blood pressure & hypertension in diabetes
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Etiology
- primary hyperaldosteronism in 14% if diabetic patients with resistant hypertension
Epidemiology
- target BP of < 130/80 (2023 ADA, ACC, AHA)[15]
- blood pressure < 130/80 mm Hg is not associated with lower risk for 3.5-year all-cause mortality in patients with newly diagnosed type 2 diabetes.
- blood pressure < 110/75 mm Hg is associated with excess mortality risk[6]
Management
- choice of antihypertensives is the same as for patients without diabetes in the absence of diabetic nephropathy[13]
- ACE inhibitors reduce proteinuria (1st line)
- no benefit for patients with microabuminuria[7]
- angiotensin II receptor antagonists (ARBs) also reduce proteinuria
- no benefit for patients with microabuminuria[7]
- olmesartan may be an exception[8]
- thiazide diuretics
- recommended as 1st line agents[3]
- synergistic effect when used with ACE inhibitor or ARB
- avoid in patients with history of gout
- caution: may worsen glycemic control
- calcium-channel blockers[13]
- beta-blockers generally avoided in the absence of specific indication
- carvedilol
- less tendency to cause hyperglycemia & dyslipidemia than other beta blockers
- may reduce risk of microalbuminuria[4]
- beta-blockers may mask symptoms of hypoglycemia
- beta-blockers may increase mortality
- ACE inhibitors reduce proteinuria (1st line)
- mortality, cardiovascular events & renal failure similar with ACE inhibitors, ARBs, calcium-channel blockers, thiazide diuretics, & beta-blockers[12]
- target BP < 130/80 mm Hg (2023 ADA)[15] (formerly < 140/90 2018 ADA)
- for stage 1 hypertension (140-159/90-99 mm Hg, now 130-149/80-89 mm Hg?), start with single agent[13]
- no benefit to target systolic blood pressure lower than prior 2018 ADA standard therapy (< 140 mm Hg) see ACCORD trial & INVEST trial[5]
- systolic blood pressure target: < 130 mm Hg[2][15]
- diastolic blood pressure target: < 80 mm Hg[10]
- diastolic blood pressure target: 60-80 mm Hg[2]
- not supported by American Diabetes Association in 2015 & 2018[10]
- diastolic blood pressure target: 60-80 mm Hg[2]
- < 130/80 mm Hg[9]
- not associated with lower mortality or MI
- associated with lower risk of stroke (absolute reduction 1%)
- higher risk of adverse effects (3.3% vs 1.7%) relative to standard treatment (< 140/90 mm Hg)
- strict control < 120/70 mm Hg not recommended[2]
- < 135/80 mm Hg (American College of Physicians*
- each 10-mm Hg drop for systolic BP > 140 associated with a 13% reduction in mortality[11]
* The American College of Physicians withdrew their guideline 'The evidence base for tight blood pressure control in the management of type 2 diabetes mellitus' in February of 2009
More general terms
Additional terms
References
- ↑ Umpierrez GE et al, Primary aldosteronism in diabetic subjects with resistant hypertension. Diabetes Care 2007, 30:1699 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17429062
- ↑ 2.0 2.1 2.2 2.3 Prescriber's Letter 17(4): 2010 Intensive Blood Pressure and Lipid Control for Patients with Diabetes: More from ACCORD Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=260404&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ 3.0 3.1 Journal Watch 23(10):78, 2003 Berl T et al, Cardiovascular outcomes in the Irbesartan Diabetic Nephropathy Trial of patients with type 2 diabetes and overt nephropathy. Ann Intern Med 138(Apr 1):542, 2003 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/12667024 <Internet> http://www.annals.org/issues/v138n7/full/200304010-00017.html
Vijan S & Hayward RA, Treatment of hypertension in type 2 diabetes mellitus: blood pressure goals, choice of agents, and setting priorities in diabetes care. Ann Intern Med 138(Apr 1):593, 2003 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/12667032 <Internet> http://www.annals.org/issues/v138n7/full/200304010-00018.html - ↑ 4.0 4.1 Internal Medicine News, April 15, 2005
- ↑ 5.0 5.1 The ACCORD Study Group. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010 Apr 29;362(17):1575-85. Epub 2010 Mar 14. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/20228401 <Internet> http://dx.doi.org/10.1056/NEJMoa1001286
- ↑ 6.0 6.1 Vamos EP et al. Association of systolic and diastolic blood pressure and all cause mortality in people with newly diagnosed type 2 diabetes: Retrospective cohort study. BMJ 2012 Aug 30; 345:e5567 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22936794
- ↑ 7.0 7.1 7.2 Prescriber's Letter 19(11): 2012 Which Diabetes Patients Need an ACE Inhibitor or ARB, Aspirin, and Statin? Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=281124&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ 8.0 8.1 Haller H et al Olmesartan for the Delay or Prevention of Microalbuminuria in Type 2 Diabetes N Engl J Med 2011; 364:907-917March 10, 2011 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/21388309 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1007994
- ↑ 9.0 9.1 McBrien K et al. Intensive and standard blood pressure targets in patients with type 2 diabetes mellitus: Systematic review and meta-analysis. Arch Intern Med 2012 Sep 24; 172:1296. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22868819 <Internet> http://archinte.jamanetwork.com/article.aspx?articleid=1307572
- ↑ 10.0 10.1 10.2 American Diabetes Association Standards of Medical Care in Diabetes-2015: Summary of Revisions Diabetes Care. Jan 2015. 38:S1-S2 http://care.diabetesjournals.org/content/38/Supplement_1
- ↑ 11.0 11.1 Emdin CA et al Blood Pressure Lowering in Type 2 Diabetes. A Systematic Review and Meta-analysis. JAMA. 2015;313(6):603-615 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25668264 <Internet> http://jama.jamanetwork.com/article.aspx?articleid=2108887
Williams B Treating Hypertension in Patients With Diabetes. When to Start and How Low to Go? JAMA. 2015;313(6):573-574 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25668260 <Internet> http://jama.jamanetwork.com/article.aspx?articleid=2108870 - ↑ 12.0 12.1 Bangalore S, Fakheri R, Toklu B, Messerli FH Diabetes mellitus as a compelling indication for use of renin angiotensin system blockers: Systematic review and meta-analysis of randomized trials. BMJ 2016 Feb 11; 352:i438. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26868137 Free Article
Majumdar SR. Antihypertensive treatments for adults with type 2 diabetes. BMJ 2016 Feb 11; 352:i560. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26867645 - ↑ 13.0 13.1 13.2 13.3 Medical Knowledge Self Assessment Program (MKSAP) 17, American College of Physicians, Philadelphia 2015
- ↑ Tucker ME Beta-Blockers May Raise Mortality in People With Diabetes Medscape - Apr 05, 2018. https://www.medscape.com/viewarticle/894878
- ↑ 15.0 15.1 15.2 15.3 Tucker ME ADA Advises New BP, Lipid Targets for People With Diabetes. Medscape. Dec 13, 2022 https://www.medscape.com/viewarticle/985482
ElSayed NA, Aleppo G, Aroda VR et al 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2023 Diabetes Care. 2023 Jan 1;46(Suppl 1):S158-S190. PMID: https://www.ncbi.nlm.nih.gov/pubmed/36507632 PMCID: PMC9810475 Free PMC article