Blood pressure-lowering treatment for prevention of major cardiovascular diseases in people with and without type 2 diabetes: an individual participant-level data meta-analysis

The prevention and management of chronic kidney disease among patients with metabolic syndrome

Treatment of patients with chronic kidney disease (CKD) requires implementation of prevention and management strategies that reduce the risk of kidney failure and CKD-associated cardiovascular risk. Metabolic syndrome is characterized by obesity, high blood pressure, dyslipidemia, and hyperglycemia, and it is common among patients with CKD. Large-scale randomized trials have led to significant advances in the management of CKD, with 5 pharmacotherapies now proven to be nephroprotective and/or cardioprotective in certain types of patients. Renin-angiotensin system inhibitors and sodium-glucose cotransporter 2 inhibitors slow kidney disease progression and reduce heart failure complications for most patients with CKD. In addition, statin-based regimens reduce low-density lipoprotein cholesterol and lower the risk of atherosclerotic disease (with no clinically meaningful effect on kidney outcomes). For patients with type 2 diabetes and albuminuric CKD, the nonsteroidal mineralocorticoid receptor antagonist finerenone and the glucagon-like peptide-1 receptor agonist semaglutide also confer cardiorenal benefits, with semaglutide additionally effective at reducing weight. Together, these randomized data strongly suggest that metabolic syndrome mediates some of the cardiorenal risk observed in CKD. Considered separately, the trials help elucidate which components of metabolic syndrome influence the pathophysiology of kidney disease progression and which separately modify risk of atherosclerotic and nonatherosclerotic cardiovascular outcomes. As we predict complementary and different mechanisms of nephroprotection and cardioprotection for these different interventions, it seems logical that they should be deployed together to maximize benefits. Even when combined, however, these therapies are not a cure, so further trials remain important to reduce the residual cardiorenal risks associated with CKD.

Mitigating heart failure risk in patients with diabetes and chronic kidney disease

PURPOSE OF REVIEW

Patients with chronic kidney disease and diabetes are at high risk of cardiovascular disease, including heart failure. Risk mitigation requires a comprehensive approach with lifestyle modifications, blood pressure management, renin-angiotensin blockade, and sodium-glucose cotransporter 2 inhibitors. Recent trials have shown that nonsteroidal mineralocorticoid receptor antagonists (ns-MRA) and glucagon-like peptide 1 receptor agonists (GLP-1 RA) should also be components of this approach. This review will discuss the comprehensive approach to mitigating risk in these high-risk patients and highlight the recent trials of ns-MRAs and GLP-1 RA.

RECENT FINDINGS

In recent years, large, randomized controlled trials of ns-MRA and GLP-1 RA have shown benefit in kidney and cardiovascular outcomes for patients with chronic kidney disease and diabetes.

SUMMARY

The substantial benefits and overall favorable safety profiles for ns-MRA and GLP-1 RA in patients with chronic kidney disease and diabetes demonstrate that these medications should be considered as a part of a comprehensive approach to cardiovascular risk reduction in this high-risk population. Future studies should consider different combination therapies and guide how and when to initiate these therapies.

Systolic blood pressure targets below 120 mm Hg are associated with reduced mortality: A meta-analysis

BACKGROUND

The optimal systolic blood pressure (SBP) target in patients with increased cardiovascular risk remains uncertain. This study evaluated the efficacy and safety of intensive SBP control (<120 mm Hg) compared to standard SBP control (<140 mm Hg) in patients with increased cardiovascular risk.

METHODS

We conducted a systematic search of PubMed, Embase, Web of Science, and Cochrane Library for RCTs published from database inception through November 2024 that compared intensive SBP control (<120 mm Hg) with standard SBP control (<140 mm Hg) in adults with high cardiovascular risk. Efficacy outcomes included all-cause mortality, major adverse cardiovascular events (MACE), cardiovascular death, stroke, myocardial infarction (MI), and heart failure. Safety outcomes included hypotension, syncope, arrhythmia, acute kidney injury, and electrolyte abnormalities.

RESULTS

Five RCTs comprising 39,434 patients were included. The all-cause mortality was significantly lower in the intensive SBP control group (672 of 19,712 [3.4%]) compared to the standard SBP control group (778 of 19,722 [3.9%]) (risk ratio 0.87 [95% confidence interval, 0.76-0.99, p = 0.03]). The incidence of MACE, cardiovascular death, MI, stroke, and heart failure was significantly lower in the intensive SBP control group as compared to standard SBP control group. The treatment effect (MACE) was consistent across all subgroups. Conversely, intensive SBP control was associated with an increased risk of hypotension, syncope, arrhythmia, acute kidney injury, and electrolyte abnormalities.

CONCLUSIONS

Targeting intensive SBP control to less than 120 mm Hg was associated with a lower incidence of all-cause mortality and MACE but a higher incidence of adverse events.

Intensive blood pressure-lowering treatment to prevent cardiovascular events in patients with diabetes: a systematic review and meta-analysis

The effect of intensive blood pressure (BP) reduction on the prevention of cardiovascular events in patients with diabetes remains unclear. This study evaluated the impact of intensive BP-lowering on cardiovascular events in patients with diabetes compared to standard treatment. A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted, comparing intensive treatment (target systolic BP < 130 mmHg or diastolic BP < 80 mmHg) with standard treatment in patients with diabetes. Eligible studies were identified through Ovid MEDLINE, Cochrane Library, and Ichushi. Outcomes included cardiovascular events, coronary artery disease, stroke, all-cause and cardiovascular death, and serious adverse events. Data were analyzed using a random-effects model. Sensitivity analyses were performed to assess the effects of systolic and diastolic BP targets separately. The search identified eight eligible trials comprising 16634 patients with diabetes. Intensive BP-lowering treatment significantly reduced cardiovascular events (risk ratio: 0.848; 95% confidence interval: 0.760, 0.947) and stroke (risk ratio: 0.705; 95% confidence interval: 0.541, 0.918), but not coronary artery disease or all-cause death in analyses including J-DOIT3 trial. Sensitivity analyses showed that DBP-targeted treatment was not associated with the risk of cardiovascular events. Incorporating the latest RCT strengthened the association between intensive treatment and reduced coronary artery disease risk, without significantly increasing the risk of serious adverse events. These findings recommend an intensive BP-lowering strategy targeting SBP < 130 mmHg or DBP < 80 mmHg to prevent cardiovascular events, particularly stroke, in patients with diabetes.

Optimizing benefits of intensive SBP control in type 2 diabetes: the crucial role of angiotensin-converting enzyme inhibitors/angiotensin-II type 2 receptor blockers

AIMS

Intensive SBP control reduces major cardiovascular events (MACE) in patients with type 2 diabetes mellitus (T2DM) and hypertension, but no information regarding the preferred antihypertensive regimen could be available. The present study aims to investigate the most effective antihypertensive regimen for reducing MACE in these patients.

METHODS

Participants from the ACCORD BP trial with intensive SBP control were included. Cox proportional hazards models were used to analyze the effects of various antihypertensive regimens on MACE and all-cause mortality. Cost-effectiveness analysis was evaluated using the Markov model. Potential deaths averted were projected based on the referenced data from NHANES cohort.

