Bp And Target Organ Damage In Diabetes Mellitus
Diabetes mellitus is associated with a high risk for CV disease, and is the leading cause of end-stage renal disease , blindness, and nontraumatic amputations in western countries. Coronary heart disease is far more common in patients with both diabetes and hypertension than in those who have either disease by itself. In the Prospective Cardiovascular Munster trial, the incidence of CHD during 4 years was 6 per 1,000 in those without hypertension, diabetes, or hyperlipidemia, 14 or 15 per 1,000 in those with hypertension or diabetes, respectively, and as high as 48 per 1,000 when both hypertension and diabetes were present in the same patient. The simultaneous presence of diabetes and hypertension results in more severe cardiomyopathy than would be expected with either hypertension or diabetes mellitus alone. We showed that the prevalence of left ventricular hypertrophy was 72% in patients with both diabetes and hypertension, and only 32% in those with a similar level of hypertension but no diabetes.
Hypertension, mainly systolic, is strongly and directly related to stroke in all age groups. The presence of diabetes more than doubles the risk of stroke in patients with hypertension. Lowering the BP in patients with hypertension and diabetes reduces the risk of stroke by 44%.
BP control can slow the progression of renal disease in patients with diabetes. Diabetes mellitus may cause diabetic retinopathy, and hypertension accelerates the development of diabetic retinopathy.
Recommendation For Intensive Blood Pressure Lowering In Patients With Diabetes Mellitus And Chronic Kidney Disease
The first clinical trial to determine whether further intensive lowering of BP reduces CV outcomes was the hypertension optimal treatment study. In this study, 18,790 patients age 5080 with baseline DBP of 100115 mmHg were randomized to target DBP of 90, 85, and 80 mmHg. Overall, there was no significant difference in CV events among the three treatment arms with the lowest incidence of major CV events occurring at mean achieved DBP of 82.6 mmHg. However, in 1,501 patients with diabetes mellitus, there was a 51% reduction in major CV events in the DBP 80 mmHg treatment target arm compared to the DBP 90 mmHg arm.
For patients with CKD, the modification of diet in renal disease randomized 840 patients with non-diabetic chronic renal disease to usual BP treatment target versus intensive BP target . The study showed that in subjects with proteinuria of more than 1 g/day, intensive BP lowering was associated with significantly slower decline in the glomerular filtration rate. In 2003, based on the above mentioned evidence, the JNC 7 recommended a treatment target BP of 140/90 mmHg and BP goal of less than 130/80 mmHg for patients with diabetes and chronic renal disease.
Diabetes And High Blood Pressure
When your blood pressure is high, your heart has to work harder and your risk for heart disease, stroke, and other problems go up.
The thing you may not know is that high blood pressure wont go away without treatment. That could include lifestyle and dietary changes and, if your doctor prescribes it, medication.
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Bp Levels In Diabetic Patients With Stable Coronary Artery Disease
The beneficial effects of anti-hypertensive drugs on clinical and cardiovascular outcomes are well established , and strict BP control is strongly recommended by most previous guidelines for general patients . However, this therapeutic strategy has been challenged in hypertensive patients with T2DM , especially for those with coronary artery disease .
Evidence For Drug Therapy Of Hypertension
There are a number of trials demonstrating the superiority of drug therapy versus placebo in reducing outcomes including cardiovascular events and microvascular complications of retinopathy and progression of nephropathy. These studies used different drug classes, including angiotensin-converting enzyme inhibitors, angiotensin receptor blockers , diuretics and -blockers, as the initial step in therapy. All of these agents were superior to placebo however, it must be noted that many patients required three or more drugs to achieve the specified target levels of blood pressure control. Overall there is strong evidence that pharmacologic therapy of hypertension in patients with diabetes is effective in producing substantial decreases in cardiovascular and microvascular diseases.
