March 24th, 2010
ACCORD: Bigger Issues for Our Patients
JoAnne M. Foody, MD
We are now at a point where it is increasingly difficult to demonstrate the incremental value of any preventive therapy, as we are successful in reducing CV risk to lower and lower levels. What is my take on the ACCORD BP study? It’s that we should focus on ensuring that all patients achieve at least the “conservative” risk factor goals that were achieved in ACCORD.
While we argue over which target to achieve for BP, millions of Americans remain unaware of their blood pressure, and few with elevated levels are treated to even conservative goals. To me, this is the bigger issue for our patients and for us as clinicians and healthcare providers.
…what are your thoughts?
3 Responses to “ACCORD: Bigger Issues for Our Patients”
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intensive BP lowering needs to be targeted
Joanne, it is interesting that no one has mentioned that for the half of ACCORD that was randomized to the moderate glucose-lowering arm, intensive BP lowering did prevent the primary endpoint. This is buried in one of the supplementary appendices, and speaks to a harmful interaction between intensive glucose lowering and intensive BP lowering. I also think that the days of blanket prescribing of a specific approach across the board in diabetes is over. Intensive BP lowering should probably be targeted in a personalized medicine fashion to key patient subtypes: 1) patients with target organ damage such as LVH, microalbuminuria, retinopathy; 2) patients with a history of ischemic or hemorrhagic stroke, especially lacunar stroke syndromes; 3) patients with identifiable readily treatable causes of HTN such as high renin hypertension and hyperaldosteronism, which together account for >50% of cases of resistant hypertension.
The Challenge
Seems to me that at this point we do not have the evidence to proceed with an intensive blood pressure strategy for anyone. It is interesting to speculate about whether there are subgroups that might benefit – but we need stronger evidence than can be obtained from a subgroup analysis of ACCORD in order to justify it.
Don’t throw out the baby with the bathwater just yet…
The finding of substantially and significantly reduced stroke, albeit a secondary endpoint, should not be overlooked. In addition, in the 50% of patients who were randomized to moderate glucose lowering, intensive BP lowering did prevent the primary endpoint. Taken together, these two findings dispute the argument that intensive BP lowering lacks benefit.