypertension is common in older diabetics, with its prevalence increasing with advancing age 1. Hypertension and diabetes mellitus are both major independent risk factors for coronary events, stroke, peripheral arterial disease, and congestive heart failure in older individuals 2–7. Left ventricular hypertrophy associated with hypertension increases cardiovascular events 3,8. Reduction of left ventricular hypertrophy by antihypertensive treatment of hypertension reduces cardiovascular events and mortality 9–11.
Hypertension guidelines since 2011 have recommended a blood pressure target goal of less than 140/90 mmHg in diabetics younger than 80 years of age and of less than 150/90 mmHg in diabetics aged 80 years and older 2,12–18. The 2014 American Society of Hypertension/International Society of Hypertension guidelines recommended considering lowering the blood pressure to less than 140/90 mmHg in diabetics aged 80 years and older 17. We have already reported data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study 19. This study included 4181 participants aged 55–64 years, 3737 participants aged 65–74 years, and 1839 participants aged 75 years and older (mean age 79.3 years) on antihypertensive drug therapy. Data from this study also supported a blood pressure target goal of less than 140/90 mmHg in older individuals 19.
The new guidelines for treating patients with hypertension will be strongly influenced by the reported data from the Systolic Blood Pressure Intervention Trial (SPRINT) 20. SPRINT randomized 9361 adults with a systolic blood pressure of 130–180 mmHg and an increased cardiovascular risk, but without diabetes mellitus, history of stroke, symptomatic heart failure within the past 6 months, a left ventricular ejection fraction of less than 35%, and an estimated glomerular filtration rate less than 20 ml/min/1.73 m2 to a systolic blood pressure goal of less than 120 mmHg or to a systolic blood pressure goal of less than 140 mmHg 20. The participants were aged 50 years and older, with a mean age of 67.9 years. Of the 9361 participants, 2636 (28.2%) were aged 75 years and older, 3332 (35.6%) were women, 5399 (57.7%) were non-Hispanic white, 2947 (31.5%) were black, and 984 (10.6%) were Hispanic. Cardiovascular disease was present in 1877 participants (20.1%) and the Framingham 10-year cardiovascular disease risk score was greater than or equal to 15% in 5737 participants (61.3%) 20.
At 1 year, the mean systolic blood pressure was 121.4 mmHg in the intensive treatment group and 136.2 mmHg in the standard treatment group. The intervention was stopped early after a median follow-up of 3.26 years 20.
The primary composite outcome was myocardial infarction, other acute coronary syndrome, stroke, heart failure, or death from cardiovascular causes, and was reduced by 25% (P<0.001) by intensive blood pressure treatment 20. All-cause mortality was reduced by 27% (P=0.003) by intensive blood pressure treatment. Heart failure was reduced by 38% (P=0.002) by intensive blood pressure treatment. Death from cardiovascular causes was reduced by 43% (P=0.005) by intensive blood pressure treatment. The primary composite outcome or death was reduced by 22% (P<0.001) by intensive blood pressure treatment. Intensive blood pressure treatment insignificantly decreased myocardial infarction by 17%, caused the same incidence of other acute coronary syndrome, and insignificantly reduced stroke by 11%. Intensive blood pressure treatment significantly reduced the primary outcome by 33% in patients aged 75 years and older and significantly reduced the primary outcome by 20% in patients aged 50 to 74 years 20.
Serious adverse events were similar in both treatment groups 20. However, intensive blood pressure therapy caused more hypotension (2.4 vs. 1.4%, P=0.001), more syncope (2.3 vs. 1.7%, P=0.05), more electrolyte abnormality (3.1 vs. 2.3%, P=0.02), and more acute kidney injury or acute renal failure (4.1 vs. 2.5%, P<0.001). The incidence of bradycardia, injurious falls, and orthostatic hypotension with dizziness was similar in both treatment groups 20.
The new hypertension guidelines will have to answer by expert medical opinion many questions not answered by SPRINT. One of these questions is what should the systolic blood pressure treatment goal be in diabetics?
In The ACTION to Control Cardiovascular Risk in Diabetes Blood Pressure (ACCORD BP) trial, lowering systolic blood pressure to less than 120 mmHg in 4733 participants insignificantly reduced the composite primary outcome of myocardial infarction, stroke, or cardiovascular death 12%, but significantly reduced the incidence of stroke (a prespecified secondary outcome) 41% (P=0.01) 21. The sample size was approximately double in SPRINT (9361 participants) than in ACCORD BP (4733 participants), and there were important methodological differences between both of these trials 20–24. The participants in SPRINT were older (mean age 67.9 years) than those in ACCORD BP (mean age 62.2 years). The participants in ACCORD BP were at lower risk than the participants in SPRINT. Participants with dyslipidemia were assigned to the lipid arm and excluded from the blood pressure arm in ACCORD BP. Participants with a serum creatinine above 1.5 mg/dl were also excluded from ACCORD BP. The diuretics used were also different in these two trials. ACCORD BP often used hydrochlorothiazide, whereas SPRINT primarily used chlorthalidone (my preference) 24.
A post-hoc analysis of the data from ACCORD BP showed that the primary cardiovascular disease outcome was 26% less in participants randomized to intensive blood pressure treatment and standard glycemia goals than in participants randomized to standard blood pressure treatment and standard glycemia goals 23. In addition, a systolic blood pressure of less than 120 mmHg in ACCORD BP was associated with a 39% reduced risk of ECG left ventricular hypertrophy (P=0.008) 25.