There are limited data from trials comparing different classes of drugs in patients with diabetes and hypertension. The UKPDS-Hypertension in Diabetes Study showed no significant difference in outcomes for treatment based on an ACE inhibitor compared with a -blocker. There were slightly more withdrawals due to side effects and there was more weight gain in the -blocker group. In postmyocardial infarction patients, -blockers have been shown to reduce mortality.
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Your Blood Pressure Results
Youll get your results straight away. The reading on the monitor lets your healthcare team know whether your blood pressure is too high, too low or just right. But its important you understand your results too. Make a note of your reading at each appointment and get to know what the numbers mean.
Your healthcare team will agree a target level thats safe for you. Its important you do everything you can to keep in your target range. The longer your blood pressure is high, the more at risk you are of getting serious complications. Weve got lots of information and advice to help you bring your to the target level you’ve agreed with your healthcare team.
Epidemiology Of Hypertension Among Those With Diabetes
The estimated prevalence of hypertension in adults with diabetes is 2060%, which is 1.53 times higher than that in age-matched individuals without diabetes., The onset of hypertension differs for people with type 1 versus those with type 2 diabetes. Individuals with type 1 diabetes usually develop hypertension because of diabetic nephropathy, with 30% eventually being affected. By contrast, hypertension may be present when type 2 diabetes is diagnosed or may predate the onset of hyperglycemia. Type 2 diabetes is frequently accompanied by advanced age or obesity, both of which increase the risk of hypertension and thereby make it difficult to ascribe elevated BP solely to diabetes.
The presence of hypertension in individuals with diabetes doubles the risk for cardiovascular disease . With uncontrolled hypertension, there is a consistent positive relationship between elevated systolic BP and increased risk for micro- and macrovascular diseases. Accordingly, > 65% of deaths in patients with diabetes are from CVD.
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Papers Of Particular Interest Published Recently Have Been Highlighted As: Of Importance Of Major Importance
Chan JC, Malik V, Jia W, Kadowaki T, Yajnik CS, Yoon KH, et al. Diabetes in Asia: epidemiology, risk factors, and pathophysiology. JAMA. 2009 301:212940.
Hogan P, Dall T, Nikolov P. Economic costs of diabetes in the US in 2002. Diabetes Care. 2003 26:91732.
Zhang P, Zhang X, Brown J, Vistisen D, Sicree R, Shaw J, et al. Global healthcare expenditure on diabetes for 2010 and 2030. Diabetes Res Clin Pract. 2010 87:293301.
Gaede P, Vedel P, Larsen N, Jensen GV, Parving HH, Pedersen O. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med. 2003 348:38393.
Gaede P, Lund-Andersen H, Parving HH, Pedersen O. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med. 2008 358:58091.
Ravid M, Savin H, Lang R, Jutrin I, Shoshana L, Lishner M. Proteinuria, renal impairment, metabolic control, and blood pressure in type 2 diabetes mellitus. A 14-year follow-up report on 195 patients. Arch Intern Med. 1992 152:12259.
Kannel WB, Wilson PW, Zhang TJ. The epidemiology of impaired glucose tolerance and hypertension. Am Heart J. 1991 121:126873.
UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ. 1998 317:70313.