RESULTS

A total of 2362 patients with T2DM and hypertension were included. ACEI/ARB-based antihypertensive regimen, but not other antihypertensive drugs-based ones, were associated with a reduced risk of MACE, and the protective efficiencies were similar across the whole cohort (standard and intensive glycemia control), intensive SBP control cohort [hazard ratio = 0.558, 95% confidence interval (95% CI): 0.420-0.741], standard glycemia/intensive SBP control cohort (hazard ratio = 0.563, 95% CI: 0.373-0. 850), and propensity score-matched standard glycemia/intensive SBP control cohort (hazard ratio = 0.522, 95% CI: 0.315-0.864). The protections were more prominent in patients with older age, CVD history, baseline SBP at least 140 mmHg, and higher Framingham score. All-cause mortality was also reduced with this regimen. Moreover, it was predicted to increase 2.18 quality-adjusted life years and to produce $29 611.97 net monetary benefit and was projected to prevent 494 742 deaths per year in the USA.

CONCLUSION

In patients with hypertension and T2DM, ACEI/ARB is the mandatory antihypertensive medication if intensive SBP control implemented for better clinical benefits.

The Moderating Effect of Age on the Association Between Circadian Syndrome and Instrumental Activities of Daily Living Disability in People With Diabetes: A Cross-Sectional Study

PURPOSE

To examine the association between circadian syndrome (CircS) and instrumental activities of daily living (IADL) disability in middle-aged and older adults with diabetes, as well as the moderating effect of age on CircS and IADL disability.

METHOD

Participants included 939 individuals with diabetes. IADL disability was defined as having trouble finishing specific tasks. CircS was defined as having four or more specific symptoms. Binary logistic regression analysis was used to examine associations among CircS, age, and IADL disability.

RESULTS

Of total participants, 29.3% had IADL disability. CircS and age were associated with IADL disability (CircS: odds ratio [OR] = 1.898, 95% confidence interval [CI] [1.370, 2.630]; age: OR = 1.045, 95% CI [1.027, 1.063]; both p < 0.001). The interaction effect of age on CircS and IADL disability was significant (OR = 1.047, 95% CI [1.004, 1.092], p = 0.032).

CONCLUSION

Individuals with diabetes and CircS had a higher risk of IADL disability than those without CircS, and the difference in predicted probabilities of IADL disability between the two groups increased with age. [Journal of Gerontological Nursing, 51(4), 37-45.].

Healthy lifestyle factors and combined macrovascular and microvascular events in diabetes patients with high cardiovascular risk: results from ADVANCE

BACKGROUND

To explore whether healthy lifestyle factors (HLFs) predict a lower risk of major macrovascular and microvascular events and death in people with type 2 diabetes (T2D) with a high risk of vascular complications.

METHODS

Post hoc analyses of 11,133 participants with T2D in the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial who were assigned a score ranging from 0 to 4 based on the number of baseline HLFs: never smoked, moderate-to-vigorous physical activity, ideal waist/hip ratio, and low-to-moderate alcohol consumption. Multivariable Cox models were used to determine associations of 0, 1, 2, and ≥ 3 HLFs with vascular events and all-cause mortality.

RESULTS

Compared to participants with no HLFs, hazard ratios for participants with 3 or 4 HLFs were 0.68 (95% confidence interval [CI] 0.57-0.81) for the composite of major macrovascular or microvascular events, 0.58 (0.46-0.75) for major macrovascular events, 0.78 (0.61-0.99) for microvascular events, and 0.48 (0.37-0.63) for all-cause mortality during a median follow-up of 5 years. Each increment in HLF score was significantly associated with lower rates of these outcomes. There was no heterogeneity in the effect on any outcome by HLF across randomized intensive blood glucose control and blood pressure lowering treatments.

CONCLUSIONS

HLFs are associated with lower risks of major macrovascular and microvascular events and lower rates of death in high-risk adults with T2D.

[Elevated blood pressure and hypertension : Focus of the 2024 ESC guidelines on risk reduction]

The 2024 guidelines of the European Society of Cardiology (ESC) for the management of elevated blood pressure and hypertension introduce the new category "elevated blood pressure" (120-139/70-89 mm Hg). All patients with elevated blood pressure are advised to implement lifestyle modifications. The aim is to reduce the cardiovascular risk at an early stage. In addition, a structured assessment should be carried out based on the comorbidities, such as coronary artery disease, heart failure and stroke as well as on risk factors, which can result from an antihypertensive treatment in cases of moderate to high risk and a blood pressure of 130/80 mm Hg or more despite 3 months of lifestyle modifications. For patients with hypertension (≥ 140/90 mm Hg), the guidelines now recommend initiating lifestyle modifications and antihypertensive medication concurrently. The new target systolic blood pressure is 120-129 mm Hg, with establishment of individualized treatment goals in cases of frailty or age ≥85 years. Compared to the guidelines of the European Society of Hypertension (ESH) and the German national guidelines (NVL), the ESC extends the treatment recommendations to patients with elevated blood pressure even below the threshold of 140/90 mm Hg. For resistant hypertension spironolactone is recommended, with renal denervation being an alternative option to increasing the antihypertensive medication.

Prediction model for type 2 diabetes mellitus and its association with mortality using machine learning in three independent cohorts from South Korea, Japan, and the UK: a model development and validation study

Background

Type 2 diabetes mellitus (T2DM) is a significant global public health concern that has steadily increased over the past few decades. Thus, this study aimed to predict the incidence of T2DM within 5 years and the risk of mortality following the onset of T2DM. Data from three independent cohorts worldwide were used.

Methods

We utilized data from three independent, large-scale, general population-based, and worldwide cohort studies. The Korean cohort (NHIS-NSC cohort; discovery cohort; n = 973,303), conducted between 1 January, 2002 and 31 December, 2013, was used for training and internal validation, whereas the Japanese cohort (JMDC cohort; validation cohort A; n = 12,143,715) and UK cohort (UK Biobank; validation cohort B; n = 416,656) were used for external validation. We employed various machine learning (ML)-based models, using 18 features, to predict the incidence of T2DM within five years of regular health checkups and calculated the Shapley Additive Explanation (SHAP) values. To ensure the robustness of our ML-based prediction model, we investigated the potential association between the model probability divided into tertiles and the risk of mortality following the onset of T2DM.

Findings

In the discovery cohort, the ensemble model using voting with logistic regression and adaptive boosting achieved a balanced accuracy of 72.6% and an area under the receiver operating characteristics curve (AUROC) of 0.792. The SHAP value analysis of our proposed model revealed that age was the most important predictor of incident T2DM, followed by fasting blood glucose, hemoglobin, γ-glutamyl transferase level, and body mass index. The model probability is associated with an increased risk of mortality (T1: adjusted hazard ratio, 2.82 [95% CI, 2.01-3.94]; T2: 3.89 [2.74-5.53]; and T3: 7.73 [5.37-11.12]). Similar patterns and trends were observed in the validation cohorts (T1: 1.74 [1.49-2.03], T2: 1.97 [1.69-2.30], and T3: 3.31 [2.82-3.38] in validation cohort A; T1: 1.33 [1.03-1.71], T2: 1.54 [1.21-1.96], and T3: 1.73 [1.36-2.20] in validation cohort B).

Interpretation

This study derived and validated an ML-based model to predict the incidence of T2DM within 5 years across three countries (South Korea, Japan, and the UK), showing that the model probability is associated with an increased risk of mortality.

Funding

Institute of Information & Communications Technology Planning & Evaluation, South Korea.

