Diabetes Metab J.  2021 Sep;45(5):753-764. 10.4093/dmj.2020.0134.

Appraisal of Guidelines for the Management of Blood Pressure in Patients with Diabetes Mellitus: The Consensuses, Controversies and Gaps

• Liu M
• Zhang S
• Chen X
• Guo Y
• Zhong X
• Xiong Z
• Lin Y
• Zhou H
• Huang Y
• Zhang Z
• Wang L
• Zhuang X
• Liao X

• KMID: 2520857
• DOI: http://doi.org/10.4093/dmj.2020.0134

Abstract

Background
Currently available guidelines contain conflicting recommendations on the management of blood pressure (BP) in patients with diabetes mellitus (DM). Therefore, it is necessary to appraise the guidelines and summarize the agreements and differences among recommendations.
Methods
Four databases and the websites of guideline organizations were searched for guidelines regarding BP targets and thresholds for pharmacologic therapy in DM patients, and the included guidelines were appraised with the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument.
Results
In 6,498 records identified, 20 guidelines met our inclusion criteria with 64.0% AGREE II scores (interquartile range, 48.5% to 72.0%). The scores of the European and American guidelines were superior to those of the Asian guidelines (both adjusted P<0.001). Most of the guidelines advocated systolic BP targets <130 mm Hg (12 guidelines, 60%) and diastolic BP targets <80 mm Hg (14 guidelines, 70%) in DM patients. Approximately half of the guidelines supported systolic BP thresholds >140 mm Hg (10 guidelines, 50%) and diastolic BP thresholds >90 mm Hg (nine guidelines, 45%). The tiny minority of the guidelines provided the relevant recommendations regarding the lower limit of official BP targets and the ambulatory BP monitoring (ABPM)/home BP monitoring (HBPM) targets and thresholds in DM patients.
Conclusion
The lower official BP targets (<130/80 mm Hg) in patients with DM are advocated by most of the guidelines, but they contain conflicting recommendations on the official BP thresholds. Moreover, the gaps regarding the lower limit of official BP targets and the ABPM/HBPM targets and thresholds need to be considered by future study.

Keyword

Blood pressure; Diabetes mellitus; Guideline; Systematic review

Figure

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  Fig. 1. Flow chart of the search for and selection of guidelines.

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  Fig. 2. Appraisal of Guidelines for Research and Evaluation (AGREE) II scores of the guidelines in the six domains across different regions. ESC, European Society of Cardiology; EASD, European Association for the Study of Diabetes; NICE, National Institute for Health and Clinical Excellence; ESH, European Society of Hypertension; SIGN, Scottish Intercollegiate Guidelines Network; ADA, American Diabetes Association; ACC, American College of Cardiology; AHA, American Heart Association; VA/DoD, U.S. Department of Veterans Affairs and Department of Defense; AACE/ACE, American Association of Clinical Endocrinologists; JNC 8, Eighth Joint National Committee; KDA, Korean Diabetes Association; JSH, Japanese Society of Hypertension; KSH, Korean Society of Hypertension; MOH, Ministry of Health, Singapore; TSOC, Taiwan Society of Cardiology; THS, Taiwan Hypertension Society; JDS, Japan Diabetes Society; CDA, Canadian Diabetes Association; CHEP, Canadian Hypertensive Education Program; NHFA, National Heart Foundation of Australia; Baker IDI, Baker Heart and Diabetes Institute; IDF, International Diabetes Federation.

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  Fig. 3. Summary of recommendations regarding blood pressure management in patients with diabetes mellitus (DM). SBP, systolic blood pressure; DBP, diastolic blood pressure; ABPM, ambulatory blood pressure monitoring; HBPM, home blood pressure monitoring. a The proportion of “strongly recommended” guidelines that provided relevant recommendations among the 12 “strongly recommended” guidelines, b The proportion of guidelines that provided relevant recommendations among the 20 included guidelines.

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