Hypertension is a major independent CV risk factor in diabetes, and a direct correlation between blood pressure levels and CV risk has been demonstrated. Several recent studies using various antihypertensive drug regimens have demonstrated the benefit of lowering blood pressure to less than 140 mm Hg systolic and 80 mm Hg diastolic in subjects with diabetes. The UKPDS trial showed that tight blood pressure control may be more beneficial than tight glycemic control in terms of CV risk reduction in diabetes. Based on these clinical trials and epidemiologic studies, a target blood pressure goal of less than 130/80 mm Hg for diabetic patients has been recommended (see Table 2-9).7 Behavioral factors that favorably affect hypertension include weight loss, regular aerobic activity, and limitation of alcohol and sodium intake. These nonpharmacologic strategies may also positively affect glycemic and lipid control. Additional pharmacologic therapy should be initiated early if lifestyle modifications are insufficient or in the presence of moderate to severe hypertension at the time of diagnosis. Among diabetic patients, hypertension can rarely be managed within the target zone with only one agent, and at least one third of patients require three or more medications.
ACE inhibitors or angiotensin receptor blockers (ARB), often in combination with a thiazide diuretic, should be considered as initial therapy (Table 2-10). The use of P-blockers in diabetic patients with CAD is associated with improved survival, even in those without a previous MI. Therefore, in this subgroup of patients, P-blockers and the combination of P-blockers and ACE inhibitors are considered the regimens of choice. It should be emphasized that P-blockers are not contraindicated in diabetic subjects with impaired hypoglycemia awareness, nor in those with PAD, particularly if cardioselective P1-blockers are used. With respect to calcium channel blockers, dihydropyridines have been shown to decrease cardiac events and stroke, whereas nondihy-dropyridines reduce the progression of diabetic nephropathy.131 Because randomized trials have
ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CAD, coronary artery disease.
shown that the efficacy of dihydropyridine calcium channel blockers on CV event reduction is inferior to that observed with ACE inhibitors, calcium antagonists should be used as a second- or third-line regimen. On a broad perspective, optimal blood pressure control is more important than the drug class used to achieve it.
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Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...