Target BP levels and preference of drugs in diabetic patients in several guidelines
Guidelines
Hypertension
Target BP
Preference of drugs
ACC/AHA 2017
140/90 mmHg
< 130/80 mmHg
No preference
HCGC 2020
130/80 mmHg
< 130/80 mmHg
A (if not satisfactory A + D)
ISH 2020
140/90 mmHg
< 130/80 mmHg (< 140/80 mmHg in elderly)
A + C (C + D for blacks)
ESH 2023
140/90 mmHg
< 130/80 mmHg
A + C or D
ESC 2024
140/90 mmHg
< 130/80 mmHg
A + C or D
ADA 2025
130/80 mmHg
< 130/80 mmHg
< 150/90 mmHg: A or C or D; A (if albuminuria or CAD)> 150/90 mmHg: two of A or C or D; A + C or D (if albuminuria or CAD)
β-blockers are recommended in the presence of compelling indications like left ventricular dysfunction, coronary artery disease (CAD), or tachycardia. ACC: American College of Cardiology; ADA: American Diabetes Association; AHA: American Heart Association; BP: blood pressure; ESC: European Society of Cardiology; ESH: European Society of Hypertension; HCGC: Hypertension Canada Guidelines Committee; ISH: International Society of Hypertension. A: angiotensin-converting enzyme inhibitor/angiotensin receptor blockers; C: dihydropyridine calcium-channel blockers; D: diuretics
Declarations
Author contributions
YG: Writing—review & editing.
Conflicts of interest
The author declares that there are no conflicts of interest.
Open Exploration maintains a neutral stance on jurisdictional claims in published institutional affiliations and maps. All opinions expressed in this article are the personal views of the author(s) and do not represent the stance of the editorial team or the publisher.
References
Tsimihodimos V, Gonzalez-Villalpando C, Meigs JB, Ferrannini E. Hypertension and Diabetes Mellitus: Coprediction and Time Trajectories.Hypertension. 2018;71:422–28. [DOI] [PubMed] [PMC]
Jia G, Sowers JR. Hypertension in Diabetes: An Update of Basic Mechanisms and Clinical Disease.Hypertension. 2021;78:1197–205. [DOI] [PubMed] [PMC]
Passarella P, Kiseleva TA, Valeeva FV, Gosmanov AR. Hypertension Management in Diabetes: 2018 Update.Diabetes Spectr. 2018;31:218–24. [DOI] [PubMed] [PMC]
Lastra G, Syed S, Kurukulasuriya LR, Manrique C, Sowers JR. Type 2 diabetes mellitus and hypertension: an update.Endocrinol Metab Clin North Am. 2014;43:103–22. [DOI] [PubMed] [PMC]
Buyken AE, von Eckardstein A, Schulte H, Cullen P, Assmann G. Type 2 diabetes mellitus and risk of coronary heart disease: results of the 10-year follow-up of the PROCAM study.Eur J Cardiovasc Prev Rehabil. 2007;14:230–6. [DOI] [PubMed]
UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group.BMJ. 1998;317:703–13. [PubMed] [PMC]
Sabuncu T, Sonmez A, Eren MA, Sahin I, Çorapçioğlu D, Üçler R, et al.; TEMD Study Group. Characteristics of patients with hypertension in a population with type 2 diabetes mellitus. Results from the Turkish Nationwide SurvEy of Glycemic and Other Metabolic Parameters of Patients with Diabetes Mellitus (TEMD Hypertension Study).Prim Care Diabetes. 2021;15:332–39. [DOI] [PubMed]
National Institute for Health and Care Excellence (NICE). Hypertension in Adults: Diagnosis and Management [Internet].NICE; c2025. [cited 2025 Jan 3]. Available from: https://www.nice.org.uk/guidance/ng136
