Intensive vs standard blood pressure control in adults with type 2 diabetes: a systematic review and GRADE-based meta-analysis

Background: The optimal blood pressure (BP) target for older adults with type 2 diabetes (T2DM) remains controversial. This meta-analysis compares intensive BP control (IBPC) versus standard BP control in T2DM patients. Methods: Following PRISMA guidelines, we searched PubMed, Embase, and Cochrane Central through March 2025 for randomized controlled trials (RCTs) comparing IBPC (target <130/80 mm Hg) with standard control (<140/90 mm Hg) in adults ≥35 years with T2DM. Primary outcome was a composite of nonfatal stroke, nonfatal myocardial infarction, cardiovascular (CV) death, or heart failure hospitalization. Secondary outcomes included microvascular complications and safety. Data were pooled using random-effects models ( I 2 > 50%) or fixed-effects models ( I 2 ≤ 50%). Results: Ten RCTs ( n = 23 826) were included. IBPC significantly reduced the primary composite outcome (OR: 0.82, 95% CI: 0.74–0.91, P = 0.0001, I 2 = 0%) and stroke risk (OR: 0.62, 95% CI: 0.49–0.79, P = 0.0001). Microvascular benefits included reduced retinopathy (OR: 0.83, 95% CI: 0.71–0.97, P = 0.02) and albuminuria (OR: 0.83, 95% CI: 0.70–0.99, P = 0.03). No significant differences were observed in all-cause mortality (OR: 0.86, 95% CI: 0.71–1.04, P = 0.12), CV mortality (OR: 0.77, 95% CI: 0.53–1.11, P = 0.16), or renal failure (OR: 0.96, 95% CI: 0.34–2.69, P = 0.94). Subgroup analysis showed diastolic BP-targeted trials had greater mortality reduction (OR: 0.52, 95% CI: 0.33–0.83, P = 0.005) versus systolic BP-targeted trials ( P = 0.88). Serious adverse events did not differ between groups (OR: 1.28, 95% CI: 0.90–1.81, P = 0.17). Conclusion: In T2DM patients, IBPC reduces cardiovascular events and microvascular complications without increasing adverse events, supporting lower BP targets (<130/80 mm Hg). Diastolic BP control may offer additional mortality benefits.