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Experts will debate recommendations for blood pressure targets, metformin use


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3 minutes

Paul K. Whelton, MB, MD, MSc
Paul K. Whelton, MB, MD, MSc

Four experts will debate two clinical questions during the Virtual 80th Scientific Sessions presentation Reconciling Guideline Recommendations for Cardiovascular Risk and Disease Management in Type 2 Diabetes. The two-hour Current Issues debate will begin at 4:30 p.m. CT Sunday, June 14.

The first two presenters will debate the question, Should the blood pressure target for all individuals with type 2 diabetes and hypertension be <130/80 mmHg?

As chair of the American College of Cardiology/American Heart Association committee that recommended the <130/80 mmHg target, Paul K. Whelton, MB, MD, MSc, will argue in favor of the treatment goal. Dr. Whelton, Professor of Global Public Health in the School of Public Health and Tropical Medicine at Tulane University of Medicine, said the question is easy to answer if you go back to basics and look at cohort studies and clinical trial results.

“There’s a risk related to blood pressure,” he said. “It goes from quite low pressures up to very high pressures. There’s no threshold for risk. No matter what age or gender, you’ll see increasing risk with increasing blood pressure. In addition, risk at any level of blood pressure varies greatly, being very high in adults with high blood pressure and diabetes.”

Dr. Whelton will review data from trials, including the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, that demonstrate the benefits of lowering blood pressure in adults with diabetes.

“ACCORD is probably the trial that looked at this the most carefully,” Dr. Whelton said. “When you look at the normal glycemic group, we see tremendous benefit to intensive blood pressure reduction. When you look at the ACCORD group that got intensive glycemic intervention and intensive blood pressure intervention, they did not benefit. However, as soon at the intensive glycemic intervention was stopped, that flipped, and what you see is something very much like SPRINT (Systolic Blood Pressure Intervention Trial)—intensive blood pressure intervention becomes very beneficial. And these were huge benefits. We see major reductions in cardiovascular events and major reductions in all-cause mortality.”

Dr. Whelton added that physicians trying to reconcile differences in guidelines are better served by focusing on where recommendations are similar rather than where there is disagreement.

“When we look across the world and compare our guideline to others, what we see is tremendous consistency and consensus for blood pressure targets during antihypertensive therapy in adults with diabetes,” he said. “The recommendations are much more similar than they are different. Unfortunately, some experts emphasize differences rather than similarities, which is confusing for clinicians and patients.”

Raymond Townsend, MD, Professor of Medicine in the Perelman School of Medicine at the University of Pennsylvania, will counter Dr. Whelton by making the case that blood pressure targets should be considered in the context of underlying risk and whether lower pressure can be safely achieved as recommended by the 2019 ADA Standards of Care.

The next two presenters will debate the question, Should metformin be considered first-line therapy for individuals with type 2 diabetes with established arteriosclerotic cardiovascular disease (ASCVD) or at high risk for ASCVD?

Francesco Cosentino, MD, PhD, FESC, of the Karolinska Institutet in Stockholm, Sweden, will argue metformin is no longer justified as first-time therapy for these diabetes patients based on 2019 recommendations from the European Society of Cardiology and the European Association for the Study of Diabetes. Melanie J. Davies, CBE, MB, ChB, MD, FRCP, FRCGP, of the University of Leicester, United Kingdom, will argue that metformin is proven and should remain a first-line treatment as recommended by 2019 ADA Standards of Care.


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