The Best BP for High-risk Hypertension Patients

SOURCE: Böhm M, Schumacher H, Teo KK, et al. Lancet 2017;389:2226-2237.

The authors of the Systolic Blood Pressure Intervention Trial (SPRINT) randomized almost 10,000 high-risk, non-diabetic patients to intensive treatment (systolic blood pressure [SBP] goal: < 120 mmHg) vs. “standard” treatment (SBP goal: < 140 mmHg) and demonstrated that the group assigned to intensive treatment experienced a statistically significant reduction in both cardiovascular (CV) and all-cause mortality. Although the “costs” of intensive treatment were not trivial (more medications, more cost, more serious and non-serious adverse events), the lesson for many clinicians was that striving for SBP control better than < 120 mmHg was of merit in patients willing to shoulder the increased complexity and potential adverse effect profile of intensive treatment. But this may not be the end of the story.

Böhm et al analyzed the outcomes of two large, previously published CV trials: ONTARGET (n = 25,127) and TRANSCEND (n = 5,810). They chose to examine CV outcomes within these two trials for patients similar to the SPRINT population (high-risk adults) in relation to on-treatment BP. According to their analysis, achieving an SBP < 120 mmHg was associated with a 14% increase in composite CV outcomes compared to an SBP 120-140 mmHg. Similarly, hazard ratios for all-cause mortality and CV mortality were approximately 30% higher in persons who achieved the lower BP threshold (< 120 mmHg).

While these results might dampen enthusiasm for those who endorse the above-mentioned results of SPRINT, differences between the data sets, as well as the fact that this report relies on post-hoc analysis, include a substantial proportion of diabetics and post-stroke patients in the analysis of ONTARGET/TRANSCEND, both of whom had been excluded from SPRINT, and may have made an important difference in outcomes.

Dietary Omega-3 Fatty Acids Inversely Associated With Diabetic Retinopathy

SOURCE: Chew EY. JAMA 2017;317:2226-2227.

In the spirit of full disclosure, with rare exception (folate for reproductive age women), I am not an advocate for supplements. I want to make sure readers can clearly identify the difference between omega-3 fatty acid supplements and omega-3 fatty acids as provided by fish in the diet. The use of supplements by Americans has been fairly stable over the past decade at about 50%, despite little in the way of substantive scientific evidence support their use. However, let’s not confuse the difference between the potential benefits of enhancement of diet with enhancement of intake through supplements. For instance, data from the Women’s Health Initiative suggest that the cardiovascular effects of calcium intake through dietary enhancement differ from those of calcium supplements.

The PREDIMED clinical trial was a prospective investigation that compared a Mediterranean diet augmented with extra virgin olive oil and nuts with a control (n = 7,447). Approximately half of the PREDIMED participants were diabetic. After a follow-up of six years, the hazard ratio for new retinopathy requiring intervention was approximately half that for the Mediterranean diet group compared to the control group. Although it may be tempting to extrapolate these observations to simply take an omega-3 fatty acid supplement of comparable quantity, it remains to be determined whether this isolated ingredient from fish, when taken as a single-entity intervention, will provide similar benefits.

The Potential Long-term Payoff of Good Initial Diabetes Control

SOURCE: Svensson E, Baggesen LM, Johnsen SP, et al. Diabetes Care 2017;40:800-807.

Experts often opine that treatment of diabetes is “a marathon, not a sprint,” suggesting that careful, slow steps are wise. In reference to risk for hypoglycemia, this philosophy is likely to be particularly apt, and yet some data suggest that prompt control of type 2 diabetes (T2DM), with strong early reductions in A1c, may produce long-term benefits.

Svensson et al reported on a large population of T2DM patients (n = 24,752) in Denmark among whom baseline A1c and degree of A1c reduction within the first six months could be correlated with outcomes over the next 2.6 years (mean follow-up). The group was restricted to only those patients whose initial treatment had been metformin.

The authors found that both the lowest six-month achieved A1c level and greatest absolute degree of A1c correlated with greatest risk reduction for cardiovascular outcomes.

Although the window of observation of these patients is only modest (< 3 years), these results encourage clinicians to pursue the best control of T2DM we can attain without incurring significant adverse events, such as hypoglycemia.