Intensive blood pressure treatment does not improve cardiovascular outcomes in centrally obese hypertensive individuals with diabetes: ACCORD BP Trial

Intensive blood pressure treatment does not improve cardiovascular outcomes in centrally obese hypertensive individuals with diabetes: the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Blood Pressure Trial
Barzilay JI, Howard AG, Evans GW, et al. Intensive blood pressure treatment does not improve cardiovascular outcomes in centrally obese hypertensive individuals with diabetes: the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Blood Pressure Trial. Diabetes Care. 2012;35(7):1401-1405.Lancet. 2012;380(9841):565-571. 

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Results from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Blood Pressure (BP) trial showed that intensive lowering of BP to <120 mm Hg did not reduce the primary composite outcome of CV death, nonfatal myocardial infarction (MI), or nonfatal stroke, although an analysis of secondary outcomes demonstrated a significant reduction in stroke as compared with conventional treatment targeting systolic BP <140 mm Hg among subjects with type 2 diabetes and hypertension.1 A post-hoc analysis of ACCORD BP evaluated whether central obesity modifies the risk of CVD outcomes among study participants randomized to intensive versus standard BP treatment. 

The ACCORD trial randomized high-risk subjects with type 2 diabetes to intensive (A1C <6%) or standard (A1C 7.0-7.9%) glycemic control; these subjects were also assigned to a lipid or blood pressure substudy. The current analysis examines subjects enrolled in the ACCORD BP substudy, which randomized subjects in a 2x2 factorial design to intensive BP treatment (systolic BP <120 mm Hg) or standard treatment (systolic BP <140 mm Hg). Characteristics of the ACCORD BP cohort (N=4,687): 

  • Majority male (52.3%) 
  • Mean age: 62.2 years 
  • Mean follow-up time: 4.7 years
  • Had diabetes and hypertension (systolic BP 130-180 mm Hg and taking 3 antihypertensive agents) 
  • Prior CVD, smoking status, BMI, baseline BP, A1C, lipid and renal values balanced between intensive and standard groups 

Waist-to-height ratios were used to measure central obesity in this post-hoc analysis, and the following outcomes were assessed using proportional hazard models: 

  • Primary: composite of nonfatal MI, nonfatal stroke, or CVD death 
  • Secondary: 
    • Nonfatal MI 
    • Total stroke (fatal and nonfatal) 
    • CVD death

Findings:  

When CVD outcomes were compared by weight/height quartiles, there were no statistically significant changes between groups for the primary outcome (composite of nonfatal MI, nonfatal stroke, or CVD death; P value for interaction: 0.27).   

  • Quartile 1: Intensive, 1.7%; Standard, 1.73%  
  • Quartile 2: Intensive, 1.86%; Standard, 1.94%  
  • Quartile 3: Intensive, 2.04%; Standard, 2.06%  
  • Quartile 4: Intensive, 1.91%; Standard, 2.64%  

When CVD outcomes were compared by weight/height quartiles, there were no statistically significant changes between groups for the secondary outcomes (nonfatal MI, total stroke [fatal and nonfatal], CVD death; P>0.24 for all tests of interaction).  

  • Nonfatal MI
    • Quartile 1: Intensive, 1.08%; Standard, 1.08%  
    • Quartile 2: Intensive, 1.25%; Standard, 1.35%  
    • Quartile 3: Intensive, 1.22%; Standard, 1.11%  
    • Quartile 4: Intensive, 0.98%; Standard, 1.62% 
     
  • Total stroke (fatal and nonfatal)
    • Quartile 1: Intensive, 0.32%; Standard, 0.33%  
    • Quartile 2: Intensive, 0.42%; Standard, 0.53%  
    • Quartile 3: Intensive, 0.25%; Standard, 0.78%  
    • Quartile 4: Intensive, 0.29%; Standard, 0.39%  
     
  • CVD death
    • Quartile 1: Intensive, 0.42%; Standard, 0.36%  
    • Quartile 2: Intensive, 0.23%; Standard, 0.29%  
    • Quartile 3: Intensive, 0.76%; Standard, 0.61% 
    • Quartile 4: Intensive, 0.67%; Standard, 0.77%  
     

When waist-to-height quartiles were modeled as a single linear covariate, all tests of interaction showed P>0.25. A trend toward greater benefit of the intensive treatment regimen was observed in those with higher waist-to-height ratios for some outcomes.  

When outcomes were examined by treatment group assignment, intensive blood pressure treatment had an effect on total stroke (HR, 0.62 [95% CI, 0.41-0.94]; P=0.022); none of the other outcomes demonstrated an effect based on treatment group (primary outcome: HR, 0.89 [95% CI, 0.74-1.08]; P=0.23; nonfatal MI: HR, 0.88 [95% CI, 0.69-1.11]; P=0.27; CVD mortality: HR, 1.04 [95% CI, 0.72-1.49]; P=0.83).  

When outcomes were examined by weight-to-height quartiles, elevated quartiles correlated with increased risk of CVD mortality (HR, 2.32 [95% CI, 1.40-3.83]; P=0.0009); none of the other outcomes demonstrated an effect based on quartile (primary outcome: HR, 1.24 [95% CI, 0.97-1.61]; P=0.09; nonfatal MI: HR, 1.03 [95% CI, 0.92-1.14]; P=0.62; total stroke: HR, 1.03 [95% CI, 0.86-1.23]; P=0.76).  

1. ACCORD Study Group; Cushman WC, Evans GW, Byington RP, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362(17):1575-1585.  

 

September 2012  

This overview was created by KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional/commercial interest.  

Related content  

Read more about this study and additional cutting-edge diabetes data in the September 2012 issue of Clinical Insights® in Diabetes. Click here.   

ACCORD BP Post-hoc Analysis: Design  

ACCORD BP Post-hoc Analysis: Primary Outcome by Waist/Height Quartiles  

ACCORD BP Post-hoc Analysis: Secondary Outcomes by Waist/Height Quartiles  

ACCORD BP Post-hoc Analysis: Outcomes by Treatment Group, Waist-to-Height Quartiles  

ACCORD: Study Design  

ACCORD: Death from Any Cause  

ACCORD: Results  

ACCORD Trial: Intensive Blood Glucose Control in Patients With Type 2 Diabetes  

ACCORD Trial: CV Events With Intensive Blood Glucose Control  

ACCORD BP: Effects of Intensive BP-Control on Type 2 Diabetes 

ACCORD BP: Effects of Intensive BP-Control on Type 2 Diabetes: Results 

 

 

Last Modified: 3/4/2015