Combination blood pressure lowering therapy in patients with type 2 diabetes: messages from the ADVANCE trial

The Action in Diabetes and Vascular disease: preterAx and diamicroN Controlled Evaluation (ADVANCE) trial investigated the effects of intensive blood pressure (BP) lowering using a fixed combination of perindopril-indapamide versus placebo in type 2 diabetes (T2D). The study showed that combination perindopril-indapamide had significant benefits in reducing cardiovascular, renal, and mortality events, with consistent relative risk reductions across different patient subgroups. Secondary analyses of ADVANCE have identified novel risk markers in T2D including cessation of BP lowering therapy, absent peripheral pulses and cardiac biomarkers to name a few. ADVANCE also shed light on practical aspects of hypertension management, including the limitations of office BP, tolerability of combination BP lowering therapy across the range of BP levels and the interpretation of changes in serum creatinine after treatment initiation. This review article summarizes the findings of ADVANCE and its subsequent substudies, which have been foundational in our understanding of BP management and the use of combination BP lowering therapy in T2D.

Alterations in platelet activity and endothelial glycocalyx biomarkers by treatment with an angiotensin converting enzyme inhibitor or an alpha-1 adrenoceptor antagonist in patients with hypertension: results from the DoRa study

Drugs blocking the renin-angiotensin-aldosterone system may offer benefit on endothelial function, inflammation, and hemostasis in addition to the effects of reducing blood pressure. We have shown antithrombin effects by treatment with the angiotensin converting enzyme (ACE) inhibitor ramipril. As thrombin is a key inducer of platelet aggregation, we hypothesized that treatment with ramipril could modulate platelet reactivity and endothelial glycocalyx (eGCX) function. This study assessed platelet activity (CD40 ligand and P-selectin) and eGCX markers (E-selectin, hyaluronan, syndecan-1, and thrombomodulin) in 59 individuals with mild-to-moderate hypertension, randomized double-blind to ramipril 10 mg or doxazosin 8 mg od for 12 weeks. Ramipril and doxazosin similarly reduced blood pressure. Antihypertensive treatment reduced CD40 ligand (p < .001) with no interaction (p = .405) by treatment group (reductions by ramipril and doxazosin were 8.7 ± 30.8 ng/L, p = .044, and 13.4 ± 25.5 ng/L, p = .002, respectively). There were no changes in P-selectin by treatment within (p = .556) or between (p = .256) treatment groups. No changes were observed in E-selectin, hyaluronan, syndecan-1, or thrombomodulin by antihypertensive treatment (p = .091-.991), or between ramipril and doxazosin (p = .223-.999). Our results show a potential reduction of platelet activity by ACE inhibitor treatment. Also, the alpha 1-adrenoceptor antagonist doxazosin may reduce platelet activation. Neither drug influenced eGCX markers.

Cardiovascular disease modifies the relationship between systolic blood pressure and outcomes in people with diabetes

OBJECTIVE

We aimed to evaluate the influences of cardiovascular disease (CVD) on the relationship between baseline systolic blood pressure (SBP) and outcomes in community populations with diabetes.

METHODS

This is an observational study of 16,431 community adults with diabetes. The relationship between SBP with major adverse cardiovascular event (MACE) and all-cause death were evaluated using multivariable-adjusted Cox proportional hazard models and restricted cubic spline.

RESULTS

After a median follow-up of 3.4 (IQR 2.6, 4.3) years, 2145 (13.1 %) MACE and 1025 (6.2 %) all-cause death occurred. In participants free of CVD, in reference to SBP < 120 mmHg group, the risks for MACE increased as SBP category (120-129, 130-139, and ≥ 140 mmHg) advanced (P-trend < 0.001), and there was a linear relationship (P-nonlinear = 0.75). The risks for all-cause death were lower in SBP of 120-139 mmHg and 140-159 mmHg groups but higher in SBP ≥ 160 mmHg group, and there was a U-shaped relationship (P-nonlinear < 0.001). In participants with existing CVD the relationship between baseline SBP with MACE and all-cause death did not show any specific pattern.

CONCLUSION

Results of the current study suggest that the relationship between baseline SBP with MACE and all-cause death varied significantly by baseline CVD status.

Blood pressure management in type 2 diabetes: a review of recent evidence

The frequent concurrence of elevated blood pressure (BP) and type 2 diabetes markedly elevates the risk of cardiovascular disease and mortality. In this review, we discuss the evidence supporting the role of BP-lowering therapies in preventing cardiovascular events in people with type 2 diabetes and the most appropriate BP treatment target in these individuals. We outline possible reasons for the heterogeneous effect of BP lowering in patients with and without diabetes and consider several pathophysiological mechanisms that could potentially explain such differences. The review introduces a mediation model, delineating the intricate interplay between hypertension and diabetes and their joint contribution to cardiovascular and renal pathologies. Finally, we outline the role of lifestyle changes and other pharmacological options in attenuating cardiometabolic risks in patients with type 2 diabetes. We propose a comprehensive, patient-centred management strategy, integrating various antihypertensive therapeutic approaches and providing clinicians with a systematic framework for better decision-making.

The association of ideal cardiovascular health and its change with subclinical atherosclerosis according to glucose status: A prospective cohort study

BACKGROUND

An updated definition was developed to better evaluate cardiovascular health (CVH). We aimed to investigate whether optimal or improvement of six CVH metrics defined by new Life's Essential 8 (LE8) may counteract the risk of subclinical atherosclerosis among patients with hyperglycemia.

METHODS

We conducted a prospective analysis of 5225 participants without prior cardiovascular diseases, of whom 4768 had complete data on CVH change. Subjects with CVH scores of 0-49, 50-79, and 80-100 points were categorized as having low, moderate, or high CVH, respectively. Subclinical atherosclerosis was evaluated by brachial-ankle pulse wave velocity, pulse pressure and albuminuria, both separately and in combination.

RESULTS

Of the 5225 participants, 1937 (37.1%) had normal glucose regulation, while 3288 (62.9%) had hyperglycemia. The multivariable-adjusted odds ratio (OR) for composite subclinical atherosclerosis was 2.34 (95% confidence interval [CI], 1.88-2.91), 1.43 (95% CI, 1.21-1.70), and 0.74 (95% CI, 0.46-1.18), for participants with hyperglycemia who had low, moderate, or high overall CVH scores, respectively, compared with participants with normal glucose regulation. In addition, compared with those with stable CVH and normal glucose regulation, participants who exhibited greater improvements in overall CVH from 2010 to 2014 had a reduced risk of composite subclinical atherosclerosis with an OR of 0.72 (95% CI, 0.53-0.98) for those with normal glucose regulation, and 1.13 (95% CI, 0.87-1.48) for those with hyperglycemia.

CONCLUSIONS

The novel defined CVH using six metrics was inversely associated with subsequent risk of subclinical atherosclerosis. Both the status of CVH and its changes modified the relationship between hyperglycemia and subclinical atherosclerosis.

Comprehensive Multiple Risk Factor Control in Type 2 Diabetes to Mitigate Heart Failure Risk: Insights From a Prospective Cohort Study

OBJECTIVE

The impact of comprehensive risk factor control on heart failure (HF) risk and HF-free survival time in individuals with type 2 diabetes (T2D) was evaluated in this study.

RESEARCH DESIGN AND METHODS

This prospective study included 11,949 individuals diagnosed with T2D, matched with 47,796 non-T2D control study participants from the UK Biobank cohort. The degree of comprehensive risk factor control was assessed on the basis of the major cardiovascular risk factors, including blood pressure, BMI, LDL cholesterol, hemoglobin A1c, renal function, smoking, diet, and physical activity. Cox proportional hazards models were used to measure the associations between the degree of risk factor control and HF risk. Irwin's restricted mean was used to evaluate HF-free survival time.

RESULTS

During a median follow-up of 12.3 years, 702 individuals (5.87%) with T2D and 1,402 matched control participants (2.93%) developed HF. Each additional risk factor controlled was associated with an average 19% lower risk of HF. Optimal control of at least six risk factors was associated with a 67% lower HF risk (hazard ratio [HR] 0.33; 95% CI 0.20, 0.54). BMI was the primary attributable risk factor for HF. Notably, the excess risk of HF associated with T2D could be attenuated to levels comparable to those of non-T2D control participants when individuals had a high degree of risk factor control (HR 0.66; 95% CI 0.40, 1.07), and they exhibited a longer HF-free survival time.

CONCLUSIONS

Comprehensive management of risk factors is inversely associated with HF risk, and optimal risk factor control may prolong HF-free survival time among individuals with T2D.

Office measurement vs. ambulatory blood pressure monitoring: associations with mortality in patients with or without diabetes

BACKGROUND AND AIMS

Guidelines suggest similar blood pressure (BP) targets in patients with and without diabetes and recommend ambulatory BP monitoring (ABPM) to diagnose and classify hypertension. It was explored whether different levels of ambulatory and office BP and different hypertension phenotypes associate with differences of risk in diabetes and no diabetes.

METHODS

This analysis assessed outcome data from the Spanish ABPM Registry in 59 124 patients with complete available data. The associations between office, mean, daytime, and nighttime ambulatory BP with the risk in patients with or without diabetes were explored. The effects of diabetes on mortality in different hypertension phenotypes, i.e. sustained hypertension, white-coat hypertension, and masked hypertension, compared with normotension were studied. Analyses were done with Cox regression analyses and adjusted for demographic and clinical confounders.

RESULTS

A total of 59 124 patients were recruited from 223 primary care centres in Spain. The majority had an office systolic BP >140 mmHg (36 700 patients), and 23 128 (40.6%) patients were untreated. Diabetes was diagnosed in 11 391 patients (19.2%). Concomitant cardiovascular (CV) disease was present in 2521 patients (23.1%) with diabetes and 4616 (10.0%) without diabetes. Twenty-four-hour mean, daytime, and nighttime ambulatory BP were associated with increased risk in diabetes and no diabetes, while in office BP, there was no clear association with no differences with and without diabetes. While the relative association of BP to CV death risk was similar in diabetes compared with no diabetes (mean interaction P = .80, daytime interaction P = .97, and nighttime interaction P = .32), increased event rates occurred in diabetes for all ABPM parameters for CV death and all-cause death. White-coat hypertension was not associated with risk for CV death (hazard ratio 0.86; 95% confidence interval 0.72-1.03) and slightly reduced risk for all-cause death in no diabetes (hazard ratio 0.89; confidence interval 0.81-0.98) but without significant interaction between diabetes and no diabetes. Sustained hypertension and masked hypertension in diabetes and no diabetes were associated with even higher risk. There were no significant interactions in hypertensive phenotypes between diabetes and no diabetes and CV death risk (interaction P = .26), while some interaction was present for all-cause death (interaction P = .043) and non-CV death (interaction P = .053).

CONCLUSIONS

Diabetes increased the risk for all-cause death, CV, and non-CV death at every level of office and ambulatory BP. Masked and sustained hypertension confer to the highest risk, while white-coat hypertension appears grossly neutral without interaction of relative risk between diabetes and no diabetes. These results support recommendations of international guidelines for strict BP control and using ABPM for classification and assessment of risk and control of hypertension, particularly in patients with diabetes.

CLINICAL TRIAL REGISTRATION

Not applicable.

Efficacy and safety of semaglutide combined with metformin in treating T2DM with overweight or obesity: a systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy and safety of semaglutide combined with metformin in treating type 2 diabetes mellitus (T2DM) patients who are overweight or obese.

METHODS

We conducted a comprehensive search across multiple databases including Wanfang, CNKI, Chinese Biomedical Literature, VIP, Embase, PubMed, Cochrane Library, and Web of Science. Studies were screened to include randomized controlled trials (RCTs) comparing semaglutide combined with metformin versus metformin alone in T2DM patients with obesity or who are overweight. Primary outcomes included glycemic efficacy and body mass index (BMI). Secondary endpoints included pancreatic function, blood lipids, and incidence of adverse effects. Pooled and sensitivity analyses were performed, and risk of bias was assessed.

RESULTS

Ten studies met the inclusion criteria, all involving oral semaglutide. Compared with placebo, semaglutide with metformin significantly reduced fasting blood glucose (SMD: -0.94; 95% CI: -1.53 to -0.35) and 2-hour postprandial glucose (SMD: -0.97; 95% CI: -1.44 to -1.50; P<0.0001). It also lowered HbA1c levels (SMD: -1.13; 95% CI: -1.85 to -0.42; P<0.001) and BMI (SMD: -1.08; 95% CI: -1.47 to -0.69). Improvements were also noted in HOMA-IR and blood lipid levels. However, there were no significant differences in the incidence of adverse reactions, such as hypoglycemia, gastrointestinal reactions, and dizziness and headache between the two groups (all P>0.05).

CONCLUSION

Treatment with semaglutide combined with metformin significantly improved glycemic control, insulin resistance, weight, BMI, and lipid profiles in patients with T2DM who are overweight or obese.

Lowering systolic blood pressure to less than 120 mm Hg versus less than 140 mm Hg in patients with high cardiovascular risk with and without diabetes or previous stroke: an open-label, blinded-outcome, randomised trial

BACKGROUND

Uncertainty exists about whether lowering systolic blood pressure to less than 120 mm Hg is superior to that of less than 140 mm Hg, particularly in patients with diabetes and patients with previous stroke.

METHODS

In this open-label, blinded-outcome, randomised controlled trial, participants with high cardiovascular risk were enrolled from 116 hospitals or communities in China. We used minimised randomisation to assign participants to intensive treatment targeting standard office systolic blood pressure of less than 120 mm Hg or standard treatment targeting less than 140 mm Hg. The primary outcome was a composite of myocardial infarction, revascularisation, hospitalisation for heart failure, stroke, or death from cardiovascular causes, assessed by the intention-to-treat principle. This trial was registered with ClinicalTrials.gov, NCT04030234.

FINDINGS

Between Sept 17, 2019, and July 13, 2020, 11 255 participants (4359 with diabetes and 3022 with previous stroke) were assigned to intensive treatment (n=5624) or standard treatment (n=5631). Their mean age was 64·6 years (SD 7·1). The mean systolic blood pressure throughout the follow-up (except the first 3 months of titration) was 119·1 mm Hg (SD 11·1) in the intensive treatment group and 134·8 mm Hg (10·5) in the standard treatment group. During a median of 3·4 years of follow-up, the primary outcome event occurred in 547 (9·7%) participants in the intensive treatment group and 623 (11·1%) in the standard treatment group (hazard ratio [HR] 0·88, 95% CI 0·78-0·99; p=0·028). There was no heterogeneity of effects by diabetes status, duration of diabetes, or history of stroke. Serious adverse events of syncope occurred more frequently in the intensive treatment group (24 [0·4%] of 5624) than in standard treatment group (eight [0·1%] of 5631; HR 3·00, 95% CI 1·35-6·68). There was no significant between-group difference in the serious adverse events of hypotension, electrolyte abnormality, injurious fall, or acute kidney injury.

