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Abstract: There is overwhelming evidence that hypertension is an important risk factor for both macrovascular and microvascular complications in patients with diabetes, but the problem remains to identify appropriate goals for preventive therapies. A number of guidelines (the European Society of Cardiology (ESC)/European Association for the Study of diabetes (EASD) 2007, the Joint National Committee (JNC)-VII 2003, the American diabetes Association (ADA) 2011) have for example advocated a blood pressure goal of less than 130/80 mmHg, but this suggestion has been challenged by findings in recent trials and meta-analyses (2011). The European Society of hypertension (ESH) therefore recommends a systolic blood pressure goal of “well below” 140 mmHg. Based on evidence from both randomized controlled trials (hypertension optimal treatment (HOT), action in diabetes and vascular disease: preterax and diamicron MR controlled evaluation (ADVANCE), action to control cardiovascular risk in diabetes (ACCORD)) and observational studies (ongoing telmisartan alone and in combination with ramipril global endpoint trial (ONTARGET), international verapamil-trandolapril study (INVEST), treat to new targets (TNT), and the National diabetes Register (NDR)), it has been shown that the benefit for stroke reduction remains even at lower achieved blood pressure levels, but the risk of coronary events may be uninfluenced or even increased at lower systolic blood pressure levels. In a recent meta-analysis, it was therefore concluded that the new recommended goal should be 130–135 mmHg systolic blood pressure for most patients with type 2 diabetes. Other risk factors should also be controlled with a more ambitious strategy applied in the younger patients with shorter diabetes duration, but a more cautious approach in the elderly and frail patients with a number of vascular or non-vascular co-morbidities. In patients from East Asia, such as China, the stroke risk is relatively higher than the risk of coronary events. This must also be taken into consideration for individualized goal setting in relation to total risk, for example in patients from stroke-prone families. In conclusion, the current strategy is to have a more individualized approach to risk factor control in patients with type 2 diabetes, also relevant for blood pressure control.

[1]Adler, A.I., Stratton, I.M., Neil, H.A., Yudkin, J.S., Matthews, D.R., Cull, C.A., Wright, A.D., Turner, R.C., Holman, R.R., 2000. Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): prospective observational study. BMJ, 321(7258):412-419.

[2]ADVANCE Collaborative Group, 2007. Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomised controlled trial. Lancet, 370(9590):829-840.

[3]American Diabetes Association, 2011. Standards of medical care in diabetes—2011. Diabetes Care, 34(Suppl. 1):S11-S61.

[4]Anderson, R.J., Bahn, G.D., Moritz, T.E., Kaufman, D., Abraira, C., Duckworth, W., for the VADT Study Group, 2011. Blood pressure and cardiovascular disease risk in the Veterans Affairs Diabetes Trial. Diabetes Care, 34(1):34-38.

[5]Bangalore, S., Messerli, F.H., Wun, C.C., Zuckerman, A.L., DeMicco, D., Kostis, J.B., LaRosa, J.C., for the Treating to New Targets Steering Committee and Investigators, 2009. J-curve revisited: an analysis of the Treating to New Targets (TNT) trial. J. Am. Coll. Cardiol., 53:A217.

[6]Bangalore, S., Messerli, F.H., Wun, C.C., Zuckerman, A.L., DeMicco, D., Kostis, J.B., LaRosa, J.C., for the Treating to New Targets Steering Committee and Investigators, 2010. J-curve revisited: an analysis of blood pressure and cardiovascular events in the Treating to New Targets (TNT) trial. Eur. Heart J., 31(23):2897-2908.

[7]Bangalore, S., Kumar, S., Lobach, I., Messerli, F.H., 2011. Blood pressure targets in subjects with type 2 diabetes mellitus/impaired fasting glucose: observations from traditional and bayesian random-effects meta-analyses of randomized trials. Circulation, 123(24):2799-2810.

[8]Buse, J.B., Ginsberg, H.N., Bakris, G.L., Clark, N.G., Costa, F., Eckel, R., Fonseca, V., Gerstein, H.C., Grundy, S., Nesto, R.W., et al., 2007. Primary prevention of cardiovascular diseases in people with diabetes mellitus: a scientific statement from the American Heart Association and the American Diabetes Association. Circulation, 115(1):114-126.

[9]Cederholm, J., Nilsson, P.M., Eliasson, B., Eeg-Olofsson, K., Zethelius, B., Gudbjörnsdottir, S., 2009a. Connections between risk factors and complications in diabetes. A report after 13 years with the National Diabetes Registry (NDR). Lakartidningen, 106:2684-2689 (in Swedish).

