The OPTIMAL-DIABETES trial followed nearly 9,500 adults. One group got intensive blood pressure treatment. That group had 54% more kidney problems than the group on standard care. The kidney harm was clear in the data. The heart benefit, which was the reason for the lower target, was not.
For years, experts have followed a simple rule for blood pressure: lower is better. For high-risk patients, the goal was to get systolic pressure (the top number) below 120 mm Hg. The SPRINT trial backed this up. It studied adults with high blood pressure who did not have diabetes. Aiming below 120 led to far fewer heart attacks, strokes, and other heart events than aiming below 140. But SPRINT left out people with diabetes. Whether its results apply to people with type 2 diabetes has now been tested three times.
OPTIMAL-DIABETES is the newest and largest of these tests. Its results were published in the New England Journal of Medicine. They were also presented at the American Heart Association’s 2026 Scientific Sessions.
What did the OPTIMAL-DIABETES trial find?
The trial took place at 33 centers in Brazil. It included 9,476 people aged 50 and older with type 2 diabetes and high blood pressure. Their systolic pressure was between 130 and 180 mm Hg. All had a high risk of heart disease. Some already had heart disease or early signs of it. Others had kidney disease, smoked, had high cholesterol, or were 75 or older. Patients were randomly placed in one of two groups. One group aimed for systolic pressure below 120. The other aimed for below 140.
Over about four years, the intensive group averaged 122 mm Hg. The standard group averaged 135 mm Hg. Major heart events included heart death, heart attack, stroke, and hospital stays for heart failure or unstable chest pain. These happened in 6.0% of the intensive group and 6.7% of the standard group. The American Heart Association said this gap was too small to tell apart from chance.
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Kidney problems happened in 5.7% of the intensive group and 3.7% of the standard group, the American Heart Association reported. Most were drops in how well the kidneys filter blood. People with diabetes are already at higher risk for kidney disease, so this is a real concern. The trial does not show that lower blood pressure hurts the heart. The results actually leaned slightly toward a heart benefit. But that benefit was too small to confirm in nearly 9,500 people. The kidney harm was clear.
A pattern across three trials
OPTIMAL-DIABETES is not the only trial on this question. The SPRINT trial found fewer heart events with systolic pressure below 120 in people with high blood pressure but no diabetes. The ACCORD BP trial studied people with type 2 diabetes. It found no clear heart benefit from aiming lower.
The one exception is the BPROAD trial in China. The BPROAD trial studied people with type 2 diabetes, high blood pressure, and higher heart risk. Aiming below 120 instead of below 140 cut major heart events by 21%. These included non-fatal strokes, non-fatal heart attacks, heart failure needing treatment or a hospital stay, and heart death. BPROAD and OPTIMAL-DIABETES studied similar people with the same target. Yet they came to opposite results on major heart events.
Why do kidney results matter as much as heart results?
Kidney disease is one of the main long-term problems of type 2 diabetes. It causes a lot of illness and raises heart risk. The 2025 AHA/ACC hypertension guidelines say that pushing blood pressure very low has risks. These include blood pressure that drops too low, changes in blood salts like potassium, and sudden kidney damage. The guidelines say older or frail patients should have personal blood pressure targets that balance safety and benefit.
New 2026 research also looks at which drugs are used to reach lower targets. One common type of blood pressure drug is called dihydropyridine calcium channel blockers. In people with type 2 diabetes, these drugs have been linked to a 33% higher risk of serious kidney problems. This was true even in people taking drugs to protect their kidneys. So the drugs used to reach a target matter as much as the target. ACE inhibitors and ARBs are the first drugs recommended for high blood pressure in people with diabetes, according to a 2024 review. That advice is based on decades of research showing they help protect the kidneys.
For a person with diabetes, lowering systolic pressure from 135 to 122 may or may not help the heart. But the kidney risk is clear. This is especially true for older or frail patients. The 2025 AHA/ACC guidelines keep 130/80 mm Hg as the point to diagnose and treat high blood pressure. They push for earlier control and treatment that fits each patient. Think of a 72-year-old with diabetes-related kidney disease and weak kidney function. A target that causes kidney problems in about 1 in 18 patients is a bigger risk for that person than for a younger person with healthy kidneys.
What should guide blood pressure targets in diabetes?
The evidence does not support 120 mm Hg as a target for everyone with type 2 diabetes. The 2025 AHA/ACC guidelines say adults with diabetes should start blood pressure medicine when their average is 130/80 mm Hg or higher. The goal is below 130/80.
The choice of drug matters too. ACE inhibitors and ARBs are the standard first choice for people with type 2 diabetes because they help protect the kidneys. Taking the right kidney-protecting drugs may help the kidneys more than chasing a very low number. If you have type 2 diabetes, ask about the type of blood pressure drug you take, not just your target number.
Experts still don’t agree on the best blood pressure target for people with type 2 diabetes. The idea that SPRINT’s results apply to them has been tested three times. It failed twice and worked once.
The bottom line
In the OPTIMAL-DIABETES trial, nearly 9,500 people with type 2 diabetes aimed for systolic pressure below 120. It did not clearly lower heart attacks, strokes, heart deaths, or hospital stays. It did lead to more kidney problems. These results fit with the 130/80 mm Hg target in the 2025 AHA/ACC guidelines for most people with diabetes.
If you have type 2 diabetes and high blood pressure, talk with your doctor about two things. One is your target number. The other is which drugs you take to get there. Guidelines usually suggest ACE inhibitors or ARBs first for people with diabetes, partly because they protect the kidneys. If you take a calcium channel blocker, it’s fair to ask about checking your kidneys. If your doctor suggests a target below 120, ask what benefit the research shows for someone like you. For most people with diabetes, that answer is much less certain than it once seemed.
Disclaimer: This information is not intended to be a substitute for professional medical advice, diagnosis, or treatment and is for information only. Always seek the advice of your physician or another qualified health provider with any questions about your medical condition and/or current medication. Do not disregard professional medical advice or delay seeking advice or treatment because of something you have read here.
AI Disclaimer: This article was created with the assistance of AI tools and reviewed by a human editor.