Against the background of population aging and a high prevalence of comorbid chronic diseases, type 2 diabetes mellitus (T2DM), chronic kidney disease (CKD), and hypertension form an overlapping risk network in the elderly population, with cardiovascular disease remaining the leading cause of death in this group. Blood pressure control plays a key role in reducing the incidence of cardiovascular events and mortality risk in patients with diabetes.
However, considerable uncertainty remains regarding the optimal blood pressure targets for elderly patients. Although more intensive blood pressure-lowering treatment is associated with cardiovascular protective benefits in some populations, this strategy remains controversial in elderly patients. A growing body of research suggests that overly strict blood pressure control may lead to adverse outcomes, including increased mortality, higher fall rates, renal impairment, and cognitive decline. Meanwhile, most existing hypertension clinical guidelines are based on randomized controlled trials that underrepresent or even exclude elderly individuals—especially those with multiple chronic comorbidities—markedly limiting the applicability of such evidence to real-world elderly patients.
Furthermore, while extensive attention has been paid to blood pressure levels and treatment thresholds in existing research, the prognostic significance of missing blood pressure recordings in routine clinical practice has long been overlooked. Missing blood pressure data may reflect inadequate access to healthcare, insufficient disease monitoring, or poor patient engagement in follow-up care, all of which may be closely linked to elevated cardiovascular risk. Nevertheless, the impact of missing blood pressure recordings on clinical outcomes has not been systematically evaluated and remains an important area requiring in-depth investigation.
A recent real-world study published in Diabetes, Obesity and Metabolism, including more than 180,000 elderly patients with T2DM and CKD, systematically analyzed the associations of blood pressure levels and missing blood pressure recordings with cardiovascular outcomes and all-cause mortality. Using the UK Clinical Practice Research Datalink (CPRD), the study established the largest real-world cohort in this field to date. The primary outcome was a 3-point major adverse cardiovascular event (MACE) composite of non-fatal stroke, non-fatal myocardial infarction, and cardiovascular death; the secondary outcome was all-cause mortality.
The results showed that among elderly patients with T2DM and CKD, lower systolic blood pressure (SBP) and diastolic blood pressure (DBP) were associated with a moderate increase in the risk of MACE and mortality. However, the strongest predictor of adverse outcomes was the lack of regular blood pressure monitoring.
These findings are highly consistent with previous observational studies in elderly patients with diabetes or CKD. Prior evidence has shown that in elderly or CKD patients, systolic blood pressure often exhibits a U-shaped or J-shaped relationship with mortality and cardiovascular outcomes—meaning risk increases significantly with both excessively high and low blood pressure. This study further strengthens the warning against the indiscriminate implementation of intensive blood pressure targets in high-risk elderly populations and highlights the complexity and controversy surrounding blood pressure management evidence in elderly patients with T2DM and CKD.