Mark PB, Murphy K, Mohammed AS, Morris STW, Jardine AG. Endothelial dysfunction in renal transplant recipients.Transplant Proc. 2005;37:3805–7. [DOI] [PubMed]
Gallo G, Savoia C. New Insights into Endothelial Dysfunction in Cardiometabolic Diseases: Potential Mechanisms and Clinical Implications.Int J Mol Sci. 2024;25:2973. [DOI] [PubMed] [PMC]
Ramalingam L, Menikdiwela K, LeMieux M, Dufour JM, Kaur G, Kalupahana N, et al. The renin angiotensin system, oxidative stress and mitochondrial function in obesity and insulin resistance.Biochim Biophys Acta Mol Basis Dis. 2017;1863:1106–14. [DOI] [PubMed]
Emdin CA, Anderson SG, Woodward M, Rahimi K. Usual Blood Pressure and Risk of New-Onset Diabetes: Evidence From 4.1 Million Adults and a Meta-Analysis of Prospective Studies.J Am Coll Cardiol. 2015;66:1552–62. [DOI] [PubMed] [PMC]
Brands MW. Role of Insulin-Mediated Antinatriuresis in Sodium Homeostasis and Hypertension.Hypertension. 2018;72:1255–62. [DOI] [PubMed]
Hansson L, Zanchetti A, Carruthers SG, Dahlöf B, Elmfeldt D, Julius S, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial.Lancet. 1998;351:1755–62. [DOI] [PubMed]
Patel A; ADVANCE Collaborative Group; MacMahon S, Chalmers J, Neal B, Woodward M, Billot L, Harrap S, et al. Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomised controlled trial.Lancet. 2007;370:829–40. [DOI] [PubMed]
Schrier RW, Estacio RO, Esler A, Mehler P. Effects of aggressive blood pressure control in normotensive type 2 diabetic patients on albuminuria, retinopathy and strokes.Kidney Int. 2002;61:1086–97. [DOI] [PubMed]
ACCORD Study Group; Cushman WC, Evans GW, Byington RP, Goff DC Jr, Grimm RH Jr, Cutler JA, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus.N Engl J Med. 2010;362:1575–85. [DOI] [PubMed] [PMC]
Beddhu S, Chertow GM, Greene T, Whelton PK, Ambrosius WT, Cheung AK, et al. Effects of Intensive Systolic Blood Pressure Lowering on Cardiovascular Events and Mortality in Patients With Type 2 Diabetes Mellitus on Standard Glycemic Control and in Those Without Diabetes Mellitus: Reconciling Results From ACCORD BP and SPRINT.J Am Heart Assoc. 2018;7:e009326. [DOI] [PubMed] [PMC]
SPRINT Research Group; Wright JT Jr, Williamson JD, Whelton PK, Snyder JK, Sink KM, Rocco MV, et al. A Randomized Trial of Intensive versus Standard Blood-Pressure Control.N Engl J Med. 2015;373:2103–16. [DOI] [PubMed] [PMC]
Panagiotakos D, Antza C, Kotsis V. Ambulatory and home blood pressure monitoring for cardiovascular disease risk evaluation: a systematic review and meta-analysis of prospective cohort studies.J Hypertens. 2024;42:1–9. [DOI] [PubMed]
Batta A, Singhania A, Sharma S, Gautam S, Singla A, Kalsi H, et al. Current practices and knowledge of home blood pressure monitoring among people with hypertension: Insights from a Multicentric study from North India.Indian Heart J. 2024;76:398–404. [DOI] [PubMed] [PMC]
Buckley LF, Dixon DL, Wohlford GF 4th, Wijesinghe DS, Baker WL, Van Tassell BW. Intensive Versus Standard Blood Pressure Control in SPRINT-Eligible Participants of ACCORD-BP.Diabetes Care. 2017;40:1733–8. [DOI] [PubMed]
