Prevention And Management of Diabetes Complications
CVD is the major cause of mortality for individuals with diabetes. It is also a major contributor to morbidity and direct and indirect costs of diabetes. Type 2 diabetes is an independent risk factor for macrovascular disease, and its common coexisting conditions (e.g., hypertension and dyslipidemia) are also risk factors.
Studies have shown the efficacy of reducing cardiovascular risk factors in preventing or slowing CVD. Evidence is summarized in the following sections and reviewed in detail in the ADA technical reviews on hypertension, dyslipidemia , aspirin therapy , and smoking cessation and the consensus statement on CHD in people with diabetes. Emphasis should be placed on reducing cardiovascular risk factors, when possible, and clinicians should be alert for signs and symptoms of Atherosclerosis.
1. Hypertension/blood pressure control
Text continued belowRecommendations
Screening and diagnosis
* Blood pressure should be measured at every routine diabetes visit. Patients found to have systolic blood pressure 130 mmHg or diastolic blood pressure 80 mmHg should have blood pressure confirmed on a separate day. (C)
Goals
* Patients with diabetes should be treated to a systolic blood pressure <130 mmHg. (C)
* Patients with diabetes should be treated to a diastolic blood pressure <80 mmHg. (B)
Treatment
* Patients with hypertension (systolic blood pressure 140 or diastolic blood pressure 90 mmHg) should receive drug therapy in addition to lifestyle and behavioral therapy. (A)
* Multiple drug therapy (two or more agents at proper doses) is generally required to achieve blood pressure targets. (B)
* Patients with a systolic blood pressure of 130??“139 mmHg or a diastolic blood pressure of 80??“89 mmHg should be given lifestyle and behavioral therapy alone for a maximum of 3 months and then, if targets are not achieved, in addition, be treated with pharmacological agents that block the renin-angiotensin system. (E)
* Initial drug therapy for those with a blood pressure >140/90 mmHg should be with a drug class demonstrated to reduce CVD events in patients with diabetes (ACE inhibitors, ARBs, ??-blockers, diuretics, and calcium channel blockers). (A)
* All patients with diabetes and hypertension should be treated with a regimen that includes either an ACE inhibitor or an ARB. If one class is not tolerated, the other should be substituted. If needed to achieve blood pressure targets, a thiazide diuretic should be added. (E)
* If ACE inhibitors, ARBs, or diuretics are used, monitor renal function and serum potassium levels. (E)
??? In patients with type 1 diabetes, with hypertension and any degree of albuminuria, ACE inhibitors have been shown to delay the progression of nephropathy. (A)
??? In patients with type 2 diabetes, hypertension, and microalbuminuria, ACE inhibitors and ARBs have been shown to delay the progression to macroalbuminuria. (A)
??? In those with type 2 diabetes, hypertension, macroalbuminuria, and renal insufficiency, ARBs have been shown to delay the progression of nephropathy. (A)
* In pregnant patients with diabetes and chronic hypertension, blood pressure target goals of 110??“129/65??“79 mmHg are suggested in the interest of long-term maternal health and minimizing impaired fetal growth. ACE inhibitors and ARBs are contraindicated during pregnancy. (E)
* In elderly hypertensive patients, blood pressure should be lowered gradually to avoid complications. (E)
* Patients not achieving target blood pressure despite multiple drug therapy should be referred to a physician experienced in the care of patients with hypertension. (E)
* Orthostatic measurement of blood pressure should be performed in people with diabetes and hypertension when clinically indicated. (E)
Hypertension (blood pressure 140/90 mmHg) is a common comorbidity of diabetes, affecting the majority of people with diabetes, depending on type of diabetes, age, obesity, and ethnicity. Hypertension is also a major risk factor for CVD and microvascular complications such as retinopathy and nephropathy. In type 1 diabetes, hypertension is often the result of underlying nephropathy. In type 2 diabetes, hypertension may be present as part of the metabolic syndrome (i.e., obesity, hyperglycemia and dyslipidemia) that is accompanied by high rates of CVD.