INTERPRETATION

For hypertensive patients at high cardiovascular risk, regardless of the status of diabetes or history of stroke, the treatment strategy of targeting systolic blood pressure of less than 120 mm Hg, as compared with that of less than 140 mm Hg, prevents major vascular events, with minor excess risk.

FUNDING

The Ministry of Science and Technology of China and Fuwai Hospital.

TRANSLATION

For the Mandarin translation of the abstract see Supplementary Materials section.

The benefits of hypoglycemic therapy for patients with obstructive sleep apnea

PURPOSE

Obstructive sleep apnea (OSA) is often associated with glycemic abnormalities. This study is conducted to investigate the effects of hypoglycemic therapy on OSA-related indicators.

METHOD

We systematically searched Web of Science, PubMed, Embase, and the Cochrane Library for articles on OSA patients receiving any hypoglycemic drugs, published until December 25, 2022. Seven original studies were finally included. The proposal was registered with PROSPERO (CRD42022351206).

RESULTS

In summary, in addition to reduced glycosylated hemoglobin A1c (HbA1c), we found that hypoglycemic treatment can lower the apnea-hypopnea index (AHI) by 7.07/h (p = 0.0001). Although long-term treatment (> 12 weeks) achieved a more significant reduction in HbA1c (- 1.57% vs. - 0.30%) compared to short-term treatment (≤ 12 weeks), there was no significant difference between the two in terms of AHI (intergroup p-value = 0.27). We also found that patients using sodium glucose cotransporter 2 inhibitors (SGLT2i) experienced a greater reduction in AHI (- 11.00/h, p < 0.00001). Additionally, hypoglycemic treatment also showed certain improvements in related indicators like Epworth Sleepiness Scale, body mass index, and blood pressure.

CONCLUSIONS

Our results affirm the benefits of hypoglycemic treatment for OSA patients and highlight the notable effect of SGLT2i. Further researches are needed to help doctors gain a comprehensive understanding of the interaction between OSA and glycemic abnormalities.

Differences in the impact of newly diagnosed type 2 diabetes on cardiovascular mortality between normotensive and hypertensive individuals

OBJECTIVE

We investigated the interrelationship between hyperglycemia and hypertension on cardiovascular mortality in the middle-aged and elderly people.

METHODS

In this retrospective cohort study that used data from the Hiroshima Study on Glucose Metabolism and Cardiovascular Diseases, we included 16,564 participants without cardiovascular disease (mean age: 65.8 years; 6179 normoglycemic people, 3017 people with newly diagnosed type 2 diabetes, and 7368 people with prediabetes per the 75-g oral glucose tolerance test). Hypertension was defined as the use of antihypertensive medications and/or having a systolic/diastolic blood pressure of at least 140/90 mm Hg.

RESULTS

During a median follow-up period of 12.4 years, a total of 1513 cardiovascular death occurred. Cardiovascular death rates per 1000 participant-years were 4.01, 4.98, 8.33, 8.22, 8.81, and 11.1 among normotensive participants with normal glycemia, prediabetes, and diabetes and hypertensive participants with normal glycemia, prediabetes, and diabetes, respectively. Prediabetes was significantly associated with a high risk of cardiovascular mortality in normotensive individuals [hazard ratio: 1.24, 95% confidence interval (95% CI): 1.02-1.50] but not in hypertensive individuals. Type 2 diabetes was associated with a high risk of cardiovascular mortality in both normotensive (hazard ratio: 1.94, 95% CI: 1.55-2.43) and hypertensive individuals (hazard ratio: 1.35, 95% CI: 1.13-1.62). Stratified analyses revealed no significant impact of type 2 diabetes on cardiovascular mortality in hypertensive individuals aged at least 65 years.

CONCLUSION

The effect of hyperglycemia on cardiovascular death differed with age and the presence or absence of hypertension, demonstrating the clinical importance of case-specific risk assessments.

Advances in secondary prevention mechanisms of macrovascular complications in type 2 diabetes mellitus patients: a comprehensive review

Type 2 diabetes mellitus (T2DM) poses a significant global health burden. This is particularly due to its macrovascular complications, such as coronary artery disease, peripheral vascular disease, and cerebrovascular disease, which have emerged as leading contributors to morbidity and mortality. This review comprehensively explores the pathophysiological mechanisms underlying these complications, protective strategies, and both existing and emerging secondary preventive measures. Furthermore, we delve into the applications of experimental models and methodologies in foundational research while also highlighting current research limitations and future directions. Specifically, we focus on the literature published post-2020 concerning the secondary prevention of macrovascular complications in patients with T2DM by conducting a targeted review of studies supported by robust evidence to offer a holistic perspective.

Hypertension care cascades and reducing inequities in cardiovascular disease in low- and middle-income countries

Improving hypertension control in low- and middle-income countries has uncertain implications across socioeconomic groups. In this study, we simulated improvements in the hypertension care cascade and evaluated the distributional benefits across wealth quintiles in 44 low- and middle-income countries using individual-level data from nationally representative, cross-sectional surveys. We raised diagnosis (diagnosis scenario) and treatment (treatment scenario) levels for all wealth quintiles to match the best-performing country quintile and estimated the change in 10-year cardiovascular disease (CVD) risk of individuals initiated on treatment. We observed greater health benefits among bottom wealth quintiles in middle-income countries and in countries with larger baseline disparities in hypertension management. Lower-middle-income countries would see the greatest absolute benefits among the bottom quintiles under the treatment scenario (29.1 CVD cases averted per 1,000 people living with hypertension in the bottom quintile (Q1) versus 17.2 in the top quintile (Q5)), and the proportion of total CVD cases averted would be largest among the lowest quintiles in upper-middle-income countries under both diagnosis (32.0% of averted cases in Q1 versus 11.9% in Q5) and treatment (29.7% of averted cases in Q1 versus 14.0% in Q5) scenarios. Targeted improvements in hypertension diagnosis and treatment could substantially reduce socioeconomic-based inequalities in CVD burden in low- and middle-income countries.

The vascular complications of diabetes: a review of their management, pathogenesis, and prevention

INTRODUCTION

This review highlights the pathogenesis of both microvascular and macrovascular complications of diabetes and how these mechanisms influence both the management and preventative strategies of these complications. The cumulative data shown in this review suggest hyperglycemic and blood pressure control remain central to this intricate process.

AREAS COVERED

We reviewed the literature including retrospective, prospective trials as well as meta-analysis, and post hoc analysis of randomized trials on microvascular andmacrovascular complications.

EXPERT OPINION

Further research is needed to explore the ideal intervention targets and preventative strategies needed to prevent macrovascular complications. Furthermore, as the data for trials looking at microvascular complications lengthen more long-term data will further elucidate the role that the duration of diabetes has on these complications. Additionally, trials looking to maximize hyperglycemic control with multiple agents in diabetes, such as metformin, SGL2isand GLP-1 receptor agonists are currently in process, which will have implications for rates of microvascular as well as macrovascular complications.

