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Hypertension and Diabetes: Addressing Common Comorbidities

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Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of morbidity and mortality in patients with diabetes.1 ASCVD is defined by the American College of Cardiology and the American Heart Association (ACC/AHA) as acute coronary syndrome, myocardial infarction, stable or unstable angina, coronary or other arterial revascularization, stroke, transient ischemic attack, or peripheral arterial disease presumed to be of atherosclerotic origin.2 Risk factors for ASCVD include hypertension, dyslipidemia, smoking, family history of premature coronary disease, chronic kidney disease, and albuminuria.3

Hypertension, a modifiable risk factor, is prevalent in patients with diabetes. Multiple studies have shown that antihypertensive therapy in these patients reduces ASCVD events; therefore, blood pressure control is necessary.1,3 The American Diabetes Association’s (ADA) 2018 Standards of Medical Care in Diabetes offers guidance on the assessment and treatment of hypertension in patients with diabetes—including the organization’s position statement on hypertensive treatment with comorbid diabetes.1,3 These guidelines are relevant and useful to both primary care and specialty providers who manage these complex patients.

Screening and Diagnosis

Every clinical care visit for patients with diabetes should include a blood pressure measurement. (Evaluation for orthostatic hypotension should also be performed at the initial visit, to help guide future treatment.1) For accuracy, blood pressure should be assessed

  • By a trained individual using the appropriate size cuff
  • In both arms on the initial visit
  • With the patient seated, with feet on the floor and arm at heart level
  • After five minutes of rest
  • With two to three readings taken one to two minutes apart and results averaged.1

If blood pressure is found to be elevated and the patient has no known history of hypertension, the elevated blood pressure should be reassessed on another visit within one month to confirm the diagnosis.1 Patients should also monitor blood pressure at home to distinguish between white coat and masked hypertension.1 Home blood pressures should be measured with arm cuffs that are the appropriate size. The bladder of the cuff should encircle 80% of the arm, should not cover clothing, and should be placed on the upper arm at the midpoint of the sternum.1

The ACC/AHA’s 2017 guidelines define stage 1 hypertension as 130-139/80-89 mm Hg and stage 2 hypertension as ≥ 140/90 mm Hg.4 The ADA defines hypertension as a sustained blood pressure ≥ 140/90 mm Hg, noting that the definition is “based on unambiguous data that levels above this threshold are strongly associated with ­ASCVD, death, disability, and microvascular complications.”1

BLOOD PRESSURE TARGETS

Evidence has shown that treatment of blood pressure to a goal of ≤ 140/90 mm Hg reduces cardiovascular events as well as microvascular complications.1 For patients with diabetes, the ADA recommends treatment to a systolic blood pressure goal of < 140 mm Hg and a diastolic blood pressure goal of < 90 mm Hg, while the ACC/AHA guidelines recommend a goal of < 130/80 mm Hg.1,4

The ADA does note that lower blood pressure targets (eg, < 130/80 mm Hg) can be appropriate for individuals at high risk for cardiovascular disease if no treatment burdens (eg, adverse effects, costs) are imposed.1 This is important, since patients with diabetes often have multiple risk factors for ASCVD and will be considered high risk. Studies suggest lower blood pressure targets may decrease the risk for stroke and albuminuria but offer little to no effect on other ASCVD events, occurrence of heart failure, or other conditions associated with diabetes (eg, peripheral neuropathy).1

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