Optimal target Blood Pressure

Hypertension optimal treatment (HOT) trial published in 1998, showed diastolic BP associated with the lowest risk of major cardiovascular events was 82.6mmHg. (non-diabetics).
In diabetic patients- 51% reduction in cardiovascular event in those with target BP of 80mmHg compared to 90 mmHg.

United Kingdom prospective diabetes study (UKPDS), published in 1998,found that strict BP control (ie at 144/82mmHg)produced significant benefits in diabetic patients. --significant reductions in any diabetes-related end point, including diabetes-related death or the development of heart failure, microalbuminuria and progression of diabetic retinopathy.

WHO-International Society of Hypertension guidelines now recommend that a BP of <130/85mmHg should be the target in patients with diabetes.

Malaysia CPG-Diabetic Nephropathy 2004 :Target blood pressure in diabetics should be less than 130/80mmHg

There are a lot of published studies on this subject and many guidelines too. Clinical Practice Guidelines take into consideration the recently published studies and generally prepared by a group of professionals in the respective field.

Two such bodies with regard to hypertension are
1. NHLBI (National Heart, Lung and Blood Institute) of USA that publishes the JNC (Joint National Committee) reports. Its 7th report was published in 2003.
2. BHS (British Hypertension Society) of UK. It's 4th report in 2004 and the NICE update in 2006 are the latest.

Now, we have to consider two terms - GOAL and TARGET (though these are used interchangeably at times).

GOAL of hypertension treatment is fairly unanimous and uniform. Reduction
of cardiovascular and renal morbidity and mortality.

But to achieve this goal, we have TARGET blood pressure values. The recommendations for this vary widely.

1. JNC 7: Target blood pressure is <140/90 mmHg (<130/80 mmHg in patients with diabetes). A significant statement by this committee is "Since most persons with hypertension, especially those age >50 years, will reach the DBP goal once SBP is at goal, the primary focus should be on achieving the SBP goal."

2. BHS IV with NICE update 2006: Target blood pressure is <140/85 mmHg (<130/80 mmHg in patients with diabetes). In addition, a minimum acceptable level of control of <150/90 mmHg is also defined.

Hence, as you can see, the target for patients with diabetes is consistent with what you have written as the Malaysian CPG suggestion.

However, in practice, things are different. There ARE gaps between theory and practice.

Blood pressure is a dynamic measurement, the values of which keep continually changing (day to day and minute to minute). In addition, there are umpteen confounding factors that affect the values including hospital visits and excessively cold air-conditioned rooms. By my experience, in practice, it is very difficult to achieve and maintain the suggested target blood pressure values. The practical goal is to have as low a blood pressure as possible without inducing symptomatic hypotension and drug adverse effects/ interactions.

More importantly, Blood pressure should not be viewed in isolation. Instead, the entire cardiovascular risk profile of the patient (including smoking, dyslipidemia, obesity, and diabetes etc.) should be considered and managed effectively.