7. HYPERTENSION & DIABETES
(NEW GUIDELINES).
Prof. GAMELA NASR , MD
Professor of Cardiology Suez Canal University ,
Consultant in Suez Canal Authority - National Insurance & Sporting Hospitals
Master of Medical Education Holland-SCU , Diploma of E Teaching NORWAY
Member of American Society of Clinical Nutrition
Trainer in Diploma for Clinical Nutrition in AUC and National Institute for
Nutrition
19. True or false …..
• Hypertension is a common co morbidity with diabetes.
• Diabetes morbidity and mortality are mainly due to cardiovascular causes.
• No general consensus of which drug to use in diabetic hypertensive patients.
• Improvement in diabetic hypertensive outcome is dependant on how low is BP.
• The target BP in diabetic hypertensive patients is <130/80 mmHg.
• RAAS blockers are recommended by all guidelines in management of
hypertension in diabetics.
20. Agenda
• What is common in Diabetes and Hypertension? What is the
link?
• Why Hypertension is important?
• Why Diabetes is important?
• Management: What do literature and guidelines recommend?
21. Agenda
• What is common in Diabetes and Hypertension? What is the link?
• Why Hypertension is important?
• Why Diabetes is important?
• Management: What do literature and guidelines recommend?
22. What is common in Hypertension and Diabetes?
◦ Prevalent
◦ Morbidity
◦ Mortality
◦ Resistant
◦ Preventable
◦ Treatable
◦ Curable
26. Agenda
• Diabetes and Hypertension, any link ?!
• Why Hypertension is important?
• Why Diabetes is important?
• Management: What do literature and guidelines recommend?
27. 0
10
20
30
40
50
Lebanon KuwaitOmanQatar EgyptBahrain Saudi
Arabia
TurkeyUAE
PREVALENCE OF HYPERTENSION IN THE MIDDLE EAST
Hypertension is defined as systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm
Hg
Raised Blood Pressure, 2008. WHO website. http://gamapserver.who.int/gho/interactive_charts/ncd/risk_factors/blood_pressure_prevalence/atlas.html. Accessed March
26, 2011.
43.7% 42.7% 41.4% 41.4% 40.4%
38.9% 38.4% 38.1%
36.1%
Prevalence,%
28. Why hypertension is important?
• One third (35%) of all adults have high blood pressure
o 53% aged 55–64
o 66% aged 65–74
o 76% aged 75+
• Each 10/5 mmHg reduction in BP associated with:
o 40% lower risk of stroke death
o 30% lower risk of other vascular mortality
• Strong correlation between hypertension and CV mortality
29. CV Mortality Risk Doubles with Each 20/10 mm Hg BP Increment
*Individuals aged 40-69 years, starting at BP 115/75 mm Hg.
Lewington S, et al. Lancet. 2002; 60:1903-1913. JNC VII. JAMA. 2003.
CV
mortality
risk
SBP/DBP (mm Hg)
0
1
2
3
4
5
6
7
8
115/75 135/85 155/95 175/105
31. Agenda
• What is common in Diabetes and Hypertension? What is the link?
• Why Hypertension is important?
• Why Diabetes is important?
• Management: What do literature and guidelines recommend?
32. Why Diabetes is Important?
• The prevalence of diabetes worldwide is estimated to be 4.4% in 2030.
• The number diabetics is projected to rise from 171 to 536 millions in
2030.
• The prevalence of diabetes is higher in men than women.
• Diabetes is expected to be the 7th leading cause of death worldwide by
2020.
Global status report on non-communicable diseases 2010. Geneva, WHO, 2011.
33.
34.
35. Clinical Impact of Diabetes Mellitus
Diabetes
Leading cause
of amputation
of LL (PAD)
Leading cause
of new cases
of ESRD
2-4 fold
increase in CV
Mortality
Leading cause
of new cases
of blindness
37. 0
0.05
0.1
0.15
0.2
0.25
Eventrate
Months6 9 153 18 2112
RR=2.88 (2.37-3.49)
24
RR=1.99 (1.52-2.60)
RR=1.71 (1.44-2.04)
RR=1.00
Diabetes/CVD (n=1,148)
No Diabetes/CVD (n=3,503)
Diabetes/No CVD (n=569)
No Diabetes/No CVD (n=2,796)
OASIS Study Mortality by Diabetes and CVD Status
Malmberg K, et al. Circulation. 2000;102:1014-1019.
OASIS=Organization to Assess Strategies for Ischemic Syndromes
38. CVD=cardiovascular disease.
aThis analysis by Stamler et al included a cohort of 342,815 men aged 35 to 57 years who did not have diabetes, and a cohort of 5,163 men who did have
diabetes at baseline. The health status of study participants was followed through an average of 12 years.
1. Stamler J et al. Diabetes Care. 1993;16(2):434–444.
Combined ImpactofHypertension
andDiabetes onCVDDeathRate inMen1,a
0
50
100
150
200
250
300
≥200180–199160–179140–159120–139<120
Systolic Blood Pressure, mmHg
CVDDeathRate,
per10,000person-years
Without diabetes
With diabetes
39. WhyHypertension andDMaredangerouscombination
MI=myocardial infarction; CHD=coronary heart disease; LVH=left ventricular hypertrophy; ESRD=end-stage renal disease; PAD=peripheral
artery disease.
1. Mancia G et al. J Hypertens. 2007;25(6):1105–1187. 2. Chobanian AV et al. Hypertension. 2003;42:1206–1252. 3. Spence JD. Hypertension. 2004;44:20–21.
