Blood Pressure Lowering and Outcomes in type 2 Diabetes: Implications of the Blood Pressure-Lowering Arm of the Advance Trial

This review focuses on trials that have examined the relationship between blood pressure (BP) lowering strategies and cardiovascular and renal outcomes in subjects with type 2 diabetes. In particular, we highlight the results of the recently completed BP-arm of the ADVANCE (Action in Diabetes and Vascular Disease: Preterax and Diamicron-MR Controlled Evaluation) study. Active therapy with perindopril and indapamide compared with placebo significantly reduced blood pressure (134.7/74.8 vs 140.4/77.0 mmHg) and the primary endpoint of the trial, a composite of major macrovascular and microvascular events. Active therapy also reduced the secondary end points of cardiovascular death and development of renal events. Importantly, the study shows that in a group of patients with BP levels within the range that would not usually be classified as hypertensive, further reductions in BP resulted in clinically significant cardiovascular and renal benefits. It supports the combination of perindopril and indapamide as an effective BP lowering strategy in type 2 diabetes. However, as other BP lowering strategies were not compared, the BP-lowering arm of the ADVANCE study does not answer the question as to what is the best medication or combination of medications that should be employed to reduce BP levels in type 2 diabetes.