Is the next STEP on the BPROAD to intensive blood pressure lowering for all type 2 diabetic patients?: consensus statements from the Korean Society of Hypertension

Abstract

The optimal blood pressure (BP) target in patients with type 2 diabetes mellitus (T2DM) continues to be debated. The 2022 guidelines from the Korean Society of Hypertension (KSH) recommend intensive BP lowering only for patients with diabetes who are at high cardiovascular (CV) risk. However, recent trials have demonstrated favorable outcomes associated with intensive BP lowering in T2DM. In response, the updated KSH consensus statements provide evidence-based recommendations supporting the implementation of intensive BP control strategies in hypertensive patients with diabetes, including those at low to moderate CV risk. The KSH consensus statements are as follows: 1) Hypertension is a common comorbidity of T2DM, with a prevalence of 59.6% among adults with diabetes aged 30 years and older in Korea. 2) In patients with T2DM, coexisting hypertension increases the risk of both macrovascular and microvascular complications; however, tight BP control reduces diabetes-related morbidity and mortality. 3) Recent guidelines advocate tailored BP targets based on individual CV risk profiles to balance treatment safety and effectiveness, and recommend a BP target of < 130/80 mmHg for patients with T2DM. 4) The BPROAD (Intensive Blood-Pressure Control in Patients with Type 2 Diabetes) trial provides the strongest evidence for intensive BP control in patients with T2DM, while the STEP (Trial of Intensive Blood-Pressure Control in Older Patients with Hypertension) and the ESPRIT (Effects of Intensive Blood Pressure Lowering Treatment in Reducing the Risk of Cardiovascular Events) trials support intensive BP lowering in high-risk diabetic patients and extend the findings to broader high-risk populations, respectively. 5) A nationwide Korean study suggests that, if patients with T2DM can safely tolerate it, lower BP levels in patients with T2DM may provide protection even without established CV disease. 6) As white coat hypertension becomes more frequent following treatment in diabetic patients, precise BP measurement is essential to avoid overtreatment, particularly in real-world clinical settings. 7) The proportion of patients with T2DM who are at low to moderate risk is small. Accordingly, the updated consensus statement from the KSH recommends a target BP of 130/80 mmHg for most patients with T2DM, provided that this target is well tolerated.