Current Consensus and Controversies in Guidelines for Lipid and Hypertension Management in Diabetes

Despite major advances, many patients with diabetes are currently achieving suboptimal control of lipids and blood pressure. The new cholesterol guidelines by the ACC/AHA have reignited the emphasis on more intensive treatment with statins in the population at high risk of CVD, including those with diabetes. While these guidelines do not include specific lipid goals, several other guidelines have retained previously defined risk-based LDL-C and non-HDL-C goals. More recent data indicate potential benefits in CVD outcomes with non-statin therapy added to statin therapy. On-going long-term trials with PCSK-9 inhibitors may help answer the question of the benefits and safety of very low LDL-C. Regarding the blood pressure guidelines, there remains an inconsistency of evidence for targets to reduce CVD outcomes. The ACCORD trial weighted heavily in the recent meta-analyses, leading to currently recommended goal of <140/90 mmHg. Studies targeting blood pressure goals of <130 mmHg in younger patients with diabetes, including sub-populations of interest, may help solve the controversy. Until we have these data, perhaps it is time to shift our focus from a rigid blood pressure target to risk-based goals.