Long-term effects of ipragliflozin on blood pressure in patients with type 2 diabetes: insights from the randomized PROTECT trial

Although previous reports have shown that sodium-glucose cotransporter-2 (SGLT2) inhibitors have a blood pressure (BP) lowering effect, relevant long-term data is limited. This study aimed to evaluate the effect of the SGLT2 inhibitor ipragliflozin on BP, and associations between BP reduction and changes in cardiometabolic variables in diabetic patients. This was a sub-analysis of the PROTECT trial, a multicenter, randomized, open-label study to assess if ipragliflozin delays carotid atherosclerosis in patients with type 2 diabetes. Participants were randomized to ipragliflozin and control groups. The primary endpoint of the present sub-analysis was the trajectory of systolic BP over 24 months. Correlations between systolic BP changes and cardiometabolic variables were also evaluated. A total of 232 eligible participants with well-balanced baseline characteristics were included in each study group. Throughout the 24-month study period, mean systolic BP was lower in the ipragliflozin group. At 24 months, a between-group difference (ipragliflozin minus control) in mean systolic BP change from baseline was -3.6 mmHg (95% confidence interval, -6.2 to -1.0 mmHg), and the reduction in systolic BP in the ipragliflozin group was consistent across subgroups examined. Changes in systolic BP significantly correlated with those in body mass index in the ipragliflozin group, while no significant correlations with other cardiometabolic variables tested were observed. In conclusion, ipragliflozin treatment was associated with BP reduction throughout the 24-month follow-up period as compared to control treatment. BP reduction correlated with weight loss, which might be one of the mechanisms for the BP lowering effect of SGLT2 inhibitors.

Blood pressure-lowering effects of SGLT2 inhibitors and GLP-1 receptor agonists for preventing of cardiovascular events and death in type 2 diabetes: a systematic review and meta-analysis

AIMS

To investigate the lowering BP effects of sodium glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1 RAs) on the risk of major cardiovascular event stratified by glucose-lowering drugs, baseline BP, glycated hemoglobin (HbA1c), and history of cardiovascular disease in patients with type 2 diabetes.

METHODS

We performed a systematic review of the MEDLINE and EMBASE databases search up to December 31, 2022, (PROSPERO, CRD42023400899) to identify all large-scale cardiovascular outcomes (CVO) trials of SGLT2i and GLP-1 RAs in which more than 1,000 patient-years of follow-up in each randomized group. Outcomes included all-cause mortality, major adverse cardiovascular event (MACE) and its component (cardiovascular death, myocardial infarction [MI], and stroke), heart failure, and renal failure. A random-effects meta-analyses were used to pool the estimates.

RESULTS

Eighteen CVOTs (ten for SGLT2i and eight for GLP-1 RAs) with 127,606 patients with type 2 diabetes were included. Over 2.5 years median follow-up, the average reduction of systolic BP was 2.2 mmHg (mean difference [MD] - 2.2; 95% CI - 2.7 to - 1.7) with more important reduction (Pinteraction = 0.001) with SGLT2 inhibitors (- 2.9; - 3.4 to - 2.5) than with GLP-1 RAs (- 1.4; - 1.8 to - 1). With SGLT2i, every 5-mmHg reduction in systolic BP was associated with a significantly lower risk of mortality (hazard ratio[HR], 0.77; 95% CI 0.65-0.90), MACE (HR 0.81 [0.74-0.89]), cardiovascular death (HR 0.72 [0.59-0.88]), MI (HR 0.82 [0.71-0.95]), heart failure (HR 0.49 [0.42-0.57]), and renal failure (HR 0.46 [0.38-0.55]), while the association was not significant for stroke (HR 0.91 [0.69-1.19]). The corresponding effects for every 5-mmHg reduction in SBP with GLP-1 RAs were 0.65 (0.51-0.84) for all-cause mortality, 0.65 (0.56-0.76) for MACE, 0.62 (0.45-0.85) for CV death, 0.71 (0.52-0.76) for MI, 0.49 (0.35-0.69) for stroke, and 0.49 (0.35-0.66) for renal failure, while the association was not significant for heart failure (HR 0.82 [0.63-1.08]).

CONCLUSION

In patients with type 2 diabetes, the hypotensive effects of SGLT2i and GLP-1 RAs were significantly associated with a reduction in mortality and cardiorenal events. These findings suggest that the lowering BP effect could be seen as an additive indicator of cardiovascular protection by SGLT2i and GLP-1 RAs drugs.

Sex-Specific Effects of Blood Pressure Lowering Pharmacotherapy for the Prevention of Cardiovascular Disease: An Individual Participant-Level Data Meta-Analysis

BACKGROUND

Whether the relative effects of blood pressure (BP)-lowering treatment on cardiovascular outcomes differ by sex, particularly when BP is not substantially elevated, has been uncertain.

METHODS

We conducted an individual participant-level data meta-analysis of randomized controlled trials of pharmacological BP lowering. We pooled the data and categorized participants by sex, systolic BP categories in 10-mm Hg increments from <120 to ≥170 mm Hg, and age categories spanning from <55 to ≥85 years. We used fixed-effect one-stage individual participant-level data meta-analyses and applied Cox proportional hazard models, stratified by trial, to analyze the data.

RESULTS

We included data from 51 randomized controlled trials involving 358 636 (42% women) participants. Over 4.2 years of median follow-up, a 5-mm Hg reduction in systolic BP decreased the risk of major cardiovascular events both in women and men (hazard ratio [95% CI], 0.92 [0.89-0.95] for women and 0.90 [0.88-0.93] for men; P for interaction, 1). There was no evidence for heterogeneity of relative treatment effects by sex for the major cardiovascular disease, its components, or across the different baseline BP categories (all P for interaction, ≥0.57). The effects in women and men were consistent across age categories and the types of antihypertensive medications (all P for interaction, ≥0.14).

CONCLUSIONS

The effects of BP reduction were similar in women and men across all BP and age categories at randomization and with no evidence to suggest that drug classes had differing effects by sex. This study does not substantiate sex-based differences in BP-lowering treatment.

Unsupervised cluster analysis of clinical and metabolite characteristics in patients with chronic complications of T2DM: an observational study of real data

Introduction

The aim of this study was to cluster patients with chronic complications of type 2 diabetes mellitus (T2DM) by cluster analysis in Dalian, China, and examine the variance in risk of different chronic complications and metabolic levels among the various subclusters.

Methods

2267 hospitalized patients were included in the K-means cluster analysis based on 11 variables [Body Mass Index (BMI), Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Glucose, Triglycerides (TG), Total Cholesterol (TC), Uric Acid (UA), microalbuminuria (mAlb), Insulin, Insulin Sensitivity Index (ISI) and Homa Insulin-Resistance (Homa-IR)]. The risk of various chronic complications of T2DM in different subclusters was analyzed by multivariate logistic regression, and the Kruskal-Wallis H test and the Nemenyi test examined the differences in metabolites among different subclusters.

