Effects of intensive blood-pressure control in type 2 diabetes mellitus
Open accessAbstract
BACKGROUND: There is no evidence from randomized trials to support a strategy of lowering systolic blood pressure below 135 to 140 mm Hg in persons with type 2 diabetes mellitus. We investigated whether therapy targeting normal systolic pressure (i.e., <120 mm Hg) reduces major cardiovascular events in participants with type 2 diabetes at high risk for cardiovascular events. METHODS: A total of 4733 participants with type 2 diabetes were randomly assigned to intensive therapy, targeting a systolic pressure of less than 120 mm Hg, or standard therapy, targeting a systolic pressure of less than 140 mm Hg. The primary composite outcome was nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes. The mean follow-up was 4.7 years. RESULTS: After 1 year, the mean systolic blood pressure was 119.3 mm Hg in the intensive-therapy group and 133.5 mm Hg in the standard-therapy group. The annual rate of the primary outcome was 1.87% in the intensive-therapy group and 2.09% in the standard-therapy group (hazard ratio with intensive therapy, 0.88; 95% confidence interval [CI], 0.73 to 1.06; P=0.20). The annual rates of death from any cause were 1.28% and 1.19% in the two groups, respectively (hazard ratio, 1.07; 95% CI, 0.85 to 1.35; P=0.55). The annual rates of stroke, a prespecified secondary outcome, were 0.32% and 0.53% in the two groups, respectively (hazard ratio, 0.59; 95% CI, 0.39 to 0.89; P=0.01). Serious adverse events attributed to antihypertensive treatment occurred in 77 of the 2362 participants in the intensive-therapy group (3.3%) and 30 of the 2371 participants in the standard-therapy group (1.3%) (P<0.001). CONCLUSIONS: In patients with type 2 diabetes at high risk for cardiovascular events, targeting a systolic blood pressure of less than 120 mm Hg, as compared with less than 140 mm Hg, did not reduce the rate of a composite outcome of fatal and nonfatal major cardiovascular events. (ClinicalTrials.gov number, NCT00000620.)
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BP lowering may have an additive and significant impact on morbidity and mortality, particularly in people with standard versus intensive glycemic control.
“Although glucose and lipid management remain important, BP lowering may have an additive and significant impact on morbidity and mortality, particularly in persons with standard vs intensive glycemic control.185,201,202,226,227”
From American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update. (2022) · cites this paper as [201]
The Discussion (page not provided) states that intensive blood-pressure control did not significantly reduce the primary cardiovascular outcome or death from any cause. The Clinical Outcomes results report no significant interactions among prespecified subgroups, rather than a particular benefit under standard versus intensive glycemic control. The trial did find a reduction in stroke, but that does not establish the claimed significant impact on morbidity and mortality. (LLM, conf=0.88)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measuredClinical trial data show that intensifying BP-lowering therapy slows the progression of DKD and retinopathy.
“Clinical trial data show that intensifying therapy with BP-lowering medications slows the progression of DKD and retinopathy, though vigilance in monitoring renal function during intensive BP therapy is recommended.185,186,201–203”
From American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update. (2022) · cites this paper as [201]
The Results (Adverse Events; page unavailable) report less macroalbuminuria with intensive BP treatment, but also lower kidney filtration rates and no difference in end-stage renal disease or dialysis. The Discussion says the implications for renal outcomes are uncertain. Our copy does not report that intensive treatment slowed retinopathy progression, so it does not support the full claim. (LLM, conf=0.88)
Experimental — accuracy not yet measuredAnalysis of UKPDS data suggests that BP lowering should be a priority in managing a person presenting with newly diagnosed hypertension and diabetes.
“Analysis of the UKPDS data suggests that BP lowering should be a priority in managing a person presenting with newly diagnosed hypertension and DM.”
From American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update. (2022) · cites this paper as [201]
The Discussion (page not provided) reports that UKPDS found fewer cardiovascular events with antihypertensive therapy in patients with type 2 diabetes, supporting the importance of BP lowering. It does not specifically address people presenting with newly diagnosed hypertension and diabetes or explicitly rank BP lowering as a management priority. (LLM, conf=0.82)
Experimental — accuracy not yet measuredAntihypertensive therapy reduces the risk of albuminuria.
