Importance of blood pressure lowering in type 2 diabetes: focus on ADVANCE

Routine blood pressure lowering with the fixed combination of perindopril and indapamide in 11,140 patients with type 2 diabetes was very well tolerated and produced substantial benefits in reducing all-cause and cardiovascular mortality, the primary combined outcome of macro- or microvascular events, total coronary events, and total renal events, as reported previously. We present here a wealth of evidence, most of it previously published either in journal articles or in recent abstract form, that the relative risk reductions conferred by the combination of perindopril and indapamide are broadly consistent across subgroups defined by a wide range of baseline characteristics, including blood pressure at entry, age from below 65 to above 75 years, total cardiovascular risk defined according to the European guidelines, stage of chronic disease, and cognitive function. Furthermore, we report that the absolute risk reductions are significantly greater in those with increased cardiovascular risk, with more advanced nephropathy and in older subjects. We confirm that the effects of blood pressure lowering with perindopril-indapamide and of intensive glucose control with the gliclazide modified release (MR)-based regimen are independent and produce substantial additional benefits when combined. We also discuss these results in the context of other major trials and demonstrate how they extend the evidence on the benefits of blood pressure lowering in patients with diabetes. Finally, we present evidence that the results of The Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE trial) are broadly generalizable to patients with type 2 diabetes in community practice, and that if the joint benefits from routine blood pressure lowering with perindopril-indapamide and more intensive control with the gliclazide-MR-based regimen were applied worldwide, close to 2 million lives would be saved over the next 5 years.