By Joseph E. Scherger, MD, MPH

Vice President, Primary Care, Eisenhower Medical Center; Clinical Professor, Keck School of Medicine, University of Southern California, Los Angeles

Dr. Scherger reports no financial relationships relevant to this field of study.

SYNOPSIS: Type 2 diabetic patients with systolic blood pressure < 120 mmHg experienced more cardiovascular events than patients with systolic blood pressure up to 140 mmHg.

SOURCE: Wan EYF, Yu EYT, Chin WY, et al. Effect of achieved systolic blood pressure on cardiovascular outcomes in patients with type 2 diabetes mellitus: A population-based retrospective cohort study. Diabetes Care 2018 Mar 28. pii: dc172443. doi: 10.2337/dc17-2443. [Epub ahead of print].

Wan et al studied 28,014 primary care adult patients with type 2 diabetes with no prior diagnosis of cardiovascular disease who achieved systolic blood pressure targets of < 120 mmHg, < 130 mmHg, and < 140 mmHg. Over a follow-up period of about five years, the highest cardiovascular events occurred in patients with systolic blood pressure < 120 mmHg. These findings held for patients under and over age 65 years. Patients with systolic blood pressure up to 140 mmHg had no increased risk compared with patients with systolic blood pressure < 130 mmHg. This study supports the use of a systolic blood pressure of up to 140 mmHg as a target for control in type 2 diabetic patients.

COMMENTARY

There is controversy over which blood pressure guidelines to follow. In November 2017, the American College of Cardiology (ACC) and the American Heart Association (AHA) issued new blood pressure control guidelines defining normal blood pressure in adults at 120/80 mmHg or lower. Any value above this target is elevated.1 The American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) have criticized these guidelines and have called for the target blood pressure of 130/80 and continuing the systolic limit of 150 mmHg in the elderly as previously advocated.2,3

Previously in Internal Medicine Alert, I reviewed a study of more than 20,000 patients after a stroke that found that the healthiest blood pressure range was a systolic from 130-139 mmHg.4 This study found that patients with systolic blood pressures < 120 mmHg had an increased risk of recurrent stroke.

Overtreating blood pressure is likely to be as harmful as not treating high blood pressure. The systolic blood pressure readings in our office often are not resting blood pressure readings because of patient activity and stress of visiting the doctor. While home blood pressure is demonstrated to be more accurate, it is hard to ignore information right in front of us in the patient’s vital signs. Moreover, a quality review of our clinical practice is likely to use the office blood pressure in assessing the quality of our control of hypertension. We need to be diligent in getting accurate resting blood pressure readings in the office and not overreact to readings when the patient is likely to be normal or controlled.

I believe the new ACC/AHA guidelines will be shown to cause more harm than good. Primary care physicians need to stand up for our patients and work hard to avoid overtreatment of blood pressure and causing harm.

REFERENCES

  1. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2017 Nov 7. pii: S0735-1097(17)41519-1. doi: 10.1016/j.jacc.2017.11.006. [Epub ahead of print].
  2. Wilt TJ, Kansagara D, Qaseem A; Clinical Guidelines Committee of the American College of Physicians. Hypertension limbo: Balancing benefits, harms, and patient preferences before we lower the bar on blood pressure. Ann Intern Med 2018;168:369-370.
  3. American Academy of Family Physicians. AAFP Decides to Not Endorse AHA/ACC Hypertension Guideline, Dec. 12, 2017. Available at: https://bit.ly/2zaPmzb. Accessed April 20, 2018.
  4. Scherger JE. What is the healthiest systolic blood pressure range for patients after an ischemic stroke? Internal Medicine Alert 2011;33:188-189.