Results

Four subclusters were identified by clustering analysis, and each subcluster had significant features and was labeled with a different level of risk. Cluster 1 contained 1112 inpatients (49.05%), labeled as "Low-Risk"; cluster 2 included 859 (37.89%) inpatients, the label characteristics as "Medium-Low-Risk"; cluster 3 included 134 (5.91%) inpatients, labeled "Medium-Risk"; cluster 4 included 162 (7.15%) inpatients, and the label feature was "High-Risk". Additionally, in different subclusters, the proportion of patients with multiple chronic complications was different, and the risk of the same chronic complication also had significant differences. Compared to the "Low-Risk" cluster, the other three clusters exhibit a higher risk of microangiopathy. After additional adjustment for 20 covariates, the odds ratios (ORs) and 95% confidence intervals (95%CI) of the "Medium-Low-Risk" cluster, the "Medium-Risk" cluster, and the"High-Risk" cluster are 1.369 (1.042, 1.799), 2.188 (1.496, 3.201), and 9.644 (5.851, 15.896) (all p<0.05). Representatively, the "High-Risk" cluster had the highest risk of DN [OR (95%CI): 11.510(7.139,18.557), (p<0.05)] and DR [OR (95%CI): 3.917(2.526,6.075), (p<0.05)] after 20 variables adjusted. Four metabolites with statistically significant distribution differences when compared with other subclusters [Threonine (Thr), Tyrosine (Tyr), Glutaryl carnitine (C5DC), and Butyryl carnitine (C4)].

Conclusion

Patients with chronic complications of T2DM had significant clustering characteristics, and the risk of target organ damage in different subclusters was significantly different, as were the levels of metabolites. Which may become a new idea for the prevention and treatment of chronic complications of T2DM.

Sex-specific risks for cardiovascular disease across the glycaemic spectrum: a population-based cohort study using the UK Biobank

Background

We sought to examine sex-specific risks for incident cardiovascular disease (CVD) across the full glycaemic spectrum.

Methods

Using data from UK Biobank, we categorised participants' glycated haemoglobin (HbA1c) at baseline as low-normal (<35 mmol/mol), normal (35-41 mmol/mol), pre-diabetes (42-47 mmol/mol), undiagnosed diabetes (≥48 mmol/mol), or diagnosed diabetes. Our outcomes were coronary artery disease (CAD), atrial fibrillation, deep vein thrombosis (DVT), pulmonary embolism (PE), stroke, heart failure, and a composite outcome of any CVD. Cox regression estimated sex-specific associations between HbA1c and each outcome, sequentially adjusting for socio-demographic, lifestyle, and clinical characteristics.

Findings

Among 427,435 people, CVD rates were 16.9 and 9.1 events/1000 person-years for men and women, respectively. Both men and women with pre-diabetes, undiagnosed diabetes, and, more markedly, diagnosed diabetes were at higher risks of CVD than those with normal HbA1c, with relative increases more pronounced in women than men. Age-adjusted HRs for pre-diabetes and undiagnosed diabetes ranged from 1.30 to 1.47; HRs for diagnosed diabetes were 1.55 (1.49-1.61) in men and 2.00 (1.89-2.12) in women (p-interaction <0.0001). Excess risks attenuated and were more similar between men and women after adjusting for clinical and lifestyle factors particularly obesity and antihypertensive or statin use (fully adjusted HRs for diagnosed diabetes: 1.06 [1.02-1.11] and 1.17 [1.10-1.24], respectively).

Interpretation

Excess risks in men and women were largely explained by modifiable factors, and could be ameliorated by attention to weight reduction strategies and greater use of antihypertensive and statin medications. Addressing these risk factors could reduce sex disparities in risk of CVD among people with and without diabetes.

Funding

Diabetes UK (#15/0005250) and British Heart Foundation (SP/16/6/32726).

Recent understandings about hypertension management in type 2 diabetes: What are the roles of SGLT2 inhibitor, GLP-1 receptor agonist, and finerenone?

Diabetes and hypertension often coexist, with about half of patients with diabetes also having hypertension. The risk of cardiovascular disease increases by three to six-fold with the coexistence of diabetes and hypertension; therefore, the management of blood pressure to prevent cardiovascular disease is a particularly important issue in patients with diabetes. Clinical trial findings have resulted in recommendations to control blood pressure to <130/80 mmHg in Japanese patients with diabetes. However, the target blood pressure and selection of anti-hypertensive medications should vary depending on the duration of diabetes and comorbidities, and guidelines and clinical trial results should be interpreted flexibly to provide anti-hypertensive treatment tailored to individual patients. In recent years, a number of drugs have emerged that have significant cardio-renal protective effects in patients with diabetes, and a typical example is sodium-glucose cotransporter 2 inhibitor (SGLT2i), glucagon-like peptide-1 receptor agonist (GLP-1RA), and nonsteroidal mineralocorticoid receptor antagonist, finerenone. They have also shown modest but significant blood pressure-lowering effects. In the future, beyond considering the thresholds for how far to lower blood pressure, blood pressure management in patients with diabetes will require understanding the additive cardioprotective value of drugs aimed at lowering blood pressure and the quality of blood pressure lowering. Clinical questions of blood pressure lowering in patients with diabetes GLP-1RA, glucagon-like peptide-1 receptor agonist; SGLT2i, sodium-glucose cotransporter 2 inhibitor.

The Influence of baseline glycemic status on the effects of intensive blood pressure lowering: Results from the STEP randomized trial

BACKGROUND

Intensive systolic blood pressure (SBP) lowering showed cardiovascular benefits in the Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients (STEP) trial. We investigated whether baseline glycemic status influences the effects of intensive SBP lowering on cardiovascular outcomes.

METHODS

In this post hoc analysis of the STEP trial, participants were randomly assigned to receive intensive (110 to <130 mmHg) or standard SBP treatment (130 to <150 mmHg) and categorized by baseline glycemic status into three subgroups: normoglycemia, prediabetes, and diabetes. The primary outcome was a composite of stroke, acute coronary syndrome, acute decompensated heart failure, coronary revascularization, atrial fibrillation, or death from cardiovascular causes. A competing risk proportional hazards regression model was used in the analysis.

RESULTS

Of the 8,318 participants, 3,275, 2,769, and 2,274 had normoglycemia, prediabetes, and diabetes, respectively. Over a median follow-up of 3.33 years, intensive SBP lowering significantly reduced the risk of the primary outcome (adjusted hazard ratio 0.73, 95% confidence interval [CI] 0.59-0.91). The adjusted hazard ratios for the primary outcome in the normoglycemia, prediabetes, and diabetes subgroups were 0.72 (95% CI 0.49-1.04), 0.69 (95% CI 0.46-1.02), and 0.80 (95% CI 0.56-1.15), respectively. The intensive SBP lowering strategy resulted in similar effects among participants in the three subgroups (all interaction P >0.05). The sensitivity analyses showed consistent results with the main analysis.

CONCLUSION

The effects of intensive SBP lowering on cardiovascular outcomes were consistent among participants with normoglycemia, prediabetes, and diabetes.

Identification of a Common Variant for Coronary Heart Disease at PDE1A Contributes to Individualized Treatment Goals and Risk Stratification of Cardiovascular Complications in Chinese Patients With Type 2 Diabetes

OBJECTIVE

In this study we aim to unravel genetic determinants of coronary heart disease (CHD) in type 2 diabetes (T2D) and explore their applications.

RESEARCH DESIGN AND METHODS

We performed a two-stage genome-wide association study for CHD in Chinese patients with T2D (3,596 case and 8,898 control subjects), followed by replications in European patients with T2D (764 case and 4,276 control subjects) and general populations (n = 51,442-547,261). Each identified variant was examined for its association with a wide range of phenotypes and its interactions with glycemic, blood pressure (BP), and lipid controls in incident cardiovascular diseases.