Back To 130/80 Mmhg: Intensive Blood Pressure Treatment Target For All Hypertensives
In 2015, the publication of the Systolic Blood Pressure Intervention Trial changed the landscape of the hypertension treatment guideline. The objective of the study was to determine whether intensive SBP lowering below 120 mmHg lowers the risk of CV outcomes compared to conventional SBP lowering below 140 mmHg in individuals with SBP above 130 mmHg without diabetes. The 9,361 persons enrolled in the study were relatively high risk, with the inclusion criteria of the SPRINT study being individuals above the age of 50 with at least 1 of the following: 1) history of clinical/subclinical CVD, excluding stroke, 2) Framingham risk score of more than 15, 3) age of 75 years of age or more 4) CKD with estimated glomerular filtration rate between 2060 mL/min/1.73 m2. The clinical trial was stopped after a median follow-up of 3.26 years due to the significant, 25% lowering of the primary composite outcome in the intensive treatment group compared to the standard treatment group . One thing to keep in mind for the SPRINT study was that unattended automated office blood pressure measurement was used for clinical office BP measurement. As studies have shown that AOBP is 515 mmHg lower than usual office BP measurements, AOBP SBP target of 120 mmHg would most likely corresponded to usual clinical office SBP of 130 mmHg.,
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Blood Pressure Management In Patients With Diabetes
Amanda H. Salanitro, MD, MSPH, is a fellow in the Veterans Affairs National Quality Scholars Program, Center for Surgical, Medical Acute Care Research & Transitions at the Birmingham Veterans Affairs Medical Center and the University of Alabama at Birmingham. Christianne L. Roumie, MD, MPH, is assistant director for the Veterans Affairs National Quality Scholars Program at the VA Tennessee Valley Healthcare Geriatric Research Education Clinical Center , Clinical Research Training Center of Excellence ,and Targeted Research Enhancement Program Center for Patient Healthcare Behavior, and assistant professor in the Department of Internal Medicine and Pediatrics at Vanderbilt University in Nashville, Tenn.
Amanda H. Salanitro, Christianne L. Roumie Blood Pressure Management in Patients With Diabetes. Clin Diabetes 1 January 2010 28 : 107114.
What Is Blood Pressure
Blood pressure is the pressure your heart uses to push blood through your blood vessels and around your body.
There are two numbers used to describe blood pressure and its measured in millimetres of mercury . Its written like this: 130/80mmHg. And youll hear your doctor say ‘130 over 80’.
The first number is the systolic pressure. This is the most amount of pressure your heart uses when beating to push the blood around your body.
The second number is the diastolic pressure. This is the least amount of pressure your heart uses when it is relaxed between beats.
Using 130/80mmHg as an example, the systolic pressure here is 130mmHg and the diastolic pressure is 80mmHg.
Our video below explains all about blood pressure, and how it affects people with diabetes.
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What Should Be The Blood Pressure Goals In Patients With Diabetes
For many years, the recommended BP goal in persons with diabetes was < 130/80 mmHg,, based on the assumption that lower goals may slow the rate of progression of diabetic nephropathy and proteinuria. The treatment of hypertension in DM patients was associated with significant clinical benefits in the HOT, UKPDS, and ADVANCE trials, as detailed previously. However, although these observations support a goal BP for DM patients of < 140/90 mmHg, as recommended in the majority of patients with hypertension in general, lower targets of < 130/80 mmHg were not clearly justified by available data. In fact, the results from ACCORD BP argue against the presumption that lower is better., The SPRINT findings suggest that, in non-DM patients, early use of lower goals may result in benefits, despite the increased risk of side effects and adverse events. Individualisation of therapy, taking into account the risks and benefits and using clinical judgement, is sensible.
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What Should Your Blood Pressure Be
Readings vary, but most people with diabetes should have a blood pressure of no more than 130/80.
The first, or top, number is the “systolic pressure,” or the pressure in your arteries when your heart squeezes and fills the vessels with blood. The second, or bottom, number is the “diastolic pressure,” or the pressure in your arteries when your heart rests between beats, filling itself with blood for the next contraction.
When it comes to preventing diabetes complications, normal blood pressure is as important as good control of your blood sugar levels.
Effectiveness Of Bp Control: Real
There are multiple barriers to reaching BP goals in primary care. These include patient factors , provider factors , and system factors. Additionally, the recommended changes to diet and lifestyle are challenging for patients, and the lack of knowledge about health outcomes from poorly controlled hypertension can be a barrier to treatment. Primary care providers may fail to apply treatment guidelines or to know the therapeutic options, may disagree with the guidelines, may not know how to help their patients with self-management, or may fail to recognize the opportunity to intensify medications when BP is uncontrolled. System factorsthose that affect the delivery of high-quality health caremay include insurance coverage, medication co-payments, access to primary care, self-management programs, and reimbursement schemes., Furthermore, the way patients and physicians communicate can affect BP control. Collaborative decision making and proactive communication has been associated with better hypertension control.
