Ambulatory Systolic Blood Pressure and Carotid Atherosclerosis in Type 2 Diabetes: A Critical Role of Glycemic Control Stratification

Background: Ambulatory blood pressure monitoring (ABPM) is widely used in diabetes for cardiovascular risk assessment, but its link to early atherosclerosis, such as carotid plaques, is less clear. Aim: To assess associations between ABPM parameters and carotid plaques in type 2 diabetes by HbA1c level. Methods: This was a cross-sectional observational analysis conducted among patients with type 2 diabetes mellitus from the MMC platform.We analyzed 498 patients with 24-hour ABPM and carotid ultrasound, stratified by HbA1c (<5.7%, 5.7-6.4%, >6.4%). Logistic regression examined associations, with sensitivity and subgroup analyses.Model was adjusted for potential confounders including age, sex, BMI, history of hypertension, smoking, alcohol consumption, marital status, and educational attainment. Results: Carotid plaque prevalence was 46.6%. After covariate adjustment, elevated systolic BP (SBP) was significantly associated with plaques only in HbA1c ≥6.4%: 24-hour SBP ≥130 mmHg (OR=2.14, 95% CI: 1.30-3.56), awake SBP ≥135 mmHg (OR=1.87, 95% CI: 1.14-3.11), and asleep SBP ≥120 mmHg (OR=1.78, 95% CI: 1.08-2.95). No significant associations were observed for diastolic BP or in lower HbA1c groups. Findings were consistent across sensitivity and subgroup analyses. Conclusion: In poorly controlled diabetes, elevated SBP by ABPM is independently associated with carotid plaques, supporting combined ABPM and HbA1c assessment for early vascular risk detection.