[10]Cederholm, J., Zethelius, B., Nilsson, P.M., Eeg-Olofsson, K., Eliasson, B., Gudbjörnsdottir, S., 2009b. Effect of tight control of HbA1c and blood pressure on cardiovascular diseases in type 2 diabetes: an observational study from the Swedish National Diabetes Register (NDR). Diab. Res. Clin. Pract., 86(1):74-81.

[11]Cederholm, J., Gudbjörnsdottir, S., Eliasson, B., Zethelius, B., Eeg-Olofsson, K., Nilsson, P.M., 2010. Systolic blood pressure and risk of cardiovascular diseases in type 2 diabetes: an observational study from the Swedish National Diabetes Register. J. Hypertens., 28(10):2026-2035.

[12]Cooper-Dehoff, R.M., Gong, Y., Handberg, E.M., Bavry, A.A., Denardo, S.J., Bakris, G.L., Pepine, C.J., 2010. Tight blood pressure control and cardiovascular outcomes among hypertensive patients with diabetes and coronary artery disease. JAMA, 304(1):61-68.

[13]Edelman, D., Fredrickson, S.K., Melnyk, S.D., Coffman, C.J., Jeffreys, A.S., Datta, S., Jackson, G.L., Harris, A.C., Hamilton, N.S., Stewart, H., et al., 2010. Medical clinics versus usual care for patients with both diabetes and hypertension: a randomized trial. Ann. Intern. Med., 152(11):689-696.

[14]Eeg-Olofsson, K., Cederholm, J., Nilsson, P.M., Gudbjörnsdottir, S., Eliasson, B., for the Steering Committee of the Swedish National Diabetes Register, 2007. Glycemic and risk factor control in type 1 diabetes. results from 13612 patients in a national diabetes register. Diabetes Care, 30(3):496-502.

[15]Eeg-Olofsson, K., Cederholm, J., Nilsson, P.M., Zethelius, B., Svensson, A.M., Gudbjörnsdottir, S., Eliasson, B., 2010a. Glycemic control and cardiovascular disease in 7454 patients with type 1 diabetes. An observational study from the Swedish National Diabetes Register. Diabetes Care, 33(7):1640-1646.

[16]Eeg-Olofsson, K., Cederholm, J., Nilsson, P.M., Zethelius, B., Svensson, A.M., Gudbjörnsdottir, S., Eliasson, B., 2010b. New aspects of HbA1c as a risk factor for cardiovascular diseases in type 2 diabetes: an observational study from the Swedish National Diabetes Register (NDR). J. Intern. Med., 268(5):471-482.

[17]Franklin, S.S., 2010. Isolated systolic hypertension and the J-curve of cardiovascular disease risk. Artery Res., 4(1):1-6.

[18]Gæde, P., Vedel, P., Larsen, N., Jensen, G.V., Parving, H.H., Perdersen, O., 2003. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N. Engl. J. Med., 348(5):383-393.

[19]Gerstein, H.C., Miller, M.E., Byington, R.P., Goff, D.C.Jr., Bigger, J.T., Buse, J.B., Cushman, W.C., Genuth, S., Probstfield, J.L., Simons-Morton, D.G., et al., 2008. Effects of intensive glucose lowering in type 2 diabetes. N. Engl. J. Med., 358(24):2545-2559.

[20]Grossman, E., Messerli, F.H., 2011. Management of blood pressure in patients with diabetes. Am. J. Hypertens. [Epub ahead of print].

[21]Hanefeld, M., Fischer, S., Julius, U., Schulze, J., Schwanebeck, U., Schmechel, H., Ziegelasch, H.J., Lindner, J., the DIS Group, 1996. Risk factors for myocardial infarction and death in newly detected NIDDM: the diabetes intervention study, 11-year follow-up. Diabetologia, 39(12):1577-1583.

[22]Hansson, L., Zanchetti, A., Carruthers, S.G., Dahlof, B., Elmfeldt, D., Julius, S., Ménard, J., Rahn, K.H., Wedel, H., Westerling, S., 1998. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the hypertension optimal treatment (HOT) randomised trial. Lancet, 351(9118):1755-1762.

[23]Heart Outcomes Prevention Evaluation (HOPE) Study Investigators, 2000. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Lancet, 355(9200):253-259.

[24]Jamerson, K., Weber, M.A., Bakris, G.L., Dahlof, B., Pitt, B., Shi, V., Hester, A., Gupte, J., Gatlin, M., Velazquez, E.J., ACCOMPLISH Trial Investigators, 2008. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. N. Engl. J. Med., 359(23):2417-2428.