In conclusion, a randomized clinical trial, using a similar number of participants included in SPRINT and the design used in SPRINT, needs to be conducted in older hypertensive diabetics to investigate whether the systolic blood pressure goal in this population should be a systolic blood pressure of less than 120 mmHg or a systolic blood pressure of less than 140 mmHg. On the basis of the data available, I recommend lowering the systolic blood pressure in older hypertensive diabetics at increased cardiovascular risk to less than 120 mmHg. However, because of an increased risk of hypotension, syncope, electrolyte abnormalities, and acute kidney injury or failure in older individuals treated to a systolic blood pressure target goal of less than 120 mmHg, these individuals will require more intensive monitoring for serious adverse events with an increased cost of care.
Conflicts of interest
There are no conflicts of interest.
1. Aronow WS. Hypertension and the older diabetic. Clin Geriatr Med 2008; 24:489–501.
2. Aronow WS, Fleg JL, Pepine CJ, Artinian NT, Bakris G, Brown AS, et al. ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus. Documents developed in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventative Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension. J Am Coll Cardiol 2011; 57:2037–2114.
3. Aronow WS, Ahn C, Kronzon I, Koenigsberg M. Congestive heart failure, coronary events and atherothrombotic brain infarction in elderly blacks and whites with systemic hypertension and with and without echocardiographic and electrocardiographic evidence of left ventricular hypertrophy. Am J Cardiol 1991; 67:295–299.
4. Aronow WS, Ahn C. Risk factors for new coronary events in a large cohort of very elderly patients with and without coronary artery disease. Am J Cardiol 1996; 77:864–866.
5. Aronow WS, Ahn C, Gutstein H. Risk factors for new atherothrombotic brain infarction in 664 older men and 1488 older women. Am J Cardiol 1996; 77:1381–1383.
6. Aronow WS, Sales FF, Etienne F, Lee NH. Prevalence of peripheral arterial disease and its correlation with risk factors for peripheral arterial disease in elderly patients in a long-term health care facility. Am J Cardiol 1988; 62:644–646.
7. Aronow WS, Ahn C. Incidence of heart failure in 2737 older persons with and without diabetes mellitus. Chest 1999; 115:867–868.
8. Aronow WS, Ahn C. Association of electrocardiographic left ventricular hypertrophy with the incidence of new congestive heart failure. J Am Geriatr Soc 1998; 46:1280–1281.
9. Okin PM, Devereux RB, Jern S, Kjeldsen SE, Julius S, Nieminen MS, et al. Regression of electrocardiographic left ventricular hypertrophy during antihypertensive treatment and the prediction of major cardiovascular events. JAMA 2004; 292:2343–2349.
10. Larstorp AC, Okin PM, Devereux RB, Olsen MH, Ibsen H, Dahlof B, et al. Changes in electrocardiographic left ventricular hypertrophy and risk of major cardiovascular events in isolated systolic hypertension: the LIFE study. J Hum Hypertens 2011; 25:178–185.
11. Larstorp AC, Okin PM, Devereux RB, Olsen MH, Ibsen H, Dahlof B, et al. Regression of ECG-LVH is associated with lower risk of new-onset heart failure and mortality in patients with isolated systolic heart failure: the LIFE study. Am J Hypertens 2012; 25:1101–1109.
12. Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Bohm M, et al. ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J 2013; 34:2159–2219.
13. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. evidence-based guideline for the management of high blood pressure in adults. Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; 311:507–520.
14. Hackam DG, Quinn RR, Ravani P, Rabi DM, Dasgupta K, Daskalopoulou SS, et al. The 2013 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can J Cardiol 2013; 29:528–542.
15. National Institute for Health and Clinical Excellence. Hypertension: clinical management of primary hypertension in adults. London, UK: National Institute for Health and Clinical Excellence; 2011.
16. American Diabetes Association. Standards of medical care in diabetes – 2013. Diabetes Care 2013; 36 (Suppl 1):S11–S66.
17. Weber MA, Schiffrin EL, White WB, Mann S, Lindholm LH, Kenerson JG, et al. Clinical practice guidelines for the management of hypertension in the community. A statement by the American Society of Hypertension and the International Society of Hypertension. J Clin Hypertens 2014; 16:14–26.
18. Rosendorff C, Lackland DT, Allison M, Aronow WS, Black HR, Blumenthal RS, et al. AHA/ACC/ASH scientific statement. Treatment of hypertension in patients with coronary artery disease: a scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension. J Am Coll Cardiol 2015. 651998–652038.
19. Banach M, Bromfield S, Howard G, Howard VJ, Zanchetti A, Aronow WS, et al. Association of systolic blood pressure levels with cardiovascular events and all-cause mortality among older adults taking antihypertensive medication. Int J Cardiol 2014; 176:219–226.
20. Wright JT Jr, Williamson JD, Whelton PK, Snyder JK, Sink KM, Rocco MV, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 2015; 373:2103–2116.
21. ACCORD Study Group. Effects of intensive blood pressure control in type 2 diabetes. N Engl J Med 2010; 362:1575–1585.
22. Cushman WC, Whelton PK, Fine LJ, Wright JT Jr, Reboussin DM, Johnson KC, et al. SPRINT trial results. Latest news in hypertension management. Hypertension 2016; 67:263–265.
23. Margolis KL, O’Connor PJ, Morgan TM, Buse JB, Cohen RM, Cushman WC, et al. Outcomes of combined cardiovascular risk factor management strategies in type 3 diabetes: The ACCORD randomized trial. Diabetes Care 2014; 37:1721–1728.
24. Jones DW, Weatherly L, Hall JE. SPRINT. What remains unanswered and where do we go from here? Hypertension 2016; 67:261–262.
25. Soliman EZ, Byington RP, Bigger JT, Evans G, Okin PM, Goff DC Jr, Chen H. Effect of intensive blood pressure lowering on left ventricular hypertrophy in patients with diabetes mellitus: Action to Control Cardiovascular Risk in Diabetes Blood Pressure Trial. Hypertension 2015; 66:1123–1129.