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Complications and Comorbidities> Cardiovascular Disease, Obesity and Risk Factors>
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Hypertension Management

Nisa Maruthur, M.D., M.H.S.
06-15-2010

DEFINITION

  • Systolic blood pressure >130 mmHg or diastolic blood pressure >80 mmHg on two separate days in individuals with diabetes

EPIDEMIOLOGY

  • Hypertension present in 20-60% of those with diabetes.
  • Type 1 diabetes: Hypertension often the result of diabetic nephropathy and may occur later.
  • Type 2 diabetes: Hypertension is a common comorbid condition, often occurring before diabetes is diagnosed.
  • Hypertension associated with both macrovascular (e.g., coronary heart disease and stroke) and microvascular (diabetic retinopathy and nephropathy) complications and death (UKPDS 36).
  • Blood pressure lowering reduces complications of diabetes: macrovascular and microvascular complications and death (UKPDS 38, ADVANCE).

DIAGNOSIS

  • Systolic blood pressure > 130 mmHg or diastolic blood pressure >80 mmHg in seated position on two separate days; note this cut-off is lower than that for non-diabetes (<140/90 mmHg).
  • Laboratory screening for urinalysis, CBC, electrolytes, fasting lipid profile, electrocardiogram.
  • Evaluation for secondary causes of hypertension if: blood pressure resistant to three or more antihypertensive agents, worsening control in previously well-controlled patient, severe hypertension (>180/110 mmHg), significant hypertensive target organ damage, onset in adults <20 years or >50 years of age, lack of family history, findings on exam or laboratory results that suggest secondary cause.
  • Secondary causes of hypertension include: renal artery stenosis, renal parenchymal disease, coarctation of aorta, drugs (e.g. estrogen), diet (e.g. high salt), hyperaldosteronism, pheochromocytoma, Cushing's syndrome, obstructive sleep apnea, erythropoieitin side effect, other endocrine disorders (hyperthyroidism, hypothyroidism, hyperparathyroidism).

SIGNS AND SYMPTOMS

  • Symptoms not usually present but can include headache, chest pain, and shortness of breath.
  • Signs of chronic end-organ damage include atherosclerotic vascular disease, left ventricular hypertrophy, diastolic dysfunction, chronic kidney disease, diabetic retinopathy
  • Patients with hypertensive crises may present with stroke or myocardial infarction.
  • Secondary hypertension: abdominal bruit, elevated BUN/creatinine, delayed femoral pulses, presence of electrolyte abnormalities (i.e. hypokalemia, hypernatremia), paroxysmal hypertension and tachycardia, hirsutism, snoring and daytime somnolence.

CLINICAL TREATMENT

  • Systolic blood pressure 130-139 mmHg or diastolic blood pressure 80-89 mmHg: lifestyle (diet and physical activity) modification for up to 3 months and then proceed with pharmacologic therapy if blood pressure remains elevated.
  • Systolic blood pressure >140 mmHg or diastolic blood pressure >90 mmHg: lifestyle modification AND pharmacologic therapy
  • Diet change to reduce blood pressure includes sodium reduction to < 2.4 grams (JNC7), DASH dietary pattern (high in fruits/vegetables and low-fat dairy, low in total and saturated fat), and moderation of alcohol consumption (< 2 drinks/day for men and <1 drink/day for women).
  • Physical activity (aerobic and resistance training) of moderate intensity or greater for at least 150 minutes per week.
  • ACE inhibitor or angiotensin receptor blocker (ARB) as initial pharmacologic therapy
  • Thiazide diuretic (if GFR > 30 ml/min per 1.73 m2) or loop diuretic (if GFR < 30 ml/min per 1.73 m2) as additional therapy to achieve goal blood pressure <130/80 mmHg 
  • Add other agents (beta blockers, calcium channel blockers, etc) as needed to achieve blood pressure <130/80 mmHg
  • Initiate 2 agents for confirmed blood pressure >150/90 mmHg (JNC7).
  • Treatment of secondary causes where indicated.

FOLLOW UP

  • Home blood pressure monitoring
  • Measure blood pressure at each diabetes visit.
  • Monitor potassium and GFR regularly on ACE inhibitors, ARBs, and diuretics especially with initiation of an agent or with dose change.

EXPERT COMMENTS

  • Blood pressure control is more important than actual pharmacologic agent.
  • Hypertension treatment more important than glycemic control to decrease cardiovascular morbidity and mortality among patients with diabetes.
  • The ADVANCE Trial suggests that blood pressure lowering with a fixed combination of an ACE inhibitor and diuretic (perindopril + indapamide) may be beneficial in reducing vascular events regardless of initial hypertension status.

Basis for Recommendations

  • American Diabetes Association; Standards of medical care in diabetes--2010.; Diabetes Care; 2010; Vol. 33 Suppl 1; pp. S11-61;
    ISSN: 1935-5548;
    PUBMED: 20042772
    Rating: Basis for recommendation
    Comments:American Diabetes Association recommendations for diabetes care including the management of hypertension in patients with diabetes.

  • Chobanian AV, Bakris GL, Black HR, et al.; The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.; JAMA; 2003; Vol. 289; pp. 2560-72;
    ISSN: 0098-7484;
    PUBMED: 12748199
    Rating: Basis for recommendation
    Comments:Widely-accepted guideline for the treatment of hypertension with mention of special cases including diabetic hypertension, also describes use of DASH dietary pattern for reduction of hypertension.

  • Arauz-Pacheco C, Parrott MA, Raskin P; The treatment of hypertension in adult patients with diabetes.; Diabetes Care; 2002; Vol. 25; pp. 134-47;
    ISSN: 0149-5992;
    PUBMED: 11772914
    Rating: Basis for recommendation
    Comments:American Diabetes association technical review of the management of hypertension in patients with diabetes.

REFERENCES

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