[25]Kelly, T.N., Bazzano, L.A., Fonseca, V.A., Thethi, T.K., Reynolds, K., He, J., 2009. Glucose control and cardiovascular disease in type 2 diabetes. Ann. Intern. Med., 151(6):394-403.

[26]Mancia, G., de Backer, G., Dominiczak, A., Cifkova, R., Fagard, R., Germano, G., Grassi, G., Heagerty, A., Kjeldsen, S.E., Laurent, S., et al., 2007. 2007 guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J. Hypertens., 25(6):1105-1187.

[27]Mancia, G., Laurent, S., Agabiti-Rosei, E., Ambrosioni, E., Burnier, M., Caulfield, M.J., Cifkova, R., Clément, D., Coca, A., Dominiczak, A., et al., 2009. Reappraisal of European guidelines on hypertension management: a European Society of Hypertension Task Force document. J. Hypertens., 27(11):2121-2158.

[28]Mannucci, E., Monami, M., Lamanna, C., Gori, F., Marchionni, N., 2009. Prevention of cardiovascular disease through glycemic control in type 2 diabetes: a meta-analysis of randomized clinical trials. Nutr. Metab. Cardiovasc. Dis., 19(9):604-612.

[29]Messerli, F.H., Mancia, G., Conti, C.R., Hewkin, A.C., Kupfer, S., Champion, A., Kolloch, R., Benetos, A., Pepine, C.J., 2006. Dogma disputed: can aggressively lowering blood pressure in hypertensive patients with coronary artery disease be dangerous? Ann. Intern. Med., 144(12):884-893.

[30]Nathan, D.M., Cleary, P.A., Backlund, J.Y., Genuth, S.M., Lachin, J.M., Orchard, T.J., Raskin, P., Zinman, B., 2005. Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N. Engl. J. Med., 353(25):2643-2653.

[31]Nilsson, P.M., 2010. ACCORD and risk-factor control in type 2 diabetes. N. Engl. J. Med., 362(17):1628-1630.

[32]Nilsson, P.M., Cederholm, J., 2011. Diabetes, hypertension, and outcome studies: overview 2010. Diabetes Care, 34(Suppl. 2):S109-S113.

[33]Nilsson, P.M., Cederholm, J., Eliasson, B., Eeg-Olofsson, K., Zethelius, B., Gudbjörnsdottir, S., 2011a. Different statistical methods to present the effect of attained blood pressure on CVD risk in diabetes by use of Cox regression. J. Hypertens., 29(e-Suppl. A):e238.

[34]Nilsson, P.M., Cederholm, J., Zethelius, B., Eliasson, B., Eeg-Olofsson, K., Gudbjörnsdottir, S., 2011b. Trends in blood pressure control in patients with type 2 diabetes— data from the Swedish National Diabetes Register (NDR). Blood Pressure [Epub ahead of print].

[35]O′Donnell, M.J., Xavier, D., Liu, L., Zhang, H., Chin, S.L., Rao-Melacini, P., Rangarajan, S., Islam, S., Pais, P., McQueen, M.K., et al., 2010. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet, 376(9735):112-123.

[36]Patel, A., MacMahon, S., Chalmers, J., Neal, B., Woodward, M., Billot, L., Harrap, S., Poulter, N., Marre, M., Cooper, M., et al., 2007. Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomised controlled trial. Lancet, 370(9590):829-840.

[37]Pepine, C.J., Handberg, E.M., Cooper-DeHoff, R.M., Marks, R.G., Kowey, P., Messerli, F.H., Mancia, G., Cangiano, J.L., Garcia-Barreto, D., Keltai, M., et al., 2003. A calcium antagonist vs. a non-calcium antagonist hypertension treatment strategy for patients with coronary artery disease. The international verapamil-trandolapril study (INVEST): a randomized controlled trial. JAMA, 290(21):2805-2816.

[38]Ray, K.K., Seshasai, S.R., Wijesuriya, S., Sivakumaran, R., Nethercott, S., Preiss, D., Erqou, S., Sattar, N., 2009. Effect of intensive control of glucose on cardiovascular outcomes and death in patients with diabetes mellitus: a meta-analysis of randomised controlled trials. Lancet, 373(9677):1765-1772.

[39]Reboldi, G., Gentile, G., Angeli, F., Ambrosio, G., Mancia, G., Verdecchia, P., 2011. Effects of intensive blood pressure reduction on myocardial infarction and stroke in diabetes: a meta-analysis in 73 913 patients. J. Hypertens., 29(7):1253-1269.

