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Published ahead of print on June 1, 2005
J Am Soc Nephrol 16: 2170-2179, 2005
© 2005 American Society of Nephrology
doi: 10.1681/ASN.2004090763
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Epidemiology and Outcomes

Impact of Achieved Blood Pressure on Cardiovascular Outcomes in the Irbesartan Diabetic Nephropathy Trial

Tomas Berl*, Lawrence G. Hunsicker{dagger}, Julia B. Lewis{ddagger}, Marc A. Pfeffer§, Jerome G. Porush||, Jean-Lucien Rouleau, Paul L. Drury#, Enric Esmatjes**, Donald Hricik{dagger}{dagger}, Marc Pohl{ddagger}{ddagger}, Itamar Raz§§, Philippe Vanhille||||, Thomas B. Wiegmann¶¶, Bernard M. Wolfe##, Francesco Locatelli***, Samuel Z. Goldhaber§, Edmund J. Lewis{dagger}{dagger}{dagger} for the Collaborative Study Groupa

* University of Colorado Medical School, Denver, Colorado; {dagger} University of Iowa College of Medicine, Iowa City, Iowa; {ddagger} Vanderbilt University College of Medicine, Nashville, Tennessee; § Brigham and Women’s Hospital, Boston, Massachusetts; || Brookdale University Hospital and Medical Center, Brooklyn, New York; University of Toronto, Toronto, Ontario, Canada; # Auckland Diabetes Centre, Auckland, New Zealand; ** Hospital Clinic, University of Barcelona, Barcelona, Spain; {dagger}{dagger} Case Western Reserve University School of Medicine, Cleveland, Ohio; {ddagger}{ddagger} Cleveland Clinic, Cleveland, Ohio; §§ Hadassah University, Jerusalem, Israel; |||| Centre Hospitalier de Valenciennes, Valenciennes, France; ¶¶ University of Kansas City Medical Center and College of Health Sciences, Veterans Affairs Medical Center, Kansas City, Kansas; ## University of Western Ontario, London, Ontario, Canada; *** Monzoni Hospital, Lecco, Italy; and {dagger}{dagger}{dagger} Rush-Presbyterian-St. Luke’s Medical Center, Chicago, Illinois

Address correspondence to: Dr. Tomas Berl, University of Colorado Health Sciences Center, 4200 East 9th Avenue, C-281, Denver, CO 80262. Phone: 303-315-7204; Fax: 303-315-4852; E-mail: tomas.berl{at}uchsc.edu

Received for publication September 13, 2004. Accepted for publication April 28, 2005.

Elevated arterial pressure enhances the risk for cardiovascular (CV) events in patients with diabetic nephropathy. The optimal BP and the component of the elevated BP that affect the risk have not been defined. A post hoc analysis was performed to assess the impact of achieved systolic, diastolic, and pulse pressures on CV outcomes in 1590 adults who had overt diabetic nephropathy and were enrolled in the Irbesartan Diabetic Nephropathy Trial (IDNT) and had a baseline serum creatinine above the normal range, up to 266 µmol/L (3.0 mg/dL), 24-h urine protein >900 mg/d, and at least 6 mo of follow-up. Patients were randomized to irbesartan, amlodipine, or placebo, with other antihypertensive agents to a BP goal of ≤135/85 mmHg. Progressively lower achieved systolic BP (SBP) to 120 mmHg predicted a decrease in CV mortality and congestive heart failure (CHF) but not myocardial infarctions (MI). A SBP below this threshold was associated with increased risk for CV deaths and CHF events. Achieved diastolic BP <85 mmHg was associated with a trend to increase in all-cause mortality, significant increase in MI, but decreased risk for strokes. Increased pulse pressure predicted increased all-cause mortality, CV mortality, MI, and CHF. It is concluded that achieved SBP approaching 120 mmHg and diastolic BP of 85 mmHg are associated with the best protection against CV events in these patients. BP ≤120/85 may be associated with an increase in CV events.




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