Diabetes mellitus and hypertension

Dr. Nadia ShamsAssistant Professor Medicine

Hyperglycemia Dyslipidemia

Hyperinsulinemia Hypertension

Insulin resistance

Obesity

Insulin deficiency

Both essential hypertension and diabetes mellitus affect the same major target organs.

The common denominator of hypertensive/diabetic target organ-disease is the vascular tree.

The tide of diabetes is rising all over the globe and becoming an increasingly powerful threat to global health

The World Health Organization projects that by the year 2025 > 5% of the world population, i.e. 300 million people will suffer from diabetes.

King H, Donald E, et al. global burden of Diabetes 1995-2025. Diabetes care, Sept 1998.

Hyperinsulinemia can enhance renal sodium reabsorption and vascular reactivity

Angiotensinogen from fat cells can increase angiotensin II and thus blood pressure

Both systolic and diastolic blood pressure increase with increasing body mass index

Subcutaneous Fat

Abdominal Muscle Layer

Intra-abdominal Fat

Despres JP, Lemieux I, Prud'homme D. Treatment of obesity: need to focus on high risk abdominally obese patients. BMJ. 2001;322:716-720.

Heart DiseaseHeart Disease

Insulin ResistanceInsulin Resistance

Metabolic SyndromeMetabolic Syndrome

↑↑ Adipocytokines + Fatty AcidsAdipocytokines + Fatty Acids Liver

Abdominal AdipocytesAbdominal Adipocytes

Hepatic Insulin Clearance

Portal FFA

Plasma Insulin

Renal Na+ Reabsorption

Hypertension

Visceral Fat Stores

Fat Cell Products and HypertensionFat Cell Products and Hypertension

VascularConstriction

Angiotensin I

Angiotensin IIAngiotensinogen

Bray GA. Contemp Diagn Obes. 1998.

Chobanian AV, et al. JAMA. 2003;289:2560-2572.

Peripheral Vascular Disease Renal Failure,

Proteinuria

LVH, CHD, CHFHemorrhage,Stroke

Retinopathy

CHD = coronary heart diseaseCHF = congestive heart failureLVH = left ventricular hypertrophy

Hypertension & Diabetes

Hypertension & Diabetes

Both hypertension and diabetes are well-identified risk factors for atherogenesis.

Several mechanisms acting together mediate damage to vascular tree in diabetic hypertensive patients.

Elevated lipoprotein levels in diabetics with poor glycemic control.

Enhanced foam cell formation.

Anatomic and functional abnormalities of the vascular endothelium have been described in diabetes mellitus and hypertension

Diabetes seems to be a specific risk factor for small vessel disease.

In contrast, hypertension, at least in its nonmalignant form, seems to affect predominantly the large arteries.

Together, the two disorders synergistically damage

the arterial tree.

Diabetes, and to a lesser extent hypertension, may alter the perception of ischemic pain, leading to a high prevalence of silent ischemia.

Coronary artery disease is much more common in diabetic hypertensive patients than in patients suffering from hypertension or diabetes alone

Fisman EZ, Tenenbaum A (eds): Cardiovascular Diabetology: Clinical, Metabolic and Inflammatory Facets. Adv Cardiol. Basel, Karger, 2008, vol 45, pp 82–106

PROCAM TRIAL____________________________________________________

Those with none of three risk factors (i.e. HTN, diabetes, or hyperlipidemia), the coronary artery disease incidence was 6/1,000 in 4 years.

In contrast, the incidence of coronary artery disease in those participants who were suffering from hypertension or diabetes was 14 and 15 per 1,000 in 4 years, respectively.

When both risk factors were present in the same patient, the incidence rate increased to 48 per 1,000

Fisman EZ, Tenenbaum A (eds): Cardiovascular Diabetology: Clinical, Metabolic and Inflammatory Facets. Adv Cardiol. Basel, Karger, 2008, vol 45, pp 82–106

Melina et al. found a high prevalence of asymptomatic ST segment depression in diabetic patients with essential hypertension.

The number of ST segment depression episodes was significantly related to glycosylated hemoglobin levels, left ventricular mass, and ambulatory systolic and diastolic blood pressure variability and hypertensive peaks.

Schinzari F, Iantorno M, Melina G, et al. Differences between diabetic and non-diabetic hypertensive patients with first acute non-ST elevation myocardial infarction predictors of in-hospital

complications. J Med 2008;9:267-72.

The coexistence of diabetes and hypertension results in more severe cardiomyopathy than with either hypertension or diabetes mellitus alone

The extensive degenerative changes in the diabetic hypertensive heart may be related to abnormalities in the microcirculation.

The most striking microscopic findings of the hypertensive diabetic heart seem to be the distribution of dense interstitial connective tissue throughout the myocardium.

Clinical studies with echocardiography also showed an increased left ventricular mass in diabetic hypertensive patients.

Grossman et al. found increased septal and posterior wall thickness in patients with hypertension and diabetes compared with non-diabetic hypertensive patients.

Prevalence of LVH was 72% in diabetic hypertensive patients and only 32% in nondiabetic hypertensive patients who had a similar degree of hypertension

Grossman E, Messerli FH.: Diabetic and hypertensive heart disease. Ann Intern Med 1996; 125: 304– 310.

When hypertension is superimposed on diabetes mellitus it accelerates the decline in renal function.

Blood pressure control with levels below 130/80mm Hg can slow the progression of renal disease in diabetic patients

Franz H, Messerli, et al. Combination therapy and target organ protection in hypertension and diabetes mellitis. Am J Hypertens (1997) 10 (S6):198S-

201S.

The combined presence of hypertension and diabetes concomitantly affects glomerular filtration rate and renal blood flow, thereby greatly accelerating a decrease in renal function.

Franz H, Messerli, et al. Combination therapy and target organ protection in hypertension and diabetes mellitis. Am J Hypertens (1997) 10 (S6):198S-

201S.

Hypertension accelerates the development of diabetic retinopathy; hypertensive/diabetic cerebral disease leads to vascular dementia, transient ischemic attacks, and strokes.

Franz H, Messerli, et al. Combination therapy and target organ protection in hypertension and diabetes mellitis. Am J Hypertens (1997) 10 (S6):198S-201S.

A decrease in the hemodynamic and glycemic burden is the primary goal in the management

of the hypertensive diabetic patients__________________________________________

Category Systolic (mmHg) Diastolic (mmHg)

Normal <120 <80

prehypertension 120-139 80-89

Stage 1 HYPERTENSION 140-159 90-99

Stage 2 HYPERTENSION >160 >100

Category Sydtolic (mmHg) Diastolic( mmHg)

optimal <120 <80

normal 120-129 80-84

High normal 130-139 85-89

Grade 1 hypertension 140-159 90-99

Grade 2 hypertension 160-179 100-109

Grade3 hypertension >180 >110

Isolated hypertension >140 <90

JNC 8 guidelines (2013)

(James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members

appointed to the Eighth Joint National Committee (JNC 8). JAMA. Dec 18 2013)

For patients aged >18 years with diabetes JNC 8 recommends initiating treatment at

Systolic blood pressure (BP) levels of >140 mmHg

or at diastolic BP levels of > 90 mm Hg

Treat to a goal BP below 140/90 mm Hg.

(The JNC 7 and the 2011 American Diabetes Association (ADA) standard of medical care recommended BP control in diabetic individuals < 130/80 mm Hg)

(James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members

appointed to the Eighth Joint National Committee (JNC 8). JAMA. Dec 18 2013)

In general, patients with diabetes type 1 or type 2 and hypertension have shown clinical improvement with diuretics, ACE inhibitors, beta-blockers, ARBs, and calcium antagonists

(Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.Hypertension. Dec 2003;42(6):1206-52.)

Two or more antihypertensive drugs at maximal doses should be used to achieve optimal BP targets in patients with diabetes and hypertension.

(American Diabetes Association. Standards of medical care in diabetes--2011. Diabetes Care. Jan 2011;34 Suppl 1:S11-61)

Either an ACE inhibitor or an ARB is usually required in patients with diabetes and hypertension.

If the patient cannot tolerate one class of drugs, the other should be tried.

If needed to achieve BP goals,

a thiazide diuretic is indicated for those patients with an estimated GFR of >30 mL/min/1.73 m2 or greater

and a loop diuretic is indicated for those with an estimated GFR of < 30 mL/min/1.73 m2.

Regardless of which antihypertensive drugs are used, kidney function and serum potassium levels should be monitored.

(American Diabetes Association. Standards of medical care in diabetes--2011. Diabetes Care. Jan 2011;34 Suppl 1:S11-61)

• Hypertension occurs in 75% of patients with type 2 diabetes

• Diabetes, the metabolic syndrome and hypertension constitute a particularly dangerous combination as regards cardiovascular morbidity and mortality

• Hypertension is a promoter of macro- and microvascular disease

• There is evidence to link the RAAS with hypertension in patients with obesity, metabolic syndrome, and patients with type 2 diabetes

Target b;ood pressure in diabetic hypertensive patients < 140/90 mmHg

In patients with diabetes, the drug of choice should be a drug that blocks the RAAS (ACE inhibitor or ARB)

It is common to use more than 2 agents in order reach blood pressure goals in patients with type 2 diabetes

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