[40]Redon, J., Sleight, P., Mancia, G., Gao, O., Verdecchia, P., Fagard, R., Schumacher, H., Weber, M., Boehm, M., Williams, B., et al., 2009. Safety and efficacy of aggressive blood pressure lowering among patients with diabetes: subgroup analyses from the ONTARGET trial. J. Hypertens., 27(Suppl. 4):S16.

[41]Redon, J., Mancia, G., Sleight, P., Schumacher, H., Gao, P., Pogue, J., Fagard, R., Verdecchia, P., Weber, M., Böhm, M., et al., 2011. Safety and efficacy of low blood pressure among patients with diabetes: sub-group analyses from the ONTARGET trial. J. Hypertens., 29(e-Suppl. A):e113.

[42]Rydén, L., Standl, E., Bartnik, M., van den Berghe, G., Betteridge, J., de Boer, M.J., Cosentino, F., Jönsson, B., Laakso, M., Malmberg, K., et al., 2007. The task force on diabetes and cardiovascular diseases of the European Society of Cardiology (ESC) and of the European Association for the study of diabetes (EASD). Guidelines on diabetes, prediabetes, and cardiovascular diseases: executive summary. Eur. Heart J., 28(1):88-136.

[43]Saydah, S.H., Fradkin, J., Cowie, C.C., 2004. Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes. JAMA, 291(3):335-342.

[44]Sleight, P., Redon, J., Verdecchia, P., Mancia, G., Gao, P., Fagard, R., Schumacher, H., Weber, M., Böhm, M., Williams, B., et al., 2009. Prognostic value of blood pressure in patients with high vascular risk in the Ongoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial study. J. Hypertens., 27(7):1360-1369.

[45]Stamler, J., Vaccaro, O., Neaton, J.D., Wentworth, D., 1993. Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the multiple risk factor intervention trial. Diabetes Care, 16(2):434-444.

[46]Stratton, I.M., Cull, C.A., Adler, A.I., Matthews, D.R., Neil, H.A.W., Holman, R.R., 2006. Additive effects of glycaemia and blood pressure exposure on risk of complications in type 2 diabetes: a prospective observational study (UKPDS 75). Diabetologia, 49(8):1761-1769.

[47]Telmisartan Randomised Assessment Study in ACE intolerant Subjects with Cardiovascular Disease (TRANSCEND) Investigators, 2008. Effects of the angiotensin-receptor blocker telmisartan on cardiovascular events in high-risk patients intolerant to angiotensin-converting enzyme inhibitors: a randomised controlled trial. Lancet, 372(9644):1174-1183.

[48]The ACCORD Study Group, 2010. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N. Engl. J. Med., 362(17):1575-1582.

[49]Tseng, D.S., Kwong, J., Rezvani, F., Coates, A.O., 2010. Angiotensin-converting enzyme-related cough among Chinese-Americans. Am. J. Med., 123(2):183.e11-e15.

[50]Turnbull, F., Neal, B., Algert, C., Chalmers, J., Chapman, N., Cutler, J., Woodward, M., MacMahon, S., 2005. Effects of different blood pressure-lowering regimens on major cardiovascular events in individuals with and without diabetes mellitus: results of prospectively designed overviews of randomized trials. Arch. Intern. Med., 165(12):1410-1419.

[51]Turnbull, F.M., Abraira, C., Anderson, R.J., Byington, R.P., Chalmers, J.P., Duckworth, W.C., Evans, G.W., Gerstein, H.C., Holman, R.R., Moritz, T.E., et al., 2009. Intensive glucose control and macrovascular outcomes in type 2 diabetes. Diabetologia, 52(11):2288-2298.

[52]Turner, R.C., Millns, H., Neil, H.A., Stratton, I.M., Manley, S.E., Matthews, D.R., Holman, R.R., 1998. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom prospective diabetes study (UKPDS: 23). BMJ, 316:823-828.

[53]UK Prospective Diabetes Study Group, 1998. Tight blood pressure control and risk of macrovascular complications in type-2 diabetes: UKPDS 38. BMJ, 317:703-713.

[54]Yach, D., Hawkes, C., Gould, C.L., Hofman, K.J., 2004. The global burden of chronic diseases: overcoming impediments to prevention and control. JAMA, 291(21):2616-2622.

[55]Yusuf, S., Diener, H.C., Sacco, R.L., Cotton, D., Ounpuu, S., Lawton, W.A., Palesch, Y., Martin, R.H., Albers, G.W., Bath, P., et al., 2008. PRoFESS Study Group. Telmisartan to prevent recurrent stroke and cardiovascular events. N. Engl. J. Med., 359(12):1225-1237.