RESULTS

We identified a novel variant (rs10171703) for CHD (odds ratio 1.21 [95% CI 1.13-1.30]; P = 2.4 × 10-8) and BP (β ± SE 0.130 ± 0.017; P = 4.1 × 10-14) at PDE1A in Chinese T2D patients but found only a modest association with CHD in general populations. This variant modulated the effects of BP goal attainment (130/80 mmHg) on CHD (Pinteraction = 0.0155) and myocardial infarction (MI) (Pinteraction = 5.1 × 10-4). Patients with CC genotype of rs10171703 had >40% reduction in either cardiovascular events in response to BP control (2.9 × 10-8 < P < 3.6 × 10-5), those with CT genotype had no difference (0.0726 < P < 0.2614), and those with TT genotype had a threefold increase in MI risk (P = 6.7 × 10-3).

CONCLUSIONS

We discovered a novel CHD- and BP-related variant at PDE1A that interacted with BP goal attainment with divergent effects on CHD risk in Chinese patients with T2D. Incorporating this information may facilitate individualized treatment strategies for precision care in diabetes, only when our findings are validated.

Systolic Blood Pressure and Cardiovascular Risk in Patients With Diabetes: A Prospective Cohort Study

BACKGROUND

Whether the association between systolic blood pressure (SBP) and risk of cardiovascular disease is monotonic or whether there is a nadir of optimal blood pressure remains controversial. We investigated the association between SBP and cardiovascular events in patients with diabetes across the full spectrum of SBP.

METHODS

A cohort of 49 000 individuals with diabetes aged 50 to 90 years between 1990 and 2005 was identified from linked electronic health records in the United Kingdom. Associations between SBP and cardiovascular outcomes (ischemic heart disease, heart failure, stroke, and cardiovascular death) were analyzed using a deep learning approach.

RESULTS

Over a median follow-up of 7.3 years, 16 378 cardiovascular events were observed. The relationship between SBP and cardiovascular events followed a monotonic pattern, with the group with the lowest baseline SBP of <120 mm Hg exhibiting the lowest risk of cardiovascular events. In comparison to the reference group with the lowest SBP (<120 mm Hg), the adjusted risk ratio for cardiovascular disease was 1.03 (95% CI, 0.97-1.10) for SBP between 120 and 129 mm Hg, 1.05 (0.99-1.11) for SBP between 130 and 139 mm Hg, 1.08 (1.01-1.15) for SBP between 140 and 149 mm Hg, 1.12 (1.03-1.20) for SBP between 150 and 159 mm Hg, and 1.19 (1.09-1.28) for SBP ≥160 mm Hg.

CONCLUSIONS

Using deep learning modeling, we found a monotonic relationship between SBP and risk of cardiovascular outcomes in patients with diabetes, without evidence of a J-shaped relationship.

Long-term outcomes after catheter-based renal artery denervation for resistant hypertension: final follow-up of the randomised SYMPLICITY HTN-3 Trial

BACKGROUND

The SYMPLICITY HTN-3 (Renal Denervation in Patients With Uncontrolled Hypertension) trial showed the safety but not efficacy of the Symplicity system (Medtronic, Santa Rosa, CA, USA) at 6 months follow-up in patients with treatment-resistant hypertension. This final report presents the 36-month follow-up results.

METHODS

SYMPLICITY HTN-3 was a single-blind, multicentre, sham-controlled, randomised clinical trial, done in 88 centres in the USA. Adults aged 18-80 years, with treatment-resistant hypertension on stable, maximally tolerated doses of three or more drugs including a diuretic, who had a seated office systolic blood pressure of 160 mm Hg or more and 24 h ambulatory systolic blood pressure of 135 mm Hg or more were randomly assigned (2:1) to receive renal artery denervation using the single electrode (Flex) catheter or a sham control. The original primary endpoint was the change in office systolic blood pressure from baseline to 6 months for the renal artery denervation group compared with the sham control group. Patients were unmasked after the primary endpoint assessment at 6 months, at which point eligible patients in the sham control group who met the inclusion criteria (office blood pressure ≥160 mm Hg, 24 h ambulatory systolic blood pressure ≥135 mm Hg, and still prescribed three or more antihypertensive medications) could cross over to receive renal artery denervation. Changes in blood pressure up to 36 months were analysed in patients in the original renal artery denervation group and sham control group, including those who underwent renal artery denervation after 6 months (crossover group) and those who did not (non-crossover group). For comparisons between the renal artery denervation and sham control groups, follow-up blood pressure values were imputed for patients in the crossover group using their most recent pre-crossover masked blood pressure value. We report long-term blood pressure changes in renal artery denervation and sham control groups, and investigate blood pressure control in both groups using time in therapeutic blood pressure range analysis. The primary safety endpoint was the incidence of all-cause mortality, end stage renal disease, significant embolic event, renal artery perforation or dissection requiring intervention, vascular complications, hospitalisation for hypertensive crisis unrelated to non-adherence to medications, or new renal artery stenosis of more than 70% within 6 months. The trial is registered with ClinicalTrials.gov, NCT01418261.

FINDINGS

From Sep 29, 2011, to May 6, 2013, 1442 patients were screened, of whom 535 (37%; 210 [39%] women and 325 [61%] men; mean age 57·9 years [SD 10·7]) were randomly assigned: 364 (68%) patients received renal artery denervation (mean age 57·9 years [10·4]) and 171 (32%) received the sham control (mean age 56·2 years [11·2]). 36-month follow-up data were available for 219 patients (original renal artery denervation group), 63 patients (crossover group), and 33 patients (non-crossover group). At 36 months, the change in office systolic blood pressure was -26·4 mm Hg (SD 25·9) in the renal artery denervation group and -5·7 mm Hg (24·4) in the sham control group (adjusted treatment difference -22·1 mm Hg [95% CI -27·2 to -17·0]; p≤0·0001). The change in 24 h ambulatory systolic blood pressure at 36 months was -15·6 mm Hg (SD 20·8) in the renal artery denervation group and -0·3 mm Hg (15·1) in the sham control group (adjusted treatment difference -16·5 mm Hg [95% CI -20·5 to -12·5]; p≤0·0001). Without imputation, the renal artery denervation group spent a significantly longer time in therapeutic blood pressure range (ie, better blood pressure control) than patients in the sham control group (18% [SD 25·0] for the renal artery denervation group vs 9% [SD 18·8] for the sham control group; p≤0·0001) despite a similar medication burden, with consistent and significant results with imputation. Rates of adverse events were similar across treatment groups, with no evidence of late-emerging complications from renal artery denervation. The rate of the composite safety endpoint to 48 months, including all-cause death, new-onset end-stage renal disease, significant embolic event resulting in end-organ damage, vascular complication, renal artery re-intervention, and hypertensive emergency was 15% (54 of 352 patients) for the renal artery denervation group, 14% (13 of 96 patients) for the crossover group, and 14% (10 of 69 patients) for the non-crossover group.

INTERPRETATION

This final report of the SYMPLICITY HTN-3 trial adds to the totality of evidence supporting the safety of renal artery denervation to 36 months after the procedure. From 12 months to 36 months after the procedure, patients who were originally randomly assigned to receive renal artery denervation had larger reductions in blood pressure and better blood pressure control compared with patients who received sham control.

FUNDING

Medtronic.