DB 01-3 TREATMENT TARGET OF SYSTOLIC BLOOD PRESSURE IN DIABETES MAY DIFFER ACCORDING TO ETHNICITY (PRO).

Asians have specific characteristics of hypertension and related cardiovascular disease. Stroke is more common than coronary artery disease in Eastern Asian countries, while the coronary artery disease is more common than stroke in Western countries. The association slope between higher blood pressure (BP) and the risk of cardiovascular events is steeper in Asians than in Caucasians. This may partly explained by the recent result demonstrating that the morning BP surge in Asians is more extended (Hoshide, Kario, Parati et al. Hypertension 2016;68:54-61). Thus, 24-hr BP control including night-time and morning periods is especially important for Asian hypertensive patients (Kario. Essential manual of 24 hour blood pressure management. Wiley, UK, pp.1-158.2016).The existing direct evidence from Asian studies are limited than the accumulated evidence from Western countries. In the ACCORD BP trial which enrolled 4733 participants with type 2 diabetes and randomized them to a target systolic BP <120mmHg (intensive BP control) or <140mmHg (standard BP control). Despite the significant difference in the achieved systolic BP, there was no significant difference in the incidence of primary cardiovascular outcomes. Based on this evidence, the target systolic BP for diabetics has been revised from 130 mmHg to 140 mmHg in the majority of Western guidelines. However, in the ACCORD study, the intensive BP control was associated with significant reduction in both total stroke and nonfatal stroke. In addition, the ONTARGET study, which showed that in diabetic patients, the risk of stroke continued to decrease down to achieved SBP <115mmHg with no evidence of J curve.The new guidelines of the Japanese Society of Hypertension regarding the management of hypertension (JSH2014) were published in 2014 (Hypertens Res 2014;37:253-390). The JSH2014 guidelines use the systolic BP value 130 mmHg, a lower target clinic BP compared to the Western guidelines (140 mmHg), for hypertensive patients with diabetes or albuminuria. For these guidelines, we collected evidence from both Asian and Western studies, taking Asian characteristics into special consideration. In addition, the JSH2014 guidelines recommend that hypertensive patients with diabetes achieve home systolic BP values <125 mmHg. In our recent analysis of HONEST study, morning home systolic BP until 110 mmHg did not exhibit J-curve with both stroke and coronary artery disease in Japanese hypertensive patients including diabetic patients (Kario, et al. Hypertension 2014;64:989-996; J Am Coll Cardiol 2016;67:1519-1527).In this debate, I would like to stress the importance of ethnic differences, and the needs of Asian specific guidelines with the lower threshold of target systolic BP in Asian countries (Kario. Ann Glob Health 2016;82:254-273).