Randomized clinical trials have demonstrated the benefit (reduction of CHD events, stroke, and nephropathy) of lowering blood pressure to <140 mmHg systolic and <80 mmHg diastolic in individuals with diabetes. Epidemiologic analyses show that blood pressures >115/75 mmHg are associated with increased cardiovascular event rates and mortality in individuals with diabetes. Therefore, a target blood pressure goal of <130/80 mmHg is reasonable if it can be safely achieved.
Although there are no well-controlled studies of diet and exercise in the treatment of hypertension in individuals with diabetes, reducing sodium intake and body weight (when indicated), increasing consumption of fruits, vegetables, and low-fat dairy products, avoiding excessive alcohol consumption, and increasing activity levels have been shown to be effective in reducing blood pressure in nondiabetic individuals. These nonpharmacological strategies may also positively affect glycemia and lipid control. Their effects on cardiovascular events have not been well measured.
Lowering of blood pressure with regimens based on antihypertensive drugs, including ACE inhibitors, angiotensin receptor blockers (ARBs), ??-blockers, diuretics, and calcium channel blockers, has been shown to be effective in lowering cardiovascular events. Several studies suggest that ACE inhibitors may be superior to dihydropyridine calcium channel blockers (DCCBs) in reducing cardiovascular events. Additionally, in people with diabetic nephropathy indicate that ARBs may be superior to DCCBs for reducing heart failure but not overall cardiovascular events. Conversely, in the recently completed International Verapamil Study (INVEST) of >22,000 people with CAD and hypertension, the non-DCCB verapamil demonstrated a similar reduction in cardiovascular mortality to a ??-blocker. Moreover, this relationship held true in the diabetic subgroup.
ACE inhibitors have been shown to improve cardiovascular outcomes in high??“cardiovascular risk patients with or without hypertension. In patients with congestive heart failure (CHF), the addition of ARBs to either ACE inhibitors or other therapies reduces the risk of cardiovascular death or hospitalization for heart failure. In one study, an ARB was superior to a ??-blocker as a therapy to improve cardiovascular outcomes in a subset of diabetic patients with hypertension and left ventricular hypertrophy. The compelling effect of ACE inhibitors or ARBs in patients with albuminuria or renal insufficiency provide additional rationale for use of these agents (see section VI, B below).
The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), a large randomized trial of different initial blood pressure pharmacological therapies, found no large differences between initial therapy with a chlorthalidone, amlodipine and lisinopril. Diuretics appeared slightly more effective than other agents, particularly for reducing heart failure. The -blocker arm of the ALLHAT was terminated after interim analysis showed that doxazosin was substantially less effective in reducing CHF than diuretic therapy.
Before beginning treatment, patients with elevated blood pressure should have their blood pressure reexamined within 1 month to confirm the presence of hypertension. Systolic blood pressure 160 mmHg or diastolic blood pressure 100 mmHg, however, mandates that immediate pharmacological therapy be initiated. Patients with hypertension should be seen as often as needed until the recommended blood pressure goal is obtained and then seen as necessary. In these patients, other cardiovascular risk factors, including obesity, hyperlipidemia, smoking, presence of microalbuminuria (assessed before initiation of treatment), and glycemic control, should be carefully assessed and treated. Many patients will require three or more drugs to reach target goals.
During pregnancy in diabetic women with chronic hypertension, target blood pressure goals of systolic blood pressure 110??“129 mmHg and diastolic blood pressure 65??“79 mmHg are reasonable, as they may contribute to long-term maternal health. Lower blood pressure levels may be associated with impaired fetal growth. During pregnancy treatment with ACE inhibitors and ARBs is contraindicated, since they are likely to cause fetal damage. Antihypertensive drugs known to be effective and safe in pregnancy include methyldopa, labetalol, diltiazem, clonidine, and prazosin. Chronic diuretic use during pregnancy has been associated with restricted maternal plasma volume, which might reduce uteroplacental perfusion.
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AMERICAN DIABETES ASSOCIATION
DIABETES CARE, VOLUME 27, SUPPLEMENT 1, JANUARY 2004
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