Reducing Cardiovascular Risk in Diabetics Through Hypertension Treatment

Hypertension in Diabetics Means a Significant Increase in CV Risk

Every increase in systolic or diastolic BP in a diabetic by 5 mmHg is associated with a 20–30% increase in the risk of sudden death or non-fatal CV event! The presence of hypertension in diabetics doubles the risk of death and stroke and triples the risk of developing coronary artery disease. In addition, hypertension in diabetics significantly accelerates the progression of renal damage and is associated with more pronounced neuropathy and retinopathy.

CV diseases cause premature death in up to 90% of diabetics

Almost 90% of all premature deaths in diabetics are caused by CV diseases. It is reported that more than 40% of newly diagnosed diabetics had hypertension before the diagnosis of DM was established. In patients with type 2 DM, hypertension is evidently linked to obesity, insufficient physical activity, and aging. In these cases, isolated systolic hypertension is common. In patients with type 1 DM, normal BP values are common at the time of diagnosis, with increases occurring subsequently in connection with diabetic nephropathy.

According to experts, BP is sufficiently controlled in only about one-third of diabetics with hypertension. Adequate correction of hypertension in diabetics usually requires a combination of ≥ 2 drugs.

What Do We Consider Adequate Compensation of Hypertension?

According to current recommendations from the Czech Society for Hypertension, the Society of General Medicine of ČLS JEP, and other professional societies, the optimal compensation for arterial hypertension in diabetics is considered to be a BP value around 130/80 mmHg. Studies suggest that reducing BP below these values is not convincingly linked to improved overall cardiovascular prognosis in diabetics. Some results even indicate that a greater reduction in BP could, on the contrary, increase the incidence of adverse treatment effects.

Which Antihypertensive Treatment Do We Prefer?

Dual Combination

Long-acting RAAS blockers (ACEi/sartans) + calcium channel blockers:

• Angiotensin-converting enzyme inhibitors (ACEi): perindopril, ramipril, trandolapril;
• AT₁ receptor blockers for angiotensin II (sartans): telmisartan, candesartan, irbesartan, valsartan, eprosartan;
• Calcium channel blockers: long-acting dihydropyridines (felodipine, nitrendipine, amlodipine).

Triple Combination

The above dual combination supplemented with:

• firstly: a low dose of thiazide diuretic (indapamide 1.25 to max. 2.5 g/day, alternatively low doses of hydrochlorothiazide in the dose of 6.25–12.5 mg, exceptionally 25 mg/day);
• secondly: centrally acting antihypertensive (rilmenidine, moxonidine, urapidil);
• thirdly: beta-blocker (bisoprolol, metoprolol, nebivolol, carvedilol, celiprolol, betaxolol).

Beware of Masked Hypertension

It is reported that up to one-third of diabetics have so-called masked hypertension—adequate target values are measured during BP measurements in the doctor's office, but higher values occur during 24-hour monitoring. The cardiovascular prognosis of patients with masked hypertension is comparable to the prognosis of patients with sustained hypertension and is often associated with organ changes including micro- and macroalbuminuria. Therefore, even when target blood pressure values are achieved in office check-ups, the indication for 24-hour BP monitoring should be considered.

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Sources:
1. Charvát J, Kvapil M. Hypertension in Patients with Diabetes Mellitus: How to Affect Cardiovascular Risk? Medicine after Graduation 2011; 12 (2): 77–81.
2. Karen I, Svačina Š. Diabetes Mellitus. Novelization 2020. Recommended Diagnostic and Therapeutic Procedures for General Practitioners. SVL ČLS JEP, 2020. Available at: www.svl.cz/files/files/Doporucene-postupy/2020/DIABETES-MELLITUS-2020.pdf
3. Prokopová I. Effective and Safe Therapy of Arterial Hypertension in an Obese Patient with Metabolic Syndrome. Practical Pharmacy 2016; 12 (5): 176–181.