Beddhu S, Greene T, Boucher R, Cushman WC, Wei G, Stoddard G, et al. Intensive systolic blood pressure control and incident chronic kidney disease in people with and without diabetes mellitus: secondary analyses of two randomised controlled trials.Lancet Diabetes Endocrinol. 2018;6:555–63. [DOI] [PubMed] [PMC]
Nuyujukian DS, Koska J, Bahn G, Reaven PD, Zhou JJ; VADT Investigators. Blood Pressure Variability and Risk of Heart Failure in ACCORD and the VADT.Diabetes Care. 2020;43:1471–8. [DOI] [PubMed] [PMC]
Adamsson Eryd S, Gudbjörnsdottir S, Manhem K, Rosengren A, Svensson AM, Miftaraj M, et al. Blood pressure and complications in individuals with type 2 diabetes and no previous cardiovascular disease: national population based cohort study.BMJ. 2016;354:i4070. [DOI] [PubMed] [PMC]
Emdin CA, Rahimi K, Neal B, Callender T, Perkovic V, Patel A. Blood pressure lowering in type 2 diabetes: a systematic review and meta-analysis.JAMA. 2015;313:603–15. [DOI] [PubMed]
Thomopoulos C, Parati G, Zanchetti A. Effects of blood-pressure-lowering treatment on outcome incidence in hypertension: 10 – Should blood pressure management differ in hypertensive patients with and without diabetes mellitus? Overview and meta-analyses of randomized trials.J Hypertens. 2017;35:922–44. [DOI] [PubMed]
Liu J, Li Y, Ge J, Yan X, Zhang H, Zheng X; ESPRIT Collaborative Group. 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.Lancet. 2024;404:245–55. [DOI] [PubMed]
Zhang W, Zhang S, Deng Y, Wu S, Ren J, Sun G, et al.; STEP Study Group. Trial of Intensive Blood-Pressure Control in Older Patients with Hypertension.N Engl J Med. 2021;385:1268–79. [DOI] [PubMed]
Bi Y, Li M, Liu Y, Li T, Lu J, Duan P, et al.; BPROAD Research Group. Intensive Blood-Pressure Control in Patients with Type 2 Diabetes.N Engl J Med. 2024. [DOI] [PubMed]
Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.Hypertension. 2018;71:1269–324. [DOI] [PubMed]
Rabi DM, McBrien KA, Sapir-Pichhadze R, Nakhla M, Ahmed SB, Dumanski SM, et al. Hypertension Canada’s 2020 Comprehensive Guidelines for the Prevention, Diagnosis, Risk Assessment, and Treatment of Hypertension in Adults and Children.Can J Cardiol. 2020;36:596–624. [DOI] [PubMed]
Unger T, Borghi C, Charchar F, Khan NA, Poulter NR, Prabhakaran D, et al. 2020 International Society of Hypertension Global Hypertension Practice Guidelines.Hypertension. 2020;75:1334–57. [DOI] [PubMed]
American Diabetes Association Professional Practice Committee. 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2025.Diabetes Care. 2025;48:S207–38. [DOI]
Mancia G, Kreutz R, Brunström M, Burnier M, Grassi G, Januszewicz A, et al. 2023 ESH Guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension: Endorsed by the International Society of Hypertension (ISH) and the European Renal Association (ERA).J Hypertens. 2023;41:1874–2071. [DOI] [PubMed]
McEvoy JW, McCarthy CP, Bruno RM, Brouwers S, Canavan MD, Ceconi C, et al.; ESC Scientific Document Group. 2024 ESC Guidelines for the management of elevated blood pressure and hypertension: Developed by the task force on the management of elevated blood pressure and hypertension of the European Society of Cardiology (ESC) and endorsed by the European Society of Endocrinology (ESE) and the European Stroke Organisation (ESO).Eur Heart J. 2024;45:3912–4018. [DOI] [PubMed]
