Comment on: Rogers et al. Blood pressure trajectories prior to death in patients with diabetes. Diabetes Care 2011;34:1534-1539.

With great interest we read the article by Rogers et al. (1) in which they showed that both systolic and diastolic blood pressure declined more rapidly in the 4 years before death than in patients who remained alive. In a model adjusted for, among other factors, age, sex, use of ACE inhibitors and angiotensin receptor blockers (ARBs), and heart failure, mean systolic blood pressure decreased by 3.2 mmHg per year in the years prior to death compared with 0.7 mmHg per year in those who were alive at the end of follow-up.

The authors correctly acknowledge that their results should be interpreted with caution. Furthermore, on the basis of the available information, they cannot discern whether treatment intensification played a role in blood pressure decrease or whether declining blood pressure per se is a harbinger of the dying process. Although the authors elaborately tried to adjust for frailty and declining health, including heart failure, no attempts were described to investigate whether antihypertensive treatment, except from ACE inhibitors and ARBs, or intensification of treatment influenced the results. In our Zwolle Outpatient Diabetes project Integrating Available Care (ZODIAC-12) study (2), also referred to by the authors, we found an inverse relationship between blood pressure and mortality in elderly patients with type 2 diabetes. However, this relationship did not exist in the elderly patients who did not receive antihypertensive treatment. Furthermore, data from our study show that the mean blood pressures of the patients in the 2005 and 2008 cohorts were 144.6 mmHg (n = 4,508) and 140.0 (n = 27,438), respectively (K.J.J.v.H.,unpublished data), with at the same time a more intensive blood pressure–lowering treatment in 2008 compared with 2005.

Our data suggest that it is likely that antihypertensive treatment has intensified in patients with type 2 diabetes in the period between 2005 and 2008. Therefore, we would be very interested to hear whether it is possible to perform additional analyses in which adjustment for antihypertensive treatment or treatment intensification can be made.