4. Cerasola G et al. J Nephrol. 2008;21:368–373. 5. Cerasola G et al. J Hum Hypertens. 2010;24:44–50.
39
Proteinuria, renal failure,
ESRD
MI, CHD, LVH, AF, HF,
sudden cardiac death
Hemorrhage, stroke,
dementia
PAD
Retinopathy
40. Agenda
• What is common in Diabetes and Hypertension? What is the link?
• Why Hypertension is important?
• Why Diabetes is important?
• Management: What do literature and guidelines recommend?
41. 75% of diabetic complications are attributed to hypertension
70% of diabetic patients die of cardiovascular disease
60% of patients require >2 antihypertensive agents to achieve tight control
Treatment of hypertension in patients with diabetes reduces:
Total mortality, MI, stroke, retinopathy and progressive renal failure
ManagementofHypertension inDiabetespatients
42.
43.
44. JNC VIII
• Recommendation 5: In population >18 years with DM, initiate pharmacologic treatment to lower
BP at SBP 140mmHg or DBP 90 mmHg and treat to a goal SBP <140 mmHg and goal DBP <90
mmHg. (Expert Opinion –Grade E)
• Recommendation 6: In general nonblack population, including those with DM, initial
antihypertensive treatment should include a thiazide-type diuretic, CCBs, ACEI, or ARB.
(Moderate Recommendation– Grade B)
• Recommendation 7: In general black population, including those with DM, initial
antihypertensive treatment should include a thiazide-type diuretic or CCB. (for black patients with
DM: Weak Recommendation – Grade C)
• Recommendation 8: In population >18 years with CKD, initial antihypertensive treatment should
include ACEI or ARB to improve kidney outcomes. (Mod. Recommendation – Grade B).
45. JNC7AlgorithmfortheTreatmentofHypertension
*Compelling Indications
Heart failure
Post-MI
High coronary artery disease risk
Diabetes
Chronic kidney disease
Recurrent stroke prevention
Not at Goal Blood Pressure (<140/90 mmHg)
(<130/80 mm Hg for those with diabetes or chronic kidney
disease)
Initial Drug Choices
Drug(s) for compelling indications*
Other antihypertensive drugs
(diuretics, ACEI, ARB, BB, CCB)
as needed.
Lifestyle Modifications
Stage 2 Hypertension
(SBP >160 or DBP >100 mmHg)
2-drug combination for most
(usually thiazide-type diuretic,
ACEI, or ARB, or BB, or CCB).
Stage 1 Hypertension
(SBP 140–159/ DBP 90–99
mmHg) Thiazide-type diuretics
for most. May consider ACEI,
ARB, BB, CCB, or combination.
Without Compelling
Indications
Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
With Compelling
Indications
Chobanian AV et al. JAMA. 2003;289:2560–2572.
51. ACE inhibitor or ARB
Aged <55 years
Aged ≥55 years or
black person of African or
Caribbean family origin
of any age
CCB
ACE inhibitor or ARB + CCB
ACE inhibitor or ARB + CCB + thiazide-like diuretic
ACE inhibitor or ARB + CCB + thiazide-like diuretic +
consider further diuretic or α- or β-blocker
NICE(British)HypertensionGuidelines’TreatmentAlgorithm
18
55. Egyptian Hypertension Guidelines 2014
The diagnostic cutoff for the diagnosis
of hypertension is lower in people with
diabetes (140/90 mmHg) than those
without diabetes or low risk patients
(150/95 mmHg).
Prevalence of hypertension is 1.5-fold
higher in diabetic patients relative to
non-diabetic patients.
56.
57.
58.
59.
60. Threshold equal or over 130/80 mmHg and Target below 130/80 mmHg
With
Nephropathy,
CVD or CV risk
factors
ACE Inhibitor or
ARB
Diabetes
Without
the above
1. ACE Inhibitor
or ARB or
2. Thiazide diuretic
or DHP-CCB
• Monitor K and Cr. carefully in patients with CKD prescribed an ACEI or ARB.
• Combination ACEI & ARB are not recommended in the absence of proteinuria
• More than 3 drugs may be needed to reach target values
Combination of 2 first line
drugs may be considered
as initial therapy if SBP is
>20 mmHg or DBP >10
mmHg above target
> 2-drug
combinations
Pharmacotherapy forHypertensioninPatientswithDiabetes
61. Hypertension, Diabetes and Pregnancy
• In a pregnancy complicated by DM & hypertension, target BP goals is 130/80
mmHg.
• Lower blood pressure levels may be associated with impaired fetal growth.
• ACEi and ARBs are contraindicated, as they cause fetal damage.
• Effective and safe antihypertensive drugs include: methyldopa, labetalol,
diltiazem, clonidine, and prazosin.
• Chronic diuretic use during pregnancy is associated with restricted maternal
plasma volume, which may reduce uteroplacental perfusion.
62. Agenda
• What is common in Diabetes and Hypertension? What is the link?
• Why Hypertension is important?
• Why Diabetes is important?
• Management: What do literature and guidelines recommend?
• Why RAAS blockade in Diabetic hypertensive patients?
68. Take-Home Message
• Diabetes& Hypertension are dangerous combination
• RCTs support the general consensus & guidelines that RAAS Blockade, including
ARBs, is a class of choice as monotherapy or in combination in hypertensive
diabetic patients.
Lower all-cause & CV mortality.
Reduced risk of CV events (MI & HF).
Slower rate of deterioration in renal function.
• ?/
•?
