Treatment of Hypertension in Diabetes

What Is the Best Therapeutic Option?

Tonje A Aksnes; Sigrid N Skårn; Sverre E Kjeldsen

Disclosures

Expert Rev Cardiovasc Ther. 2012;10(6):727-734. 

In This Article

Abstract and Introduction

Abstract

Patients with diabetes mellitus have a high risk of cardiovascular disease, and the latter is the leading cause of premature mortality in diabetic patients. Treatment of risk factors and comorbidities, such as hypertension, is very important and may effectively prevent cardiovascular events. The blood pressure goal in diabetic patients should be below 140/90 mmHg, probably down to 130–135/85 mmHg, although the evidence for this is scarce. To reach this blood pressure goal, intensive lifestyle intervention and often combinations of different antihypertensive drugs must be initiated. In combination treatment, a blocker of the renin–angiotensin system should be included, and according to the results of the ACCOMPLISH trial, a combination of a renin–angiotensin system blocker and a calcium channel blocker should probably be the first choice.

Introduction

The global number of individuals with diabetes mellitus is estimated to be 346 million people, and the WHO predicts that deaths due to diabetes will double between 2005 and 2030.[101] Many patients with diabetes are undiagnosed, and the prevalence is increasing exponentially primarily because of an increase in sedentary, lifestyle and obesity.[1]

Patients with diabetes mellitus tend to have a high risk for cardiovascular disease with accelerated and more extensive atherosclerotic lesions compared with those in nondiabetic patients.[2] Cardiovascular disease is also the leading cause of premature mortality in patients with Type 2 diabetes mellitus. A meta-analysis of 102 prospective studies involving 698,782 individuals with 8.49 million years of follow-up showed that diabetes mellitus confers a twofold excess risk for coronary heart disease, major stroke and death attributable to other vascular diseases.[3] The risk of cardiovascular disease is higher when the patients also have hypertension, and the patients with both diabetes and hypertension have approximately four times the cardiovascular risk of nondiabetic nonhypertensive patients.[2,4] A difference in morbidity and mortality between patients with and without diabetes mellitus has remained despite improved therapeutic modalities that have resulted in a decline in the overall morbidity and mortality following acute coronary artery disease.[5] Possible mechanisms may be diffuse coronary atherosclerosis, diabetic cardiomyopathy, autonomic neuropathy, increased heart rate, increased thrombus formation or an impaired fibrinolytic function in diabetic patients.[6]

In follow-up studies, it has been shown that diabetic patients without any prior myocardial infarction have similar risk for fatal coronary heart disease as nondiabetic patients with prior myocardial infarction.[7] Although diabetes mellitus is associated with increased risk of cardiovascular events, recent published data from the Framingham cohort showed that much of this excess risk is attributable to coexistent hypertension in the diabetic individuals (Figure 1).[8] In this article, the authors will review selected studies and recommendations on hypertension treatment in patients with Type 2 diabetes mellitus.

Figure 1.

High blood pressure in diabetic patients in the Framingham cohort (4-year risk). Although diabetes mellitus is associated with increased risks of death and CV events in Framingham patients, much of this excess risk is attributable to coexistent hypertension.9 CV: Cardiovascular; CVD: Cardiovascular disease; HT: Hypertensive; NT: Normotensive.

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