Optimal Blood Pressure for the prevenTIon of Major vAscuLar Events in Patients With DIABETES Mellitus (OPTIMAL-DIABETES)
Optimal Blood Pressure for the prevenTIon of Major vAscuLar Events in Patients With DIABETES Mellitus (OPTIMAL-DIABETES)
High blood pressure (BP) is a major public health concern, especially in low and middle
 income countries. High BP is a highly prevalent condition, and it is usually associated with
 diabetes mellitus. Both high BP and diabetes are risk factors for major cardiovascular events
 including cardiovascular death, acute myocardial infarction, stroke, unstable angina and
 heart failure. In addition, high BP is also related to cognitive decline. The
 OPTIMAL-DIABETES trial consists of a two-arm, multicenter, randomized clinical trial designed
 to test whether a lower systolic blood pressure (SBP) target will reduce the occurrence of
 major cardiovascular events in diabetic patients compared to the standard SBP target.
Inclusion Criteria:

 -  Systolic Blood Pressure (SBP) between 130 and 180 mm Hg:

 -  130 to 150 mm Hg (if on 0-4 medications)

 -  130 to 160 mm Hg (if on 0-3 medications)

 -  130 to 170 mm Hg (if on 0-2 medications)

 -  130 to 180 mm Hg (if on 0-1 medications)

 -  Type 2 diabetes

 -  To be considered as having a high cardiovascular risk, including AT LEAST ONE of the
 following factors:

 1. Established cardiovascular disease (CVD), including:

 -  Coronary artery disease: previous myocardial infarction, previous acute
 coronary syndrome, previous percutaneous coronary intervention, previous
 coronary artery bypass graft surgery, or at least 50% stenosis in a main
 coronary artery associated with typical angina pectoris; or

 -  Cerebrovascular disease: previous stroke (except those events caused by
 intracranial aneurysm or arteriovenous malformation) or previous transient
 ischemic attack (TIA), stable for at least 2 weeks preceding inclusion in
 the study; or

 -  Carotid artery disease: previous carotid endarterectomy, previous
 percutaneous intervention with carotid stent implantation, or asymptomatic
 stenosis of at least 50% in a carotid shown by the Doppler ultrasonography;
 or

 -  Peripheral artery disease: prior surgical or percutaneous revascularization
 of a peripheral artery, limb amputation due to vascular cause, abdominal
 aortic aneurysm ≥ 5 cm (with or without prior surgical or percutaneous
 repair), or stenosis of at least 50% in a peripheral artery associated to
 intermittent claudication.

 2. Subclinical CVD, including:

 -  Coronary calcium score ≥ 300 Agatston units; or

 -  Ankle-brachial index ≤ 0.90 in the last two years; or

 -  Left ventricular hypertrophy on the electrocardiogram, echocardiogram or
 other cardiac imaging exam in the last two years.

 3. Chronic kidney disease (CKD):

 ▪ Definition of CKD: glomerular filtration rate (GFR) between 20 and 59
 ml/min/1.73m2 calculated by the Chronic Kidney Disease Epidemiology Collaboration
 (CKD-EPI).

 4. Additional cardiovascular risk factors, including:

 -  Active smoking: Defined as regular use of cigarettes or other tobacco
 products, such as cigars and pipe, in the last six months;

 -  Dyslipidemia: Defined as LDL cholesterol > 70 mg/dL or non-HDL cholesterol >
 100 mg/dL in patients with previous CVD; or LDL cholesterol > 100 mg/dL or
 non-HDL cholesterol > 130 mg/dL in patients without previous CVD; or
 Triglycerides > 200 mg/dL or HDL < 40 mg/dL regardless of treatment; or use
 of statins or other lipid lowering medication; or

 -  Age ≥ 75 years

 Exclusion Criteria:

 -  Refusal to provide written informed consent

 -  Body mass index > 45 kg/m2

 -  Known secondary cause of hypertension

 -  Severe renal dysfunction with GFR < 20 mL/min/1.73m2 calculated by the CKD-EPI
 equation

 -  Angina at rest Class IV Canadian Cardiovascular Society (CCS)

 -  Acute coronary syndrome in the last six months

 -  Symptomatic heart failure Class IV New York Heart Association (NYHA) or ejection
 fraction < 35% on Doppler echocardiography in the last six months

 -  Factors that at the research team´s judgment may limit adherence to the intervention
 and study protocol, including, but not limited to, the following examples:

 -  Recent history of alcohol and illicit drug abuse

 -  Psychiatric comorbidities (severe depression, schizophrenia, psychosis, etc.)

 -  History of poor medication adherence and attendance to consultations

 -  Any plans to move the city of residence in the next four years

 -  Any plans to leave the city of residence for more than three months in the next
 few years

 -  Living in the same residence of another patient previously included in this study

 -  Patients currently enrolled in another study for CVD prevention, including those
 evaluating pharmacological and non-pharmacological interventions

 -  Pregnancy or breastfeeding