Several trials have shown that uncontrolled hypertension is a major risk factor for the development of cardiac, vascular, renal, and cerebrovascular disease, morbidity, and mortality. However, even modest reductions in blood pressure (BP) decrease morbidity and mortality.[5]Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018 May 15;71(19):e127-248.
https://www.jacc.org/doi/full/10.1016/j.jacc.2017.11.006
http://www.ncbi.nlm.nih.gov/pubmed/29146535?tool=bestpractice.com
Systolic BP may have a greater effect on cardiovascular outcomes, but both systolic and diastolic hypertension have been shown to independently influence the risk of adverse cardiovascular events.[152]Flint AC, Conell C, Ren X, et al. Effect of systolic and diastolic blood pressure on cardiovascular outcomes. N Engl J Med. 2019 Jul 18;381(3):243-51.
https://www.nejm.org/doi/10.1056/NEJMoa1803180
http://www.ncbi.nlm.nih.gov/pubmed/31314968?tool=bestpractice.com
There is currently no randomized controlled trial evidence for the benefit of treating white-coat hypertension. One meta-analysis found that untreated white-coat hypertension is associated with an increased risk for cardiovascular events and all-cause mortality; there was no significant association between treated white coat effect and cardiovascular events or mortality.[153]Cohen JB, Lotito MJ, Trivedi UK, et al. Cardiovascular events and mortality in white coat hypertension: a systematic review and meta-analysis. Ann Intern Med. 2019 Jun 18;170(12):853-62.
http://www.ncbi.nlm.nih.gov/pubmed/31181575?tool=bestpractice.com
Masked hypertension (which can include both those receiving antihypertensive treatment and those not receiving treatment) is associated with an increased risk for cardiovascular events, including stroke and myocardial infarction.[154]Anstey DE, Pugliese D, Abdalla M, et al. An update on masked hypertension. Curr Hypertens Rep. 2017 Oct 25;19(12):94.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5723434/
http://www.ncbi.nlm.nih.gov/pubmed/29071520?tool=bestpractice.com
Out-of-office BP monitoring is critical in the management of hypertension and improving outcomes.
Further studies are needed to confirm optimal BP targets in diabetes. In one randomized clinical trial (ACCORD) a more stringent blood pressure goal for patients with type 2 diabetes did not significantly reduce the primary cardiovascular outcome or most secondary outcomes compared with standard BP goals. In this study, the number of total and nonfatal strokes was lower in the intensive therapy group, although the clinical benefit was limited (number needed to treat = 89 for 5 years to prevent one stroke).[70]Cushman WC, Evans GW, Byington RP, et al; ACCORD Study Group. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010 Apr 29;362(17):1575-85.
https://www.nejm.org/doi/full/10.1056/NEJMoa1001286
http://www.ncbi.nlm.nih.gov/pubmed/20228401?tool=bestpractice.com
Data from the ACCORD study and the Veterans Affairs Diabetes Trials were also used in an analysis to show an association between BP variability and risk of heart failure in patients with type 2 diabetes, possibly related to diastole.[155]Nuyujukian DS, Koska J, Bahn G, et al; VADT Investigators. Blood pressure variability and risk of heart failure in ACCORD and the VADT. Diabetes Care. 2020 Jul;43(7):1471-8.
http://www.ncbi.nlm.nih.gov/pubmed/32327422?tool=bestpractice.com
In patients with diabetes, the decrease in asleep BP - a novel therapeutic target requiring evaluation by ambulatory monitoring - has been shown to be the most significant independent predictor of event-free survival in some studies.[156]Hermida RC, Ayala DE, Mojón A, et al. Sleep-time blood pressure as a therapeutic target for cardiovascular risk reduction in type 2 diabetes. Am J Hypertens. 2012 Mar;25(3):325-34.
http://www.ncbi.nlm.nih.gov/pubmed/22158066?tool=bestpractice.com
[157]Hermida RC, Ayala DE, Mojón A, et al. Bedtime dosing of antihypertensive medications reduces cardiovascular risk in CKD. J Am Soc Nephrol. 2011 Dec;22(12):2313-21.
https://jasn.asnjournals.org/content/22/12/2313
http://www.ncbi.nlm.nih.gov/pubmed/22025630?tool=bestpractice.com
[158]Hermida RC, Ayala DE, Mojón A, et al. Decreasing sleep-time blood pressure determined by ambulatory monitoring reduces cardiovascular risk. J Am Coll Cardiol. 2011 Sep 6;58(11):1165-73.
http://www.ncbi.nlm.nih.gov/pubmed/21884956?tool=bestpractice.com
[159]Hermida RC, Ayala DE, Mojón A, et al. Chronotherapy with valsartan/hydrochlorothiazide combination in essential hypertension: improved sleep-time blood pressure control with bedtime dosing. Chronobiol Int. 2011 Aug;28(7):601-10.
http://www.ncbi.nlm.nih.gov/pubmed/21823969?tool=bestpractice.com
[160]Hermida RC, Ayala DE, Mojón A, et al. Influence of time of day of blood pressure-lowering treatment on cardiovascular risk in hypertensive patients with type 2 diabetes. Diabetes Care. 2011 Jun;34(6):1270-6.
https://care.diabetesjournals.org/content/34/6/1270
http://www.ncbi.nlm.nih.gov/pubmed/21617110?tool=bestpractice.com