Jab Mein Thaa , Tab Guru Nahin †Aub Guru Hai , Mein Nahin Sab Andhiyara Mit Gayaâ€

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Jab Mein Thaa , Tab Guru Nahin ‚ Aub Guru Hai , Mein Nahin Sab Andhiyara Mit Gaya‚ Jab Deepak Dekhya Mahin - PowerPoint PPT Presentation

Text of Jab Mein Thaa , Tab Guru Nahin †Aub Guru Hai , Mein Nahin Sab Andhiyara Mit ...

  • Jab Mein Thaa, Tab Guru Nahin Aub Guru Hai, Mein Nahin Sab Andhiyara Mit Gaya Jab Deepak Dekhya Mahin When "I, the Ego, was with me, then I couldnt realize the almighty within; Now, the Almighty "is" ever with me and there is no place for this Ego. All the darkness (illusion) within me is mitigated, on realizing the light (illumination) within. SK

    www.drsarma.in

    Diabetic Hypertension

  • The Two Terrorists

  • THE ENORMITY OF THE PROBLEM - COMPOUNDED

  • How Common is this Duo?HTN is twice as common in DMNew onset DM is 2.5 times in HTN20 to 40% of IGT pts have HTN40 to 50% of Type 2 DM have HTNOnly 1/4 of HTN in DM is controlledDM + HTN CV Risk 3 fold

  • What Causes HTN in DM

  • Each Perpetuates the Other

  • Relative Risk of DM + HTNDiabetes + HTN versus Diabetes Neuropathy1.6 Nephropathy 2.0 Retinopathy 2.0 Stroke 4.0 CHD 3.0Mortality2.0

  • Difficulties of HTN in DMSystolic HTN more common in DMS-HTN is a stronger predictor of CVE65% of T2DM have S-HTNS-HTN is more difficult to controlDepression is more in DM Adherence RxClinician Inertia is a big problemGlycemic control only is the focus No VP

  • The Compound Jeopardy !!Reilly MP et al Circulation 2003; 108: 1546-1551

  • THE DASAVATARAM ANDTHE VISWA ROOPAM

  • IGT, IFGIR, InsulinDyslipidemiaHypertensionED, VesselVisceral obesityPro InflammatoryPro Thrombotic

  • Perpetuating CircusCKDDiabetes BP LipidsCADED

  • The Devastating Conspiracy

  • RF for Nephropathy in DM

  • Progression of DM - Nephropathy

  • Nephropathy in DMYears after onset of DM

  • Outcomes of DM NephropathyDiabetic Nephropathy

  • THE EVIDENCE BASEDM + HT IS DANGEROUS

  • Data from King H et al. Diabetes Care. 1998;21:1414-1431. Top 3 Countries for Diabetes

  • CV Mortality Risk Doubles with Each 20/10 mm Hg BP IncrementLewington S, et al. Lancet. 2002; 60:1903-1913.JNC VII. JAMA. 2003.SBP/DBP (mm Hg)012345678115/75135/85155/95175/105

  • SBP & CV Mortality in T2DM250200150100500
  • Metabolic Syndrome and AgePrevalence, % Age in yrAdapted from: Ford ES, et al. JAMA. 2002;287:356-359.

  • HOT Study Imp. of DBPLancet 1998; 351: 175562

  • RR .66, 95% Cl .46 - .94RR .66, 95% Cl .55 - .79DiabetesNondiabetesCurb JD, et al. JAMA. 1996;276:1886-1892.351530252050105-Year Cumulative Event Rates for AllMajor Cardiovascular Events (%)Active treatmentPlaceboSHEP DM and CVE Rates

  • MortalityCV EndpointsStrokeCoronaryActive BetterSHEPSYST-EURRate in Placebo Group*SHEPSYST-EUR35.645.163.057.628.826.632.221.3-100%-50%050%Placebo Better*Number of endpoints / 1000 patient years-25-55-34-59-22-73-56-57Mortality and Morbidity in DM

  • Myocardial InfarctionMajor CV EventsStrokeCV MortalityTotal Mortality90 mmHg80 mmHg01234||||HOT Diabetic HypertensionLancet 1998; 351: 175562

  • Tight Glucose ControlTight BP Control*P < 0.05-50 --40 --30 -0 -StrokeAny DM End PointDM DeathMicrovascular ComplicationsReduction in Risk (%)UKPDS. BMJ. 1998:317;703-712.-20 --10 -BP v/s Glucose Control

  • Hypertension & DM Mortality0%20%40%60%80%100%Captopril (UKPDS) Atenolol (UKPDS)

    Diuretic(SHEP)

    Nitrendipine (Syst-Eur)

    Nitrendipine (Syst-China)

  • STENO-2 Study in DM Event Nephropathy 56%Proliferative retinopathy 55%Cardiovascular events 59%Total Mortality 40%% in Complications with intensive Rx

    NEJM 2003; 358:580

  • SOLVD: Enalapril Reductionin New-Onset DiabetesP
  • 12345Time (y)Vermes E et al. Circulation. 2003;107:1291-1296. 2550751000EnalaprilPlacebo45% risk reduction P < 0.0001Patients With IFG at Baseline (n = 55)SOLVD: Enalapril Reductionin New-Onset Diabetes in IFG

  • LIFE Study: ResultsP
  • ALLHAT: Incidence of New-Onset Diabetes at 4 YearsALLHAT Officers and Coordinators. JAMA. 2002;288:2981-2997.Chlorthalidone AmlodipineLisinopril P .001 P = .0411.6%9.8%8.1%%

  • THE EVIDENCE BASEMANAGEMENT GUIDE

  • HypertensionDyslipidemiaDysglycemiaRisk Reduction for CAD and CKD

  • Na & KSFA UFACHO GLRisk Reduction for CAD and CKD

  • Mandatory Clinical Actions

  • HTN Lifestyle modificationsRegular 30 of moderately intense exerciseNo tobacco and minimizing alcoholNa restriction to < 6 g of Nacl per dayAvoiding high salt foods pickles, savouriesFour adult family 6 x 30 x 4 = 720 g (500 g)Use of K containing foods fruits, vegetablesWeight reduction goal ideal weightReducing coffee consumption

  • HTN Lifestyle modifications

  • DASH Diet Plan

    Type of FoodServings (1600 K cal)Grains (whole grains)6 per dayVegetables3 per dayFruits (not tinned juices)4 per dayLow fat milk2 per dayLean meat, poultry3 per dayNuts, seeds (dry roast, soak)3 per weekFats and oils2 per daySweets and pastries0 per daySalt at table & salted foodsNone

  • Benefit of Quitting Smoking in HTN

  • BP Targets in DMIdeal Blood PressureWithout proteinuria< 130/80With proteinuria < 125/75Goal BP maximum for DM < 130/80Almost all DM pts require > 1 drug for HTNIdentify the co-morbidity CAD, CKD, CVD

  • ADA Guidelines on Rx. of HTN with DM SystolicDiastolicGoal (mmHg)
  • THE EVIDENCE BASE FORMANAGEMENT OPTIONS

  • Management OptionsDiureticsNDHP - CCBsMNTExerciseNew BBACEi, ARB

  • Choice of Drug Rx for HTNYounger than 55 yearsOlder than 55 yearsACEi or ARB (A)Diuretic (D) or CCB (C)A + D or CA + D + CA + D + C + new or blocker

  • HTN Rx. Algorithm in DMBP > 130/80 (2 readings)No TOD / MAU ACE/ARB + TLC 1 MYesNoAdd LD DiureticAdd VerapamilAdd new B /YesYesNoTLC cont.>140/90/MAU/TOD1 MonthSub AmlodepineNoNoNoYesYes1 Month1 Month1 Month?Diabetes Spectrum 2004, Vol. 5, # 3, 103-108

  • Physiological RAAS Effects

  • Renin Angiotensin Aldosterone System

  • The RAAS BlockadeAng IAng IIProgressive Diabetic NephropathyACERenal Injury and ProteinuriaAT2 ReceptorNon-ACEPathwaysAldosterone++

  • Adverse Renal and CVEffects of AldosteroneGlomerulosclerosisInterstitial FibrosisProteinuriaRenal FailureLVHCardiac FibrosisLV DysfunctionHeart Failure Endothelial DysfunctionInflammationOxidative StressAldosterone

  • ACEi or ARB A must for VPAntihypertensive, vasoprotective, anti-thrombotic and anti-inflammatory Inevitable in DM more so in DM + HT/CVDReduce CV events, Reduce atherosclerosis Reduce renal disease - a strong CV risk factorMetabolically friendly drugs in DM They prevent new onset DM, Nephropathy Well-tolerated with few side effects

  • ACE inhibitor or ARBRenal impairment These improve e-GFR, microalbuminuria or proteinuria LV dysfunction (along with new blocker)Previous MI (along with new blocker)Contraindicated in pregnancyRelative contraindications- Bilateral renal artery stenosis- Severe renal impairment (Cr > 3.0) - Monitor renal function- Angioedema, ACEi cough

  • Vascular Protection in DMAtorvastatin (Lipid management)ASA (Acetyl Salicylic Acid) (enteric coated)ACE inhibitors or ARBsA1c control (Glycemic control)Blood pressure goal (
  • AASKMAP
  • Chobanian AV et al. JAMA. 2003;289:25602572.JNC 7 Antihypertensive AgentsBased on Favorable Outcome Data From Clinical Trials

  • Other Effects of HTN Drugs

  • DM + Co-morbidityDM + Co-morbidityPrimary DrugAdd on Drug Rx.DM aloneDM + HT LVHDM + MAU/AUDM + CAD/MIDM + CHFACEi low doseACEi or ARBARB, (ACEi)ACEi (ARB) ACEi or ARBBP & ACR watch D + C + New B Indap + Carve Carve / New B D + AA + B

  • -Blockers and their Effects

  • Name of BReceptorISACommentAcebutolol1YesNot GoodPenbutolol1, 2YesBadPindolol1, 2YesBadPropranolol1, 2NoNo GoodNadolol1, 2NoNo GoodTimolol1, 2NoNo GoodAtenolol1NoOKMetoprolol1NoVery GoodNebivolol1NoExcellentBisoprolol1NoExcellentLabetalol, 1, 2NoEmergencyCarvedilol, 1, 2NoCHF, IHD

  • Advantages of CarvedilolGEMINI trial and OPTIMIZE-HF Study

  • Ideal anti HTN drug in DMMust decrease blood pressure to 130/80Must reduce the RAAS activity, improve ED Must prevent, improve or arrest proteinuriaMust prevent and protect from CAD, CKD, CHFMust be favourable on glycemic controlMust improve the dyslipidemia not worsen itMust not worsen peripheral arterial diseaseMust improve ED and not cause impotenceMust not decrease eGFR and serum creatinineMust not raise uric acid, serum potassium

  • What should We take home ?Clinician Inertia for HTN in DM must be overcomeHTN in DM is serious; So manage aggressivelyTLC, Lipid control, Glycemic targets VP is a mustHTN Rx. delays or arrests CVD, CKD, PAD, CVDACEi or ARBs are the main stay of Rx - RAASPostural hypotension, DAN are important in RxMAU/ACR must for all DM Predict CAD, CKDTypically 2 or more drugs are needed for HTN Rx.New B, Carvedilol, CCBs are add-on drugs

  • Amaedhya poornam, krimi raasi samkulam,Swaabhava gandham, asaucham, adhruvam | Sareeram, mootra pureesha bhaajanam Ramanti moodha, viramanti pandithaa | Full of filth, ridden with all bacteria and worms,Naturally stinking, unclean to the core & perishable,This body of ours, is drenched in excreta & secreta,Only the fools engross in it, but the wise shun it. VC by ASA

    ***************This slide presents the ADA recommendations on initial treatment and goals for adult hypertensive diabetic patients.1

    1. Arauz-Pacheco C, Parrott MA, Raskin P; American Diabetes Association. Treatment of hypertension in adults with diabetes. Diabetes Care. 2003;26(suppl):S80S82.**

    1. Chobanian AV, Bakris GL, Black HR, et al. The Se