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Your Blood Pressure Test
Your doctor or nurse uses a blood pressure monitor to check your blood pressure. Theyll put a cuff around your arm and inflate it. This restricts the blood flow for a few seconds. This can feel uncomfortable but isnt painful. The cuff then deflates, the monitor takes a reading and your doctor or nurse will take the cuff off.
You should get this test at least once a year. Its usually part of your annual review and is one of your essential diabetes health checks.
If you want to, you can buy a blood pressure monitor yourself to use at home. You can get this from a chemist or pharmacy, or order one from our shop. You dont have to do this, but some people find it helps them manage their diabetes better. In some areas, diabetes care teams have suggested people buy their own home blood pressure monitoring kit, during the coronavirus pandemic while access to routine care is disrupted. You can find a list of blood pressure monitors to use at home from the British and Irish Hypertension Society website.
We know that wont be possible for everyone, and we dont think people should have to pay for these devices. Were calling on the NHS to find other ways to make these available for free.
Its fine to use a monitor yourself, but speak to your healthcare team first to make sure youre using it right. Make a note of your readings and speak to your doctor or nurse if youre ever worried.
Medication For High Blood Pressure
Making changes to your lifestyle may not be enough and many people with diabetes also need to take medication.
The most common types of blood pressure medicines are diuretics, ACE inhibitors, beta-blockers, antiotensin-2 receptor blockers and, calcium channel blockers. Ask your healthcare team if want more info on these.
Your healthcare team may give you medication even if your blood pressure isnt high and is in the target range. This is normal but you can ask your healthcare team to explain why. Its usually because the medication itself can help protect you against diabetes complications they especially protect your kidneys.
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Bp Levels In Diabetic Patients With Acute Coronary Syndrome
Recently, White et al. evaluated the relationships between achieved clinician-measured BP and cardiovascular outcomes in 5380 patients with T2DM and recent acute coronary syndromes of the EXAMINE trial. Risks of major adverse cardiac events and cardiovascular death or heart failure were analyzed using a Cox proportional hazard model with adjustment for baseline covariates in 10 mmHg increments of diastolic BP from60 to> 100 mmHg and systolic BP from100 to> 160 mmHg during 2-year follow-up. Systolic BP of 131 to 140 mmHg and diastolic BP of 81 to 90 mmHg were used as reference groups. They observed a U-shaped relationship between cardiovascular outcome and BP. Importantly, average follow-up BP< 130/80 mmHg was associated with worsened cardiovascular outcomes, and the degree of risk was notably greater for those who had achieved average follow-up BP of< 120/70 mmHg .
Role Of Combination Therapy
If target BP levels are not achieved with standard-dose monotherapy, additional antihypertensive therapy should be used. For persons in whom combination therapy with an ACE inhibitor is being considered, a dihydropyridine CCB is preferable to a thiazide/thiazide-like diuretic. The recommendation supporting ACE/CCB combination therapy in people with type 2 diabetes is based on the Avoiding Cardiovascular events through Combination therapy in Patients Living with Systolic Hypertension trial, which compared benazepril/amlodipine combination treatment vs. benazepril/thiazide therapy . The primary endpoint was a composite of MI, stroke, CV death, hospitalization for angina, resuscitated cardiac arrest and coronary revascularization. The trial enrolled 6,946 high-risk participants with type 2 diabetes 2,842 participants were deemed to be particularly high risk by virtue of a previous cardiac, cerebrovascular or renal event. Benazepril/amlodipine reduced occurrence of the primary event compared to benazepril/thiazide in all subjects with diabetes and subgroups of subjects who were considered high risk .
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