Is lower always better? (Part 2 - blood pressure control)

In The Diabetes Answer BookI talk a lot about heart disease.  The biggest risk to your future life and health if you have diabetes is from heart disease.  If you have diabetes it is incredibly important that you do everything you can to lower your risk of heart disease.  If you smoke do everything you can to quit.  If you are over age 40 talk to your doctor about whether you should be taking a statin drug, or an ACE-inhibitor drug, or low dose aspirin.  Ask to get your cholesterol checked and try to keep the LDL cholesterol level below 100mg/dl (2.6 mmol/L).  And keep track of your blood pressure.  High blood pressure increases your risk of getting a heart attack.  Doing things to lower your blood pressure will keep you healthy and alive longer.  Nothing that I have said so far is surprising, new, or controversial.  The controversial part is to ask the question, "How low should we push the blood pressure level?"

When someone measures your blood pressure they give you two numbers.  The first number is higher.  This is called the systolic blood pressure and tells you how much pressure your heart generates when it is pumping. There is no doubt that having your systolic blood pressure at 150 is better for your long term health than having it at 170, for example.  Having your systolic blood pressure below 140 is better still, and we have been told for years that if you have diabetes you should try to get it below 130.  But would an even lower number be better still.  If you took enough medicines, drugs, and pills to push your systolic blood pressure below 120 would you live a longer and healthier life?

This very question has recently been asked in a large, well-designed, randomized controlled research trial called ACCORD.  In this study 4,733 people with type 2 diabetes, whose average age was 62 and who had had heart disease or at least two risk factors for heart disease were given two different approaches to treating their blood pressure.  Half of them were treated to get their systolic blood pressure below 140.  This group kept their blood pressure at an average of 133 for the next 4-5 years.  The second group were treated to try to get their blood pressure below 120.  they kept it at an average of 119 for the next 4-5 years.  In order to get their blood pressure at this lower level the people in this more intensive treatment group needed to be on more drugs and in bigger doses than the people in the less intensive treatment group.  Because of that the intensive group had more side effects from their treatment.  But the big question was, would they do better when they were followed up?  Would they have fewer heart attacks, and strokes? Would more of them stay alive and well during the 4-5 years of follow up? Surprisingly, the answer to those questions was NO!  Both groups did equally well.  About the same number died or developed a new cardiovascular disease (like a heart attack or a stroke).

So where does this leave us? Does the ACCORD trial tell us what the ideal systolic blood pressure is if you have diabetes?  Well, it does confirm that high blood pressure is not good for you if you have diabetes.  Getting the systolic below 140 is definitely a good goal to go for.  And, in fact, the people in the ACCORD trial who were trying to get their blood pressure below 140 ended up at 133, which is a lot closer to 130 than 140. So maybe a target of less than 130 (which is what the American Diabetes Association and other international group recommend right now) is the right target.  I wish the ACCORD trial had had a third group who were targeted to get their systolic blood pressure below 130, but they didn't.  What the study reminds us is that when taking drugs to treat any medical condition there is a balance between the drugs doing good and causing harm.  Sometimes adding more drugs and pushing the dose higher and higher only results in more cost and more side effects and may not always result in more benefit.

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In The Diabetes Answer BookI talk a lot about heart disease. The biggest risk to your future life and health if you have diabetes is from heart disease. If you have diabetes it is incredibly important that you do everything...