Abstract Body (Do not enter title and authors here): Background: Cardiovascular disease (CVD) is the leading cause of death among individuals with diabetes. However, evidence regarding optimal blood pressure (BP) targets in these patients remains uncertain.

Aim: We assessed the effectiveness of a community health worker (CHW)-led intensive BP intervention on CVD and all-cause mortality in participants with and without diabetes.

Methods: The China Rural Hypertension Control Project (CRHCP) involved 33,995 hypertensive individuals (6,300 with diabetes and 27,695 without diabetes) aged ≥40 years from 326 villages in rural China. A total of 163 villages were randomly assigned to a CHW-led intervention, while the other 163 villages were assigned to usual care. Diabetes status was defined as a self-reported history of diabetes or a fasting blood glucose level ≥126 mg/dL at the baseline visit. In the CRHCP, CHWs were trained village doctors who initiated and titrated antihypertensive medications using a stepped-care protocol to achieve a BP goal of <130/80 mmHg. The primary effectiveness outcome was a composite of myocardial infarction, stroke, heart failure, or CVD death during the 48-month follow-up period.

Results: At the end of follow-up, the mean systolic BP in the intervention group was 127.5 mm Hg compared to 149.3 mm Hg in the usual care group among participants with diabetes. Among participants with diabetes, there were 462 CVD events (3.8% per year) in the intervention group, compared to 539 CVD events (4.8% per year) in the usual care group. The intensive BP intervention resulted in a 22% reduction in CVD (hazard ratio 0.78; 95% CI 0.69 to 0.87) in participants with diabetes. Additionally, all-cause deaths were reduced by 14% (hazard ratio 0.86; 95% CI 0.74 to 0.99) among participants with diabetes in the intervention group compared to the usual care group. There was no significant difference in safety outcomes examined at 48 months, including hypotension or syncope. Overall, results were similar for participants without diabetes, and there was no evidence of interaction between the intervention and diabetes status.

Conclusion: This study showed that an intensive BP intervention targeting <130/80 mm Hg effectively reduced CVD and mortality in participants with and without diabetes. Intensive BP control in patients with diabetes should be scaled up to reduce the burden of cardiovascular disease among this population worldwide.