Samson SL, Vellanki P, Blonde L, Christofides EA, Galindo RJ, Hirsch IB, et al. American Association of Clinical Endocrinology Consensus Statement: Comprehensive Type 2 Diabetes Management Algorithm – 2023 Update.Endocr Pract. 2023;29:305–40. [DOI] [PubMed]
Campbell TM, Campbell EK, Attia J, Ventura K, Mathews T, Chhabra KH, et al. The acute effects of a DASH diet and whole food, plant-based diet on insulin requirements and related cardiometabolic markers in individuals with insulin-treated type 2 diabetes.Diabetes Res Clin Pract. 2023;202:110814. [DOI] [PubMed] [PMC]
Guo R, Li N, Yang R, Liao XY, Zhang Y, Zhu BF, et al. Effects of the Modified DASH Diet on Adults With Elevated Blood Pressure or Hypertension: A Systematic Review and Meta-Analysis.Front Nutr. 2021;8:725020. [DOI] [PubMed] [PMC]
Ren J, Qin L, Li X, Zhao R, Wu Z, Ma Y. Effect of dietary sodium restriction on blood pressure in type 2 diabetes: A meta-analysis of randomized controlled trials.Nutr Metab Cardiovasc Dis. 2021;31:1653–61. [DOI] [PubMed]
Verma S, Hatwal J, Batta A. Impact of Yoga beyond Physical Training on the Cardiovascular System: An Updated Review.J Teh Univ Heart Ctr. 2024;19:79–88. [DOI]
Joshi AM, Raveendran AV, Arumugam M. Therapeutic role of yoga in hypertension.World J Methodol. 2024;14:90127. [PubMed] [PMC]
Naha S, Gardner MJ, Khangura D, Kurukulasuriya LR, Sowers JR. Hypertension in Diabetes. In: Feingold KR, Anawalt B, Blackman MR, Boyce A, Chrousos G, Corpas E, et al., editors. Endotext. South Dartmouth (MA): MDText.com, Inc.; 2000.
Cameron AC, Lang NN, Touyz RM. Drug Treatment of Hypertension: Focus on Vascular Health.Drugs. 2016;76:1529–50. [DOI] [PubMed]
Jamerson K, Weber MA, Bakris GL, Dahlöf B, Pitt B, Shi V, et al.; ACCOMPLISH Trial Investigators. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients.N Engl J Med. 2008;359:2417–28. [DOI] [PubMed]
Lindholm LH, Hansson L, Ekbom T, Dahlöf B, Lanke J, Linjer E, et al. Comparison of antihypertensive treatments in preventing cardiovascular events in elderly diabetic patients: results from the Swedish Trial in Old Patients with Hypertension-2.J Hypertens. 2000;18:1671–5. [DOI] [PubMed]
Dahlöf B, Sever PS, Poulter NR, Wedel H, Beevers DG, Caulfield M, et al.; ASCOT Investigators. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial.Lancet. 2005;366:895–906. [DOI] [PubMed]
Mackenzie IS, Rogers A, Poulter NR, Williams B, Brown MJ, Webb DJ, et al.; TIME Study Group. Cardiovascular outcomes in adults with hypertension with evening versus morning dosing of usual antihypertensives in the UK (TIME study): a prospective, randomised, open-label, blinded-endpoint clinical trial.Lancet. 2022;400:1417–25. [DOI] [PubMed] [PMC]
Carey RM. Special Article - The management of resistant hypertension: A 2020 update.Prog Cardiovasc Dis. 2020;63:662–70. [DOI] [PubMed]
Brouwers S, Sudano I, Kokubo Y, Sulaica EM. Arterial hypertension.Lancet. 2021;398:249–61. [DOI] [PubMed]
Sinnott SJ, Tomlinson LA, Root AA, Mathur R, Mansfield KE, Smeeth L, et al. Comparative effectiveness of fourth-line anti-hypertensive agents in resistant hypertension: A systematic review and meta-analysis.Eur J Prev Cardiol. 2017;24:228–38. [DOI] [PubMed]
