Hypertensionblood pressure control

Hypertension is a common comorbidity found in the majority of patients with diabetes, particularly those with type 2. Additional risk factors include age, obesity, and ethnicity. Hypertension is a major risk factor for CVD and microvascular complications such as retinopathy and nephropathy.

Key recommendations: monitoring and preventing hypertension

• Blood pressure should be measured at every routine diabetes visit.

• Patients with diabetes should be treated to a systolic blood pressure <130 mmHg and a diastