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Considering disorders of glucose metabolism, coronary heart disease, andmyriad other health issues that an overweight or obese patient may present,high blood pressure—especially borderline cases with mildly elevatedreadings—often doesn't get the serious attention it deserves.
Less than 30% of people with diabetes in the U.S. have their hypertensionoptimally controlled in the U.S., says Michael A. Moore, MD, of Wake ForestUniversity in Winston-Salem,N.C.
In a workshop at the American Diabetes Association's (ADA's) 53rd AnnualAdvanced Postgraduate Course, held February 10–12 in San Francisco,Moore made a persuasive argument that hypertension in people with diabetes isnot treated aggressively enough by primary care doctors.
Over the years, the levels of blood pressure considered to be within ahealthy range have steadily declined. However, treatment by clinicians has notkept pace, says Moore, a founding partner of the Consortium for SoutheasternHypertension Control (COSEHC), an organization aimed at reducing the morbidityand mortality related to high blood pressure in that region of the U.S.
THE LOWER THE BETTER
A blood pressure of 140/90 mmHg is considered high. Pressures of120–139 systolic and 80–89 diastolic used to be called "highnormal" or borderline hypertension. The problem, Moore explains, is that"patients hear the `normal' part and think they're in theclear."
They aren't; people in this range are at high risk of progressing tofull-blown hypertension and have double the risk of developing heart disease.The risk of cardiovascular disease (CVD) begins when blood pressure exceeds115/75 mmHg. Every increment of 20 mmHg systolic or 10 mmHg diastolic doublesthe risk of heart attack or stroke.
"There is a strong linear relationship between blood pressure andmortality," Moore says. "The lower the pressure, the longer youlive."
In 2003, prehypertension was designated a new predisease state for bloodpressure levels of 120–139 mmHg systolic and 80–89 mmHg diastolic.The prehypertension designation was intended to imbue a sense of gravity, muchthe way a suspicious lesion is called precancerous, Moore says.
The diagnosis of prehypertension is not an occasion to pat the patient onthe back and make another appointment for 6 months hence."Prehypertension is an indication for cardiovascular assessment andfollow-up," Moore says.
Indeed, a study published in the February issue of the American Journalof Medicine found subjects with blood pressure levels just under the highblood pressure diagnosis cut-off point have an increased risk ofcardiovasculardisease.1 Elderly,obese, diabetic, or African-American individuals with prehypertension have aneven greater risk of CVD, according to the Atherosclerosis Risk in CommunitiesStudy of 9,000 men and women.
DIET AND DRUG INTERVENTIONS
Blood pressures within the prehypertensive range are most amenable tonondrug interventions, with such lifestyle modifications as losing weight,consuming less alcohol, and restricting dietary sodium. The Dietary Approachto Stop Hypertension (DASH) diet can effectively reduce high blood pressure inmany people, particularly African Americans. (See FYI.)
For people with diabetes, the hypertension situation is even more severe. Ahealthy blood pressure in people with diabetes is <130/80 mmHg; as forreducing heath risks, the lower the better.
The U.K. Prospective Diabetes Study found that blood pressure was apowerful predictor of death for people withdiabetes.2 Mooresays the study showed that reducing blood pressure in people with diabetescould have a significant impact on morbidity and mortality. The study, whichfollowed 1,148 people with diabetes and hypertension, found that loweringblood pressure to <114/82 mmHg reduced mortality by 24%.
Reaching those goals when lifestyle modifications fail, however, is anothermatter. There are five main classes of drugs used to manage hypertension inpatients with diabetes: thiazide diuretics, beta-blockers, calcium-channelblockers, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin IIreceptor-blockers (ARBs).
Additional drugs, less commonly used in diabetes, are other diuretics(furosemide, spironolactone, triamterene, amiloride), alpha-blockers(prazosin, doxazosin, terazosin), centrally acting agents (methyldopa,clonidine), and direct vasodilators (hydralazine, minoxidil).
"Almost all hypertensive patients will require more than one class ofantihypertensive drug to reach goal blood pressure," Moore says.
According to ADA treatment guidelines, initial drug therapy for those witha blood pressure >140/90 mmHg should be with a drug class demonstrated toreduce cardiovascular events in patients with diabetes, such as ACEinhibitors, ARBs, beta-blockers, diuretics, and calcium-channel blockers. Allpatients with diabetes and hypertension should be treated with an ACEinhibitor or an ARB. If one class is not tolerated, the other should besubstituted. A thiazide diuretic should be added if needed to reach bloodpressuretargets.3
Controlling hypertension is critical to reducing mortality and morbidity,especially for people with type 2 diabetes. It takes persistence anddedication on the part of clinicians. But Moore's message at the ADA'sPostgraduate Course was clear: "There are ways to do it."
Footnotes
For information about the Dietary Approach to Stop Hypertension(DASH) diet, visitwww.nhlbi.nih.gov/health/public/heart/hbp/dash/.
References
2. U.K. Prospective Diabetes Study Group: Tight blood pressure controland risk of macrovascular and microvascular complications in type 2 diabetes:UKPDS 38. BMJ 317:703–713, 1998.
3. American Diabetes Association: Standards of medical care indiabetes–2006 (Position Statement). DiabetesCare 29 (Suppl. 1):S4–S42, 2006.
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