BY
Hypertension
Diabetes
Hypertension affecting 2060% of patients with diabetes. In type 2 diabetes, hypertension is often present as part of the metabolic syndrome while in type 1 diabetes, hypertension may reflect the onset of diabetic nephropathy. Hypertension substantially increases the risk of both macrovascular and microvascular complications. Hypertensive diabetic patients are also at increased risk for diabetes-specific complications including retinopathy and nephropathy. In recent years, adequate data from well-designed randomized clinical trials have demonstrated the effectiveness of aggressive treatment of hypertension in reducing both types of diabetes complications.
Hypertension
Diabetes
Diabetes increases the risk of coronary events twofold in men and fourfold in women after menopause. People with both diabetes and hypertension have approximately twice the risk of cardiovascular disease as non-diabetic people with hypertension In the U.K. Prospective Diabetes Study (UKPDS) epidemiological study, each 10-mmHg decrease in mean systolic blood pressure was associated with reductions in risk of 12% for any complication related to diabetes, 15% for deaths related to diabetes, 11% for myocardial infarction, and 13% for microvascular complications.
Normotensive Hypertension
In recent years, adequate data from well-designed randomized clinical trials have demonstrated that structural changes in vessels start 5 years before BP elevated . patients who still have normal BP but have the high risk to develop high Bp(Patient at risk) are classified as normotensive hypertension and of course one of them is diabetic patients and they should be managed as soon as possible .
ACEIs Vs ARBs
ACEIs Vs ARBs
Angiotensinogen Other Substrates? Renin Bradykinin & other substrates ACE
Renin Blockade
Angiotensin I ACE inhibitors
Angiotensin II
?
AT2
Actions?
AT1
Psychological actions
ACEIs Vs ARBs
Evidence for beneficial outcomes (especially renal) with ARBs is growing but varying opinion on their optimal role. Unfortunately, several ARB outcome trials have avoided a head-to-head comparison with ACEIs. Losartan was not superior to captopril in patients with heart failure( ELITE II) , captopril reduced CV-death in post-MI patients more than losartan( OPTIMAAL) However, both of these studies found that less patients discontinued losartan due to adverse effects ARBs are an alternative in patients who develop ACEI induced cough but are more expensive than most ACEIs ACEI-ARB combinations show some promise for renal outcomes( CALM, COOPERATE), however they are expensive.
B = -blocker
D = diuretic low-dose
If initial drug is A or B adding drug C or D provides a synergistic effect. If initial drug is C or D adding drug A or B provides a synergistic effect; (C+diuretic, also option).
Verapamil or diltiazem with a -blocker negative effects on heart (e.g. heart rate and cardiac output) CCBS and -blockers potential for excessive hypotension; increased risk of falls, etc.
Drug therapy in
Hypertension with Diabetes
Monotherapy 1st potion ACEIs
nd OR 2 option ARBs
+
Combination Thiazide like diuretic (low doseHCT 12.5-25mg od) B blocker (cardioselective-e.g. atenolol, metoprolol) Long acting calcium channel blockers (amlodipine)
Summary
Non-pharmacological measures (particularlyweight loss
and reduction in salt intake) should be encouraged in all patients with diabetes, independently of the existing blood pressure. The goal blood pressure to aim at during behavioural or pharmacological therapy is below 130/80 mmHg. To reach this goal, most often combination therapy
will be required.
It is recommended that all effective and well tolerated antihypertensive agents are used, generally in combination.
Summary,cont
In diabetic patients with high blood pressure, who
Summary,cont
DCCBs (compared with ACE inhibitors, ARBs,
-blockers, or diuretics) should be used as
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