Early, Aggressive Treatment of Hypertension in Diabetes Urged


NEW YORK — Patient-centered management and early, aggressive treatment of hypertension is necessary in patients with diabetes to address the sevenfold mortality increase in this patient population, according to an updated guidance from the American Society of Hypertension.

Physicians need to take a more integrated, individualized approach to treating hypertension in patients with diabetes by “treating the intricacies of each patient profile, rather than focusing on the disease in isolation,” according to a statement by ASH.

The new recommendations were addressed in a press briefing and published in a position paper in the Journal of Clinical Hypertension (2008;10:707).

The guidance does not alter the fundamental treatment of blood pressure goals for this patient population, but it does emphasize that early detection of risk factors unique to each patient is needed and that earlier, more-aggressive treatment should be implemented, including the identification and reduction of proteinuria.

Once high blood pressure is identified, initiation of ACE inhibitors or angiotensin receptor blocker therapy along with either thiazide-like diuretics or calcium antagonists is needed to maintain a target blood pressure of 130/80 mm Hg. More frequent patient follow-up also is needed, according to the guidance.

Previous studies show that, compared with conventional treatment, aggressive blood pressure control is associated with far fewer cardiovascular events in diabetic patients, Dr. George Bakris, professor of medicine at the University of Chicago, said during the briefing. Yet physicians are not being as aggressive as necessary to get blood pressure under control. Physicians also need to empower patients to take control, and they need to focus on the goal of reducing morbidity.

Physicians need to emphasize that the need for treatment is not transient but is lifelong. That said, obese patients who lose weight can successfully reduce their antihypertensive pill burden, he noted.

“These patients require an integrated therapeutic intervention that, in addition to blood pressure control, should include glycemic and lipid control and antiplatelet therapy,” Dr. Bakris noted in an ASH statement. It is imperative that all risk factors be attacked simultaneously to manage the profile of each patient more vigilantly, he added.

The challenges of identifying and treating hypertension are not limited to adults.

Nearly a third of obese teens also have high blood pressure, Dr. Bonita Falkner, a nephrologist at Thomas Jefferson University, Philadelphia, said during the briefing.

Overall, about 3.5% of children have hypertension and another 3.5% have prehypertension. It is likely that these children have—or will develop—blood pressure levels that require therapy and that they will become hypertensive young adults, said Dr. Falkner.

Additional clinical research involving adolescents is needed to define the disease pathway and to improve detection and treatment methods, she said. But for now, she recommended that blood pressure be measured as part of routine health care beginning at age 3 years, and in those younger than 3 years with chronic disease or unexplained symptoms, and that an appropriate evaluation be conducted in those with detected and verified hypertension.

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