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Blood Pressure and DiabetesBlood Pressure and Diabetes
Colin M. Dayan
University of Bristol/UBHT
40
15 13 1310
4 5
0
10
20
30
40
50
Perc
en
t of
death
s
Geiss LS, et al. In: Diabetes in America. National Institutes of Health;1995.
Causes of Death in Causes of Death in People With DiabetesPeople With Diabetes
Isch
emic
hear
t di
seas
e
Oth
er h
eart
dise
ase
Dia
bete
s
Mal
igna
nt
neop
lasm
s
Cere
brov
ascu
lar
dise
ase
Pneu
mon
ia/
influe
nza
All ot
her
www.hypertensiononline.org
Any diabetes-related endpointsAny diabetes-related endpoints
0%
10%
20%
30%
40%
50%
0 3 6 9
% o
f pat
ient
s w
ith e
vent
s
Years from randomisation
Tight blood pressure control (758)
Less tight blood pressure control (390)
risk reduction24% p=0.0046
Benefits of Tight BP and Tight Glucose Benefits of Tight BP and Tight Glucose Control Control UKPDSUKPDS
-50
-40
-30
-20
-10
0
Tight glucose controlTight BP control
Microvascularendpoints
*
StrokeAny diabetes-
related endpointDiabetes-related
deaths
*
*
*
*P<0.02, tight BP control (achieved BP 144/82 mm Hg) vs.. less tight control (achieved BP 154/87 mm Hg).†P<0.03, intensive glucose control (achieved HbA1c 7.0%) vs. less intensive control (achieved HbA1c 7.9%).UKPDS Group. BMJ. 1998;317:703-713.UKPDS Group. Lancet. 1998;352:837-853.
Risk reduction
(%)
†
†
Case 1Case 1
• 61 yr old man• Type 2 diabetes diagnosed last year• Albumin/creatinine ratio = 13.5• Creatinine = 103• BP = 155/90• Cholesterol = 5.5• HbA1c = 7.2% on Metformin
Trea t A L L ris k fac to rsB P < 1 3 0 /7 5 , A S A s ta tin , H b A 1 c
E xc lu d e in fec tion (M S U )
P os it ive - d o n o t sc reen fo r m ic roa lb
Trea t A L L ris k fac to rs
> 3 on 2 /3 occas ion s= m ic roa lb u m in u ria
R esu m e an n u a l s c reen in g
> 3 on less th an 2 /s occas ion s
N eg ative - sen d a lb /c rea t(id ea lly firs t am )
D ip s tic k tes t fo r p ro te inTyp e t it le h e re
European Guidelines on European Guidelines on hypertension in T2DM 2002hypertension in T2DM 2002
• Review BP if single reading >140/85 (130/75 if microalb)
• Consider HBPM or ABPM (cut-off ?130/75) 12-20/8-12mmHg less.
• Address all CV risk factors - statin, ASA• NB Statins also reduce microalb excretion• Target 140/85 • Drugs
European Guidelines on European Guidelines on hypertension in T2DM 2002 - hypertension in T2DM 2002 -
DrugsDrugs• Nephropathy - ACE, A2RA, CCBs,
indapamide• Hyperkalaemia - Loop diuretics or thiazides• Angina - Beta block or CCB• MI or LV dsyfunction - beta block and ACE• ISH - thiazides and CCBs• Not alpha blockers as first line• Use once daily dosing to aid compliance
HbAHbA1c1c cross-sectional, median values
06
7
8
9
0 3 6 9 12 15
HbA
1c (
%)
Years from randomisation
Conventional
Intensive
6.2% upper limit of normal range
Blood Pressure : Tight vs Less Tight Blood Pressure : Tight vs Less Tight Control Control
60
80
100
140
160
180
0 2 4 6 8
mm
Hg
Years from randomisation
cohort, median values
Less tight control Tight control
Bristol Integrated Care Bristol Integrated Care PathwayPathway
• 140/80• In the presence of nephropathy: 135/75 or
lower.
Bristol Integrated Care Bristol Integrated Care PathwayPathway
• Step 1 Lifestyle• Step 2 ACE (or A2RA if cough)• Step 3 Diuretic (BFZ, Frusemide)• Step 4 beta blocker
PANDIPP
Case 2Case 2
• 69 yr old woman with Type 2 diabetes diagnosed 7 years ago
• BMI = 33• Proteinuria ++ on 3 occasions• BP = 160/95• Creatinine = 135• K+ = 5.9• HbA1c = 9.0% on Glibenclamide and Metformin
Case 3Case 3
• 28 yr old woman with Type 1 diabetes since age 12
• Retinopathy - laser 2 years ago• BP = 144/88• Alb/creat = 5.4• HbA1c = 10.1%• Cholesterol = 5.3
Perkins, B. A. et al. N Engl J Med 2003;348:2285-2293
Microalbuminuria can disappear in 58% of cases
Case 4Case 4
• 74 yr old man with T2DM diagnosed 4 years ago
• BP = 140/80• Proteinuria + on 2 occasions• Cholesterol = 4.9• HbA1c = 7.3%
The British Hypertension Society recommendations for combining The British Hypertension Society recommendations for combining Blood Pressure Lowering drugsBlood Pressure Lowering drugs
Younger (e.g.<55yr)and Non-Black
Older (e.g.55yr) or Black
Step 1
Step 2
Step 3
Step 4Resistant Hypertension
Add: either -blocker or spironolactone or other diuretic
A: ACE Inhibitor or angiotensin receptor blocker B: - blockerC: Calcium Channel Blocker D: Diuretic (thiazide)
A (or B)
A
A or B C or D
C or D +
+ +C D
Adapted from : ‘Better blood pressure control: how to combine drugs’Journal of Human Hypertension (2003) 17, 81-86
Treating Hypertension in Treating Hypertension in NephropathyNephropathy
Lewis et al 2001
Is home blood pressure Is home blood pressure monitoring useful?monitoring useful?
Home BP vs clinic BPHome BP vs clinic BP