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] 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]

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] 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] 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] 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]

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][157][158][159][160]

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