Intensive vs standard blood pressure control in adults with type 2 diabetes: a systematic review and GRADE-based...

The optimal blood pressure (BP) target for older adults with type 2 diabetes (T2DM) remains controversial. This meta-analysis compares intensive BP control (IBPC) versus standard BP control in T2DM patients.

Following PRISMA guidelines, we searched PubMed, Embase, and Cochrane Central through March 2025 for randomized controlled trials (RCTs) comparing IBPC (target <130/80 mm Hg) with standard control (<140/90 mm Hg) in adults ≥35 years with T2DM. Primary outcome was a composite of nonfatal stroke, nonfatal myocardial infarction, cardiovascular (CV) death, or heart failure hospitalization. Secondary outcomes included microvascular complications and safety. Data were pooled using random-effects models (I ² > 50%) or fixed-effects models (I ² ≤ 50%).

Ten RCTs (n = 23 826) were included. IBPC significantly reduced the primary composite outcome (OR: 0.82, 95% CI: 0.74-0.91, P = 0.0001, I ² = 0%) and stroke risk (OR: 0.62, 95% CI: 0.49-0.79, P = 0.0001). Microvascular benefits included reduced retinopathy (OR: 0.83, 95% CI: 0.71-0.97, P = 0.02) and albuminuria (OR: 0.83, 95% CI: 0.70-0.99, P = 0.03). No significant differences were observed in all-cause mortality (OR: 0.86, 95% CI: 0.71-1.04, P = 0.12), CV mortality (OR: 0.77, 95% CI: 0.53-1.11, P = 0.16), or renal failure (OR: 0.96, 95% CI: 0.34-2.69, P = 0.94). Subgroup analysis showed diastolic BP-targeted trials had greater mortality reduction (OR: 0.52, 95% CI: 0.33-0.83, P = 0.005) versus systolic BP-targeted trials (P = 0.88). Serious adverse events did not differ between groups (OR: 1.28, 95% CI: 0.90-1.81, P = 0.17).

In T2DM patients, IBPC reduces cardiovascular events and microvascular complications without increasing adverse events, supporting lower BP targets (<130/80 mm Hg). Diastolic BP control may offer additional mortality benefits.