Intensive Blood Pressure (BP) Lowering in Diabetes: Key Findings from the BPROAD Trial

Lowering systolic blood pressure (BP) below 120 mm Hg significantly reduces the risk of major cardiovascular (CV) events in patients with type 2 diabetes and hypertension over four years. This finding is based on the BPROAD trial, which builds upon data from the SPRINT trial, extending its implications to diabetic patients.

The 2015 SPRINT trial, which excluded diabetic patients, influenced the 2017 US hypertension guidelines to recommend treatment goals below 130/80 mm Hg. Similarly, the latest European guidelines have adopted systolic BP targets below 130 mm Hg for patients at high cardiovascular risk.

In contrast, the 2010 ACCORD trial failed to demonstrate CV benefits from intensive BP control in diabetics, possibly due to its dual focus on lipid and BP management. The BPROAD trial clarifies these discrepancies, showing that diabetic patients benefit from intensive BP lowering, akin to non-diabetics.

Study Design and Results

The BPROAD trial enrolled 12,821 Chinese patients with type 2 diabetes and hypertension between 2019 and 2021. Participants were randomized to either intensive BP control (<120 mm Hg) or standard BP control (<140 mm Hg).

After one year, the average systolic BP dropped to 121.6 mm Hg in the intensive group and 133.2 mm Hg in the standard group. Over a median follow-up of 4.2 years, the primary endpoint—a composite of nonfatal stroke, nonfatal MI, treated heart failure, or CV death—was lower in the intensive group (HR 0.79, 95% CI 0.69-0.90). The benefits were largely driven by reductions in stroke rates.

Adverse Events and Monitoring

While adverse events like symptomatic hypotension (0.1% vs <0.1%, p=0.05) and hyperkalemia (2.8% vs 2.0%, p=0.003) were slightly higher in the intensive group, the overall rate of serious events was similar across groups (~36%). Notably, intensive BP control also reduced the incidence of albuminuria, indicating better kidney outcomes.

Researchers emphasize the need for careful monitoring during intensive BP treatment, particularly for hypotension and hyperkalemia.

Broader Implications

The BPROAD trial reinforces the importance of intensive BP control for diabetic patients, addressing a critical knowledge gap. Although some differences in outcomes between the BPROAD and SPRINT trials may reflect population diversity, the consistency in benefits is evident.

Experts argue that intensive BP lowering provides significant CV protection, and the risks of hypotension or hyperkalemia are manageable compared to the potential benefits of reduced stroke and CV mortality.

Take-Home Points

1. Intensive systolic BP control (<120 mm Hg) reduces major CV events in patients with diabetes and hypertension.
2. The findings align with broader BP guidelines and address limitations of earlier studies like ACCORD.
3. Intensive BP control lowers the risk of stroke and albuminuria but requires monitoring for hypotension and hyperkalemia.
4. These results highlight the importance of global implementation of intensive BP strategies for diabetic patients at CV risk.

By filling a critical gap, the BPROAD trial confirms the value of aggressive BP management in diabetes, encouraging its application worldwide.