The American Diabetes Association (ADA) Blood Pressure Recommendations

CARDIOLOGY

“The American Diabetes Association (ADA) defines hypertension as SBP ≥140 mmHg and DBP ≥90 mmHg that is confirmed during separate clinic visits (). Current ADA guidelines recommend a treatment goal of SBP <140 mmHg and DBP <90 mmHg for most patients with diabetes (Table 1). Those at higher cardiovascular risk may require more intensive blood pressure control to <130/80 mmHg. The 2018 ADA recommendations are based on the ACCORD BP trial that compared CVD outcomes in diabetes patients randomized to intensive versus less intensive blood pressure control (). The ACCORD BP trial showed no benefit to the primary composite end point of nonfatal myocardial infarction, nonfatal stroke, and CVD death in the group treated to the more intensive blood pressure goal of SBP <120 mmHg compared to the standard group for whom SBP was maintained at <140 mmHg, while demonstrating an increased incidence of adverse effects (hypotension and worsening renal function) in the more intensively treated group.

TABLE 1.

Summary of Blood Pressure Goals and Initial Choice of Antihypertensive Agent for Patients With Diabetes Endorsed by Different Professional Societies or Expert Groups

Recommendation (Year) Blood Pressure Goals (mmHg) First-Line Pharmacological Treatment
ADA (2018) <140/90 (<130/80*) ACEI/ARB†, thiazide-like diuretic, or dihydropyridine CCB
ACC/AHA (2017) <130/80 No preference
JNC 8 (2014) <140/90 Non-black: ACEI/ARB, thiazide-like diuretic, or CCB Black: thiazide-like diuretic or CCB
VA/DoD (2014) <150/85 (140/85**) Thiazide-like diuretic (chlorthalidone or indapamide)
CDA (2013) <130/80 ACEI/ARB‡, thiazide-like diuretic, or dihydropyridine CCB
ESH/ESC (2013) <140/85 ACEI/ARB†, thiazide-like diuretic, or CCB
*May be appropriate for individuals at high risk of CVD.
**Suggested for patients who can tolerate the antihypertensive medications necessary to reach this goal.
†Recommended if hypertension is associated with proteinuria and suggested if hypertension is associated with microalbuminuria as the preferred first-line agent.
‡Recommended in the presence of known kidney disease, including microalbuminuria, or CVD.

The AHA, American College of Cardiology (ACC), and multiple other professional societies released joint guidelines for the management of hypertension in 2017 (). These guidelines recommend initiating antihypertensive therapy for patients with diabetes at a blood pressure ≥130/80 mmHg with a goal blood pressure <130/80 mmHg. Although the ACC/AHA guidelines also use data from the ACCORD BP trial to support this recommendation, the lower blood pressure goal of <130/80 mmHg for all patients with diabetes is based on the assumption that patients with diabetes have a high cardiovascular risk and on the results of two meta-analyses that showed better cardiovascular and microvascular risk reduction if SBP is maintained at <130 mmHg (,).”

 

Source of Material

Passarella P, Kiseleva TA, Valeeva FV, Gosmanov AR. Hypertension Management in Diabetes: 2018 Update. Diabetes Spectr. 2018;31(3):218-224. doi:10.2337/ds17-0085; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6092891/

print