CATEGORY: METABOLIC & BLOOD SUGAR
How low should blood pressure go when you have type 2 diabetes? Doctors have argued about it since 2010, because the one big trial to ask the question never got a clear answer. Now a much larger trial has one. Among 12,821 adults with type 2 diabetes, driving systolic pressure below 120 instead of the usual 140 lowered the combined rate of heart attack, stroke, heart failure and cardiovascular death by 21%.1 A companion trial in a broader group of high-risk adults found a more modest 12% reduction, so the honest range of benefit runs from roughly 12% to 21%.2
The Question ACCORD Couldn’t Settle
Systolic pressure is the top number on a reading, the force of blood when the heart squeezes. Back in 2010, a US trial called ACCORD tested this same below-120 target in 4,733 people with diabetes. The result teased: 12% fewer major heart events, but not statistically solid, alongside clearly fewer strokes and clearly more side effects.3 Guidelines kept softer targets for diabetes, and the question sat open for well over a decade. The new trial, named BPROAD, was built to close it. Three times the people. Enough heart trouble, sadly, to count properly.
Fourteen Points Apart, Four Years of Counting
At 145 clinics across China, researchers enrolled adults 50 and older who had type 2 diabetes, elevated systolic pressure and extra cardiovascular risk. A computer, not any doctor’s judgment, sorted each person to one of two goals: below 120, or below 140. Medication was then adjusted until readings got there. A year in, the strict group averaged 121.6 while the standard group averaged 133.2. The typical participant was then followed for 4.2 years while the trial counted nonfatal strokes, nonfatal heart attacks, heart failure needing treatment or a hospital stay, and deaths from cardiovascular causes.
What a 21% Reduction Looked Like in People
Events arrived for 393 people under the strict target and 492 under the standard one. Per 100 people followed for a year, that’s 1.65 events against 2.09. Picture two auditoriums, each seating 6,400 of these patients: after four years, 393 people in the strict-target room had suffered a serious cardiovascular event, versus 492 next door. Most people in both rooms stayed well. The strict goal carried a price, though. Symptomatic low blood pressure, felt as dizziness or lightheadedness, showed up more often, and so did hyperkalemia, an excess of potassium in the blood that can disturb heart rhythm. Serious adverse events overall were about as common in both groups.
Does It Travel Beyond This Trial?
The obvious next question: does this apply to people whose situation looks different? The trial can’t fully say. Its participants were 50 and older, all in China, all carrying added risk factors. What strengthens the case is agreement. ESPRIT, a 2024 trial that enrolled 11,255 high-risk adults including 4,359 with diabetes, landed the same way: 9.7% versus 11.1% had a major event over 3.4 years, a 12% reduction, with no sign the benefit differed by diabetes status.2 Fifteen years after ACCORD muddied the water, two large trials now point in the same direction. A stricter target asks more of patients, more medication, more monitoring, more dizziness. It also means fewer of the events people with diabetes fear most.
Key Takeaways
- Targeting systolic pressure below 120 lowered the combined rate of heart attack, stroke, heart failure and cardiovascular death by 21% compared with a below-140 target, across roughly four years of follow-up.
- The trade-off was more dizziness from low pressure and more high potassium, though serious adverse events overall were no more common.
- Earlier evidence was genuinely murky: ACCORD saw a similar-sized trend in 2010 that didn’t reach statistical significance.
- A companion trial in a broader high-risk group found a 12% reduction, so the realistic benefit likely sits between 12% and 21%.
References
- Bi Y, Li M, Liu Y, et al. Intensive Blood-Pressure Control in Patients with Type 2 Diabetes. New England Journal of Medicine. 2025;392(12):1155–1167. link
- Liu J, Li Y, Ge J, et al. Lowering systolic blood pressure to less than 120 mm Hg versus less than 140 mm Hg in patients with high cardiovascular risk with and without diabetes or previous stroke: an open-label, blinded-outcome, randomised trial. The Lancet. 2024;404(10449):245–255. link
- Cushman WC, Evans GW, Byington RP, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. New England Journal of Medicine. 2010;362(17):1575–1585. link