Tight Blood Pressure Control in Chronic Kidney Disease

Hypertension affects over a billion people worldwide and is the leading cause of cardiovascular disease and premature death worldwide, as well as one of the key determinants of chronic kidney disease worldwide. People with chronic kidney disease and hypertension are at very high risk of renal outcomes, including progression to end-stage renal disease, and, even more importantly, cardiovascular outcomes. Hence, blood pressure control is crucial in reducing the human and socio-economic burden of renal and cardiovascular outcomes in those patients. However, current guidelines from hypertension and renal societies have issued different and sometimes conflicting recommendations, which risk confusing clinicians and potentially contributing to a less effective prevention of renal and cardiovascular outcomes. In this review, we critically appraise existing evidence and key international guidelines, and we finally formulate our own opinion that clinicians should aim for a blood pressure target lower than 130/80 in all patients with chronic kidney disease and hypertension, unless they are frail or with multiple comorbidities. We also advocate for an even more ambitious systolic blood pressure target lower than 120 mmHg in younger patients with a lower burden of comorbidities, to minimise their risk of renal and cardiovascular events during their lifetime.

Intensive blood pressure control in obese diabetic patients: clinical relevance of stroke prevention in the ACCORD trial

In the ACCORD clinical trial, lowering blood pressure (BP) to normal levels, below currently recommended levels, did not significantly reduce the combined risk of fatal or nonfatal cardiovascular (CV) disease events in adults with Type 2 diabetes. A new post hoc analysis of the same trial also suggests that lowering BP in centrally obese diabetic patients is not a useful means for CV prevention. The authors discuss these findings in the light of accumulated evidence on the relationship between the degree of BP reduction and the risk of CV events in patients with diabetes. In particular, the authors focus on trial and systematic review findings, suggesting that a more intensive reduction of BP in Type 2 diabetes effectively protects from stroke.

Tight blood pressure control in diabetes: evidence-based review of treatment targets in patients with diabetes

Blood pressure (BP) targets in diabetic patients stills represent the object of a major debate, fueled by the recent publication of post hoc observational analyses of the INVEST and the ONTARGET trials, suggesting an increased risk of cardiovascular events with tighter control, the J-curve effect, and by the results of the ACCORD trial, showing no improvements in the composite primary outcome of nonfatal myocardial infarction, stroke, or cardiovascular death in the intensive BP-lowering arm (<120/80 mmHg). In the present review, we focus on existing evidence about different BP targets in diabetic subjects and we present the results of our recent meta-analysis, showing that tight BP control may significantly reduce the risk of stroke in these patients without increasing the risk of myocardial infarction. Therapeutic inertia (leaving diabetic patients with BP values of 140/90 mmHg or higher) should be avoided at all costs, as this would lead to an unacceptable toll in terms of human lives, suffering, and socioeconomic costs.