Bakris GL, Agarwal R, Anker SD, Pitt B, Ruilope LM, Rossing P; FIDELIO-DKD Investigators. Effect of Finerenone on Chronic Kidney Disease Outcomes in Type 2 Diabetes.N Engl J Med. 2020;383:2219–29. [DOI] [PubMed]
Gnanenthiran SR, Webster R, Silva A, Maulik PK, Salam A, Selak V, et al.; TRIUMPH Study Group. Reduced efficacy of blood pressure lowering drugs in the presence of diabetes mellitus—results from the TRIUMPH randomised controlled trial.Hypertens Res. 2023;46:128–35. [DOI] [PubMed]
Liu W, Higashikuni Y, Sata M. Optimizing antihypertensive therapy in patients with diabetes mellitus.Hypertens Res. 2023;46:797–800. [DOI] [PubMed]
Chow CK, Atkins ER, Hillis GS, Nelson MR, Reid CM, Schlaich MP, et al.; QUARTET Investigators. Initial treatment with a single pill containing quadruple combination of quarter doses of blood pressure medicines versus standard dose monotherapy in patients with hypertension (QUARTET): a phase 3, randomised, double-blind, active-controlled trial.Lancet. 2021;398:1043–52. [DOI] [PubMed]
Parving HH, Brenner BM, McMurray JJ, de Zeeuw D, Haffner SM, Solomon SD, et al.; ALTITUDE Investigators. Cardiorenal end points in a trial of aliskiren for type 2 diabetes.N Engl J Med. 2012;367:2204–13. [DOI] [PubMed]
Ferdinand KC, White WB, Calhoun DA, Lonn EM, Sager PT, Brunelle R, et al. Effects of the once-weekly glucagon-like peptide-1 receptor agonist dulaglutide on ambulatory blood pressure and heart rate in patients with type 2 diabetes mellitus.Hypertension. 2014;64:731–7. [DOI] [PubMed]
Singh A, Sohal A, Batta A. GLP-1, GIP/GLP-1, and GCGR/GLP-1 receptor agonists: Novel therapeutic agents for metabolic dysfunction-associated steatohepatitis.World J Gastroenterol. 2024;30:5205–11. [PubMed] [PMC]
Soresi M, Giannitrapani L. Glucagon-like peptide 1 agonists are potentially useful drugs for treating metabolic dysfunction-associated steatotic liver disease.World J Gastroenterol. 2024;30:3541–7. [DOI] [PubMed] [PMC]
Xiang B, Zhao X, Zhou X. Cardiovascular benefits of sodium-glucose cotransporter 2 inhibitors in diabetic and nondiabetic patients.Cardiovasc Diabetol. 2021;20:78. [DOI] [PubMed] [PMC]
Bakris GL, Saxena M, Gupta A, Chalhoub F, Lee J, Stiglitz D; KARDIA-1 Study Group. RNA Interference With Zilebesiran for Mild to Moderate Hypertension: The KARDIA-1 Randomized Clinical Trial.JAMA. 2024;331:740–9. [DOI] [PubMed] [PMC]
Freeman MW, Halvorsen YD, Marshall W, Pater M, Isaacsohn J, Pearce C, et al. Phase 2 trial of baxdrostat for treatment-resistant hypertension.N Engl J Med. 2023;388:395–405. [DOI]
Schlaich MP, Bellet M, Weber MA, Danaietash P, Bakris GL, Flack JM, et al. Dual endothelin antagonist aprocitentan for resistant hypertension (PRECISION): a multicentre, blinded, randomised, parallel-group, phase 3 trial.Lancet. 2022;400:1927–37. [DOI] [PubMed]
Barbato E, Azizi M, Schmieder RE, Lauder L, Böhm M, Brouwers S, et al. Renal denervation in the management of hypertension in adults. A clinical consensus statement of the ESC Council on Hypertension and the European Association of Percutaneous Cardiovascular Interventions (EAPCI).Eur Heart J. 2023;44:1313–30. [DOI] [PubMed]