Blood Pressure Levels and Outcomes in Type 2 Diabetes: Dose-Response Meta-Analysis of 5.87 Million Cohort Participants

Clinical Snapshot

Key Findings

• P Value: Not reported in abstract

• Effect Size: J-shaped curves for SBP with mortality and CV events; linear associations for renal outcomes

• Primary Outcome: J-shaped association between systolic BP and all-cause mortality in type 2 diabetes

• Nnt Or Sensitivity: Dose-response relationships suggest lower SBP targets may be beneficial for CV outcomes without mortality penalty

• Confidence Interval: Not reported in abstract

Clinical Application

Highly feasible as BP measurement and management are standard diabetes care components Directly relevant to RACGP diabetes guidelines and PBS-subsidised antihypertensive medications; supports individualised BP targets in diabetes management Adults with type 2 diabetes in primary care and specialist endocrinology settings

Abstract

BACKGROUND: The dose-response relationships between systolic and diastolic blood pressure (SBP and DBP) levels and risks of all-cause mortality, cardiovascular and renal outcomes in type 2 diabetes remain poorly characterized, particularly at lower blood pressure (BP) levels. OBJECTIVE: This study aimed to examine risk patterns of major clinical outcomes across a wide range of BP levels in participants with type 2 diabetes. METHODS: We systematically searched PubMed, Embase, and Web of Science from inception to November 30, 2024, for cohort studies assessing associations of BP levels with all-cause mortality, cardiovascular, and renal outcomes. One-stage mixed-effects dose-response meta-analysis was conducted to assess the curvilinear associations. RESULTS: A total of 89 cohorts from 113 articles of 5,875,364 participants with type 2 diabetes were identified. A J-shaped association was observed for SBP with all-cause mortality. J-shaped associations were also observed for SBP with cardiovascular events and for DBP with all-cause mortality, with flattened risks at lower BP levels. After excluding studies with participants who had baseline cardiovascular diseases or cancer, a significantly lower risk of cardiovascular events was observed at lower SBP levels, as well as a flattened risk of all-cause mortality. Positive linear or monotonic trends were observed for renal events, estimated glomerular filtration rate decline, and development or progression of albuminuria. CONCLUSIONS: In type 2 diabetes, BP is linearly or monotonically associated with most cardiovascular and renal outcomes. Low SBP does not appear to be associated with an elevated risk of all-cause mortality compared with higher BP targets, suggesting that previously reported associations are likely due to reverse causation and unmeasured confounding.

References

1. 1.Wang, S., Wang, K., Gu, H., Zhang, J., Cai, L., Xie, W., Yang, Q., Zheng, R., Zhang, X., Xiang, Y., Wang, T., Zhao, Z., Li, M., Zheng, J., Xu, M., Lu, J., Ning, G., Wang, W., Bi, Y., & Xu, Y. (2026). Blood pressure levels and outcomes in type 2 diabetes: Dose-response meta-analysis of 5.87 million cohort participants. Journal of the American College of Cardiology. https://doi.org/10.1016/j.jacc.2025.10.068