“Antihypertensive therapy reduces the risk of albuminuria (67)(68)(69)(70), and among people with type 1 or 2 diabetes with established CKD (eGFR <60 mL/min/1.73m 2 and UACR $300 mg/g creatinine), ACE inhibitor or ARB therapy reduces the risk of progression to ESKD (71)(72)(73)(74)(75)(76)(77)(78)(79)(80).”
From 11. Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes—2025 (2025) · cites this paper as [68]
The Results (Adverse Events) report significantly less macroalbuminuria at the final visit with intensive than with standard blood-pressure therapy. This supports a benefit for macroalbuminuria in people with type 2 diabetes, but does not establish that antihypertensive therapy generally reduces the risk of albuminuria compared with no therapy. (LLM, conf=0.86)
Experimental — accuracy not yet measuredAntihypertensive therapy reduces the risk of albuminuria.
“Antihypertensive therapy reduces the risk of albuminuria (68-71), and among people with type 1 or 2 diabetes with established CKD (eGFR <60 mL/min/1.73m 2 and UACR ≥300 mg/g creatinine), ACE inhibitor or ARB therapy reduces the risk of progression to kidney failure (72)(73)(74)(75)(76)(77)(78)(79)(80)(81).”
From 11. Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes—2026 (2026) · cites this paper as [69]
The Results (Adverse Events; page unavailable) report significantly less macroalbuminuria at the final visit with intensive than with standard blood-pressure therapy in people with type 2 diabetes. This supports a narrower claim, but does not establish that antihypertensive therapy generally reduces the risk of albuminuria compared with no therapy. (LLM, conf=0.86)
Experimental — accuracy not yet measured
The results of ACCORD BP and SPRINT have been interpreted to be generally consistent, but ACCORD BP was viewed as underpowered due to the composite primary end point being less sensitive to blood pressure regulation.
“The results have been interpreted to be generally consistent between the two trials, but ACCORD BP was viewed as underpowered due to the composite primary end point being less sensitive to blood pressure regulation (38,40).”
From 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2025 (2025) · cites this paper as [40]
The Discussion (page not available in our copy) says ACCORD BP had reduced power because the observed event rate was almost 50% lower than expected. The Methods identify a composite primary outcome, but the paper does not attribute reduced power to that outcome being less sensitive to blood-pressure control or compare ACCORD BP with SPRINT. (LLM, conf=0.88)
Experimental — accuracy not yet measuredIn ACCORD BP, adverse events attributed to blood pressure treatment, including hypotension, syncope, bradycardia, hyperkalemia, and elevations in serum creatinine, occurred more frequently in the intensive treatment arm than in the standard therapy arm.
“Adverse events attributed to blood pressure treatment, including hypotension, syncope, bradycardia, hyperkalemia, and elevations in serum creatinine, occurred more frequently in the intensive treatment arm than in the standard therapy arm.”
From 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2025 (2025) · cites this paper as [40]
The Results > Adverse Events section reports more serious events attributed to antihypertensive treatment and more serum-creatinine elevations in the intensive group. It reports hypokalemia, not the claimed hyperkalemia, and does not establish higher rates of syncope or bradycardia; symptoms of orthostatic hypotension were similar between groups. No page number is available in our copy. (LLM, conf=0.88)
Experimental — accuracy not yet measuredACCORD BP provides the strongest direct assessment of the benefits and risks of intensive blood pressure management in people with type 2 diabetes.
“ACCORD BP provides the strongest direct assessment of the benefits and risks of intensive blood pressure management in people with type 2 diabetes (40).”
From 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2025 (2025) · cites this paper as [40]
In ACCORD BP, the primary composite outcome of nonfatal MI, nonfatal stroke, or death from cardiovascular causes was not significantly reduced in the intensive treatment group.
“The primary composite outcome of nonfatal MI, nonfatal stroke, or death from cardiovascular causes was not significantly reduced in the intensive treatment group.”
From 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2025 (2025) · cites this paper as [40]
In ACCORD BP, the prespecified secondary outcome of stroke was significantly reduced by 41% in the intensive treatment group.
“The prespecified secondary outcome of stroke was significantly reduced by 41% in the intensive treatment group.”
From 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2025 (2025) · cites this paper as [40]
ACCORD BP did not demonstrate that aiming for a systolic blood pressure <120 mmHg in people with diabetes results in decreased cardiovascular event rates, but the prespecified secondary outcome of stroke was reduced by 41% with intensive treatment.
“While the relatively underpowered ACCORD (Action to Control Cardiovascular Risk in Diabetes) blood pressure trial (ACCORD BP) did not demonstrate that aiming for a systolic blood pressure <120 mmHg in people with diabetes results in decreased cardiovascular event rates, the prespecified secondary outcome of stroke was reduced by 41% with intensive treatment (45).”
From 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2026 (2026) · cites this paper as [45]
In ACCORD BP, the primary composite outcome of nonfatal MI, nonfatal stroke, or death from cardiovascular causes was not significantly reduced in the intensive treatment group, although the prespecified secondary outcome of stroke was significantly reduced by 41%.
“The primary composite outcome of nonfatal MI, nonfatal stroke, or death from cardiovascular causes was not significantly reduced in the intensive treatment group, although the prespecified secondary outcome of stroke was significantly reduced by 41% in the intensive treatment group.”
From 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2026 (2026) · cites this paper as [45]
In a 10-year posttrial monitoring observational study, the UKPDS group found that the benefit of tight blood pressure control was lost within 2 years when tight control was not maintained.
“The UKPDS group performed a 10-year posttrial monitoring observational study that demonstrated a loss of benefit within 2 years if tight BP control was not maintained.”
From American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update. (2022) · cites this paper as [201]
The Discussion mentions UKPDS findings during antihypertensive treatment, but does not describe a 10-year posttrial study or a loss of benefit within two years. Searches for posttrial monitoring and the two-year loss of benefit found no passage addressing that claim in our copy. (LLM, conf=0.76)
Experimental — accuracy not yet measuredType 2 diabetes patients were explicitly excluded from SPRINT, making it hard to know whether SPRINT findings apply to type 2 diabetes with coronary disease.
“Importantly, at least in part due to the ACCORD trial (Action to Control Cardiovascular Risk in Diabetes),72 patients with T2DM were explicitly excluded from SPRINT, so it is difficult to determine whether the results of SPRINT can extend to patients with T2DM and CAD.”
From Clinical management of stable coronary artery disease in patients with type 2 diabetes mellitus: a scientific statement from the American Heart Association (2020) · cites this paper as [72]
The ACCORD BP study found no improvement in the primary endpoint, slight reductions in the secondary endpoint of strokes, and an increase in side effects with a lower target systolic blood pressure below 120 mmHg.
“There was no improvement in the primary endpoint, with slight reductions in the secondary endpoint of strokes, and an increase in side effects with a lower target.”
From European Guidelines on cardiovascular disease prevention in clinical practice (version 2012) (2012) · cites this paper as [451]
ACCORD BP provides the strongest direct assessment of the benefits and risks of intensive blood pressure control in people with type 2 diabetes.
“ACCORD BP provides the strongest direct assessment of the bene fi ts and risks of intensive blood pressure control in people with type 2 diabetes (35).”
From 10. Cardiovascular Disease and Risk Management: <i>Standards of Care in Diabetes—2023</i> (2023) · cites this paper as [35]
In ACCORD BP, the prespecified secondary outcome of stroke was significantly reduced by 41% in the intensive treatment group.
“The prespeci fi ed secondary outcome of stroke was signi fi cantly reduced by 41% in the intensive treatment group.”
From 10. Cardiovascular Disease and Risk Management: <i>Standards of Care in Diabetes—2023</i> (2023) · cites this paper as [35]
In ACCORD BP, adverse events attributed to blood pressure treatment, including hypotension, syncope, bradycardia, hyperkalemia, and elevations in serum creatinine, occurred more frequently in the intensive treatment arm than in the standard therapy arm.
“Adverse events attributed to blood pressure treatment, including hypotension, syncope, bradycardia, hyperkalemia, and elevations in serum creatinine occurred more frequently in the intensive treatment arm than in the standard therapy arm ( Table 10.1 ).”
From 10. Cardiovascular Disease and Risk Management: <i>Standards of Care in Diabetes—2023</i> (2023) · cites this paper as [35]
ACCORD BP and SPRINT targeted a similar systolic blood pressure below 120 mmHg, but the primary composite cardiovascular end point was nonsignificantly reduced in ACCORD BP.
“Of note, the ACCORD BP and SPRINT trials targeted a similar systolic blood pressure < 120 mmHg, but in contrast to SPRINT, the primary composite cardiovascular end point was nonsigni fi cantly reduced in ACCORD BP.”
From 10. Cardiovascular Disease and Risk Management: <i>Standards of Care in Diabetes—2023</i> (2023) · cites this paper as [35]
ACCORD BP did not confirm that targeting systolic blood pressure below 120 mmHg in people with diabetes results in decreased cardiovascular event rates, but the prespecified secondary outcome of stroke was reduced by 41% with intensive treatment.
“While the ACCORD (Action to Control Cardiovascular Risk in Diabetes) blood pressure trial (ACCORD BP) did not con fi rm that targeting a systolic blood pressure of < 120 mmHg in people with diabetes results in decreased cardiovascular event rates, the prespecifi ed secondary outcome of stroke was reduced by 41% with intensive treatment (35).”
From 10. Cardiovascular Disease and Risk Management: <i>Standards of Care in Diabetes—2023</i> (2023) · cites this paper as [35]
In ACCORD BP, the primary composite outcome of nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes was not significantly reduced in the intensive treatment group.
“The primary composite outcome of nonfatal MI, nonfatal stroke, or death from cardiovascular causes was not signi fi cantly reduced in the intensive treatment group.”
From 10. Cardiovascular Disease and Risk Management: <i>Standards of Care in Diabetes—2023</i> (2023) · cites this paper as [35]
The ACCORD-BP trial showed no benefit on the primary outcome (major adverse CV events) of SBP targets <120 mm Hg compared to <140 mm Hg, but found a significant reduction in stroke, a secondary outcome.
“The ACCORD-BP trial showed no benefit on the primary outcome (major adverse CV events) of SBP targets < 120 mm Hg compared to < 140 mm Hg, but found a significant reduction in stroke, a secondary outcome46.”
From Diabetes in Older Adults: A Consensus Report (2012) · cites this paper as [46]
Selected trials have shown benefit with blood pressure targets progressively lower, down to SBP <140 mm Hg and diastolic <80 mm Hg.
“Selected trials have shown benefit with targets progressively lower, down to SBP < 140 mm Hg and diastolic < 80 mm Hg45.”
From Diabetes in Older Adults: A Consensus Report (2012) · cites this paper as [45]
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Type 2 Diabetes Mellitus and Hypertension
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11. Chronic Kidney Disease and Risk Management: <i>Standards of Medical Care in Diabetes—2022</i>
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- Authors
- The ACCORD Study Group
- Corresponding author
- The ACCORD Study Group
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2010-04-29
- Volume
- 362
- Issue
- 17
- Pages
- 1575-1585
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- PMC
- PMC4123215
- OpenAlex
- W2136145230
- Semantic Scholar
- d0702c1baab9686d8675e0cbbfcb28a8c1ee7abd
- Cited by
- 3,598
- References
- 19
- Citations by year
- 2026: 98 · 2025: 149 · 2024: 140 · 2023: 144 · 2022: 140 · 2021: 179 · 2020: 202 · 2019: 221 · 2018: 298 · 2017: 274 · 2016: 279 · 2015: 232 · 2014: 243 · 2013: 223 · 2012: 277
- FWCI
- 217.13
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institutes of Health (n01hc95183-23-0-0, n01hc95180-24-0-1, n01hc95184-24-0-1, n01hc95181-23-0-1, n01hc95182-23-0-1, n01hc95178-28-0-1, n01hc95179-25-0-0)
- National Heart, Lung, and Blood Institute (N01- HC-95181, R01HL073030, N01 HC095184, N01-HC- 95180, N01-HC-95178, N01 HC095182, N01 HC095181, Y01 HC001010, Y1-HC-9035, N01-HC-095183, N01 HC095178, N01-HC-95184, N01HC95179, N01 HC095180, Y1-HC-1010, N01‐HC‐95183, N01-HC-95182, N01 HC095179)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Blood Pressure and Hypertension Studies
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
- Keywords
- type 2 diabetes, intensive blood pressure control, systolic blood pressure, antihypertensive therapy, cardiovascular events, myocardial infarction, stroke, cardiovascular mortality, high cardiovascular risk, primary prevention of cardiovascular disease, renin-angiotensin system inhibitors, ACE inhibitors, calcium channel blockers, beta-blockers
- MeSH terms
- Aged, Antihypertensive Agents, Blood Pressure, Cardiovascular Diseases, Creatinine, Diabetes Mellitus, Type 2, Female, Glomerular Filtration Rate, Humans, Hypertension, Hypokalemia, Male, Middle Aged, Myocardial Infarction, Proportional Hazards Models, Stroke, Kaplan-Meier Estimate
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