Lowering systolic blood pressure below 120 mm Hg in middle-aged adults with Type 2 diabetes did not significantly reduce the incidence of cardiovascular death, stroke, heart attack or other cardiovascular events compared to standard treatment targeting below 140 mm Hg, according to preliminary late-breaking research presented at the American Heart Association’s Scientific Sessions 2026 in Chicago and simultaneously published in the New England Journal of Medicine.
The OPTIMAL-DIABETES trial, conducted at 33 sites in Brazil, enrolled 9,476 adults aged 50 and older with elevated systolic blood pressure between 130 and 180 mm Hg, Type 2 diabetes, and either established cardiovascular disease, subclinical cardiovascular disease, chronic kidney disease or other risk factors. Participants were randomly assigned to intensive therapy (target <120 mm Hg) or standard therapy (target <140 mm Hg). Over a median follow-up of four years, the intensive group achieved an average systolic pressure of 122 mm Hg, while the standard group averaged 135 mm Hg.
The primary composite outcome—cardiovascular death, heart attack, stroke, hospitalization for heart failure or unstable angina—occurred in 6.0% of the intensive group versus 6.7% of the standard group, a non-significant 10% relative risk reduction. However, kidney-related events were about 55% higher in the intensive group (5.7% vs. 3.7%), primarily declines in kidney function, though end-stage renal disease rates were similar.
“These findings add important evidence about optimal blood pressure targets for adults with Type 2 diabetes,” said lead author Karla Santo, M.D., Ph.D., of Einstein Hospital Israelita in São Paulo. “While this trial did not find a statistically significant reduction in major cardiovascular events, more intensive blood pressure treatment may still have modest yet meaningful health benefits.”
The results come amid ongoing debate over optimal blood pressure targets. The American Heart Association/American College of Cardiology’s 2025 Joint Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults recommends keeping systolic pressure below 130 mm Hg and encourages reaching below 120 mm Hg for people at increased cardiovascular disease risk. High high blood pressure is the leading preventable risk factor for stroke, heart attack and heart failure, and people with Type 2 diabetes face elevated risks.
“These findings should not be interpreted as evidence that more intensive blood pressure lowering is ineffective for people with Type 2 diabetes,” said Otavio Berwanger, M.D., Ph.D., chair of the trial’s steering committee. “Rather, they suggest that any cardiovascular benefit may be smaller than that observed in individuals without Type 2 diabetes.” He emphasized that “a target below 120 mm Hg should not necessarily be applied universally to all patients, and treatment decisions should balance potential cardiovascular benefits, kidney effects, treatment burden and patient preferences.”
The trial’s open-label design and its exclusively Brazilian population limit generalizability. Still, the findings add to a complex evidence base. Separate research has suggested that Managing high blood pressure could prevent >500K CVD deaths annually in 20 countries, while another AHA release noted that a New high blood pressure guideline emphasizes prevention, early treatment to reduce CVD risk. For patients, the takeaway is that blood pressure management in Type 2 diabetes remains a nuanced balance, and clinicians should weigh cardiovascular benefits against kidney risks and individual tolerability. The full abstract is available in the conference’s online program planner.
