Notwithstanding the current recommendation that OBP measurement remains the cornerstone of hypertension diagnosis and management, there is now a general consensus that isolated OBP readings alone are no longer sufficient. In line with these findings, evidence has also been provided that in hypertensive patients with coexisting type 2 diabetes, tighter control of clinic BP is particularly important in order to improve CV protection ( 12– 23). Evidence on this has been provided from several studies, showing a continuous direct and synergic relationship of elevated BP levels and type 2 diabetes with risk of target-organ damage and CV events without any evidence of BP threshold level ( 8– 11).
Patients with diabetes and elevation in clinic BP levels are at higher CV risk compared with nondiabetic individuals ( 8– 10). The aim of the present article is to review the available evidence on the prognostic importance of BP mean levels and of BP variability (BPV) estimates and to critically evaluate whether antihypertensive treatment strategies should be targeted at reducing not only average BP levels but also the degree of BPV in order to optimize CV protection in diabetic patients. These findings are of upmost relevance in the case of diabetic patients who are characterized by a significantly higher risk of CV events compared with nondiabetic individuals, with diabetes itself currently considered a CV disease equivalent ( 5, 6). In particular, 1) average BP measured in everyday life conditions may be an even better predictor of CV outcomes than isolated OBP readings and 2) the extent of fluctuations of BP over time may provide additional, independent prognostic information compared with both isolated office readings and average ambulatory BP (ABP) levels, respectively.
However, application over the last 40 years of techniques for out-of-office BP monitoring including home BP monitoring (HBPM) and 24-h ambulatory BP monitoring (ABPM) has led to further important findings. Overwhelming evidence is now available showing that BP measured in the office shows a linear relationship with a number of CV and renal outcomes as well as with overall mortality and that lowering of office BP (OBP) with treatment is effective in reducing morbidity and mortality ( 3, 4). Elevated blood pressure (BP) is a major risk factor for cardiovascular (CV) events and mortality ( 1) and a leading contributor to the global disease burden ( 2).