Intensive Blood Pressure Control, Falls, and Fractures in Patients with Type 2 Diabetes: The ACCORD Trial
There are few rigorous studies to confirm or refute the commonly cited concern that control of blood pressure to lower thresholds may result in an increased risk of falls and fractures.
To compare falls and fractures in participants with type 2 diabetes in the intensive (targeting a systolic blood pressure of < 120 mmHg) and standard (targeting a systolic blood pressure of < 140 mmHg) blood pressure control arms of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) randomized trial (N = 4,733).
A subset of 3,099 participants self-reported annually on the occurrence of falls and non-spine fractures. Fractures were centrally adjudicated.
The incidence of falls in the two treatment groups was compared using a random-effects negative binomial model, and fracture risk was compared using Cox proportional hazards models.
At enrollment in both groups, the mean age was 62 years, 44 % were women, 25 % were Black, and mean blood pressure was 138/75 mmHg. During follow-up, all classes of medications, particularly thiazide diuretics, were more commonly prescribed in the intensive group. After 1 year of follow-up, the mean systolic blood pressure was 133 ± 15 mmHg in the standard group and 119 ± 14 mmHg in the intensive group. The adjusted rate of falls did not differ in the intensive and standard groups (62.2/100 person-years vs. 74.1/100 person-years, RR = 0.84, 95 % CI 0.54–1.29, p = 0.43). The risk of non-spine fractures was nonsignificantly lower in the intensive than in the standard blood pressure group (HR 0.79, 95 % CI 0.62–1.01, p = 0.06).
We conclude that intensive antihypertensive treatment that lowered mean systolic blood pressure to below 120 mmHg was not associated with an increased risk of falls or non-spine fractures in patients age 40 to 79 years with type 2 diabetes.
KEY WORDStype 2 diabetes mellitus hypertension falls fractures
- 1.Collins R, Peto R, MacMahon S, Hebert P, Fiebach N, Eberlein K, Godwin J, Qizilbash N, Taylor J, Hennekens C. Blood pressure, stroke, and coronary heart disease. Part 2, short-term reductions in blood pressure: overview of randomised drug trials in their epidemiological context. Lancet. 1990;335:827–38.PubMedCrossRefGoogle Scholar
- 3.Czernichow S, Zanchetti A, Turnbull F, Barzi F, Ninomiya T, Kengne AP, Lambers Heerspink HJ, Perkovic V, Huxley R, Arima H, Patel A, Chalmers J, Woodward M, MacMahon S, Neal B. The effects of blood pressure reduction and of different blood pressure-lowering regimens on major cardiovascular events according to baseline blood pressure: meta-analysis of randomized trials. J Hypertens. 2011;29(1):4–16.PubMedCrossRefGoogle Scholar
- 5.Riefkohl EZ, Bieber HL, Burlingame MB, Lowenthal DT. Medications and falls in the elderly: a review of the evidence and practical considerations. Pharm Ther. 2003;28(11):724–33.Google Scholar
- 7.Curb J, Applegate W, Vogt T, Pressel S, Lee M, Hoffmeier M, Schron R, Bearden D, Huber M, Moye L, Systolic Hypertension in the Elderly Program Cooperative Group. Antihypertensive therapy and falls and fractures in the systolic hypertension in the elderly program. J Am Geriatr Soc. 1993;41:SA15.Google Scholar
- 8.Peters R, Beckett N, Burch L, de Vernejoul MC, Liu L, Duggan J, Swift C, Gil-Extremera B, Fletcher A, Bulpitt C. The effect of treatment based on a diuretic (indapamide) +/− ACE inhibitor (perindopril) on fractures in the Hypertension in the Very Elderly Trial (HYVET). Age Ageing. 2010;39(5):609–16.PubMedCrossRefGoogle Scholar
- 10.Buse JB, Bigger JT, Byington RP, Cooper LS, Cushman WC, Friedewald WT, Genuth S, Gerstein HC, Ginsberg HN, Goff DC Jr, Grimm RH Jr, Margolis KL, Probstfield JL, Simons-Morton DG, Sullivan MD. Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial: design and methods. Am J Cardiol. 2007;99(12A):21i–33i.PubMedCrossRefGoogle Scholar
- 11.Cushman WC, Grimm RH Jr, Cutler JA, Evans GW, Capes S, Corson MA, Sadler LS, Alderman MH, Peterson K, Bertoni A, Basile JN. Rationale and design for the blood pressure intervention of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. Am J Cardiol. 2007;99(12A):44i–55.PubMedCrossRefGoogle Scholar
- 12.Schwartz AV, Margolis KL, Sellmeyer DE, Vittinghoff E, Ambrosius WT, Bonds DE, Josse RG, Schnall AM, Simmons DL, Hue TF, Palermo L, Hamilton BP, Green JB, Atkinson HH, O’Connor PJ, Force RW, Bauer DC. Intensive glycemic control is not associated with fractures or falls in the ACCORD randomized trial. Diabetes Care. 2012;35(7):1525–31.PubMedCentralPubMedCrossRefGoogle Scholar
- 13.Gibson MJ, Andres RO, Isaacs B. The prevention of falls in later life. A report of the Kellogg International Work Group on the Prevention of Falls by the Elderly. Dan Med Bull. 1987;34(Suppl 4):1–24.Google Scholar
- 14.National Kidney Foundation Kidney Disease Outcomes Quality Initiative. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002;39(2 Suppl 1):S1–246.Google Scholar
- 15.Beckett NS, Peters R, Fletcher AE, Staessen JA, Liu L, Dumitrascu D, Stoyanovsky V, Antikainen RL, Nikitin Y, Anderson C, Belhani A, Forette F, Rajkumar C, Thijs L, Banya W, Bulpitt CJ. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358(18):1887–98.PubMedCrossRefGoogle Scholar
- 42.Butt DA, Mamdani M, Austin PC, Tu K, Gomes T, Glazier RH. The risk of hip fracture after initiating antihypertensive drugs in the elderly. Arch Intern Med. 2012;19:1–6.Google Scholar
- 53.Gangavati A, Hajjar I, Quach L, Jones RN, Kiely DK, Gagnon P, Lipsitz LA. Hypertension, orthostatic hypotension, and the risk of falls in a community-dwelling elderly population: the maintenance of balance, independent living, intellect, and zest in the elderly of Boston study. J Am Geriatr Soc. 2011;59(3):383–9.PubMedCentralPubMedCrossRefGoogle Scholar