Hypertension and Diabetes
- Hypertension co-exists in a significant proportion of people with diabetes. Patients with diabetes and hypertension have twice the risk of cardiovascular disease (CVD) as non-diabetic hypertensive patients. In addition, hypertension increases the risk of diabetic retinopathy (eye damage leading to blindness) and nephropathy (kidney damage leading to dialysis).
- Lowering blood pressure (BP) produces dramatic benefits in these subjects and blood pressure targets have been modified specifically to avert disabling and fatal complications in the form of nephropathy, retinopathy, and CVD events.1 2
- Medications should be started early if the targets are not achieved by lifestyle changes alone.3 Many patients with diabetes will require lifestyle modifications and three or more drugs to achieve the blood pressure goals. Meeting these goals may be difficult in some patients. Nonetheless, one has to balance the benefits with the cost of medication and side effects.
- Resistant hypertension (requiring four or more medications for treatment of blood pressure) is particularly common among diabetics. Salt restriction and diuretics must be part of the treatment for resistant hypertension.
- The use of renin-angiotensin system (RAS) modifying agents [angiotensin-converting enzyme inhibitors (ACEi) or angiotensin-II receptor blockers (ARB)] provides additional benefits in people with diabetes. These include; forestalling CVD and renal complications on top of BP control.4
- The JNC-7 report as well as American Diabetes Association and the National Kidney Foundation recommends a goal BP of <130/80 mm Hg in hypertensive diabetic patients as opposed to <140/90 mm Hg in people with uncomplicated hypertension. 3
- Because of the heightened risk, the recommended targets are lower for all Indians<130/85 and <120/80 for those with diabetes or heart failure.5, 6
Sources
1. Adler A I, Stratton IM, Neil HA, et al. Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): prospective observational study. BMJ. Aug 12 2000;321(7258):412-419.
2. Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: Principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet. 1998;351(9118):1755-1762.
3. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. Jama. 2003;289(19):2560-2572.
4. Pahor M, Psaty BM, Alderman MH, Applegate WB, Williamson JD, Furberg CD. Therapeutic benefits of ACE inhibitors and other antihypertensive drugs in patients with type 2 diabetes [In Process Citation]. Diabetes Care. 2000;23(7):888-892.
5. Enas EA, Singh V, Gupta R, Patel R, et al. Recommendations of the Second Indo-US Health Summit for the prevention and control of cardiovascular disease among Asian Indians. Indian heart journal. 2009;61:265-74.
6. Enas EA, Singh V, Munjal YP, Bhandari S, Yadave RD, Manchanda SC. Reducing the burden of coronary artery disease in India: challenges and opportunities. Indian heart journal. Mar-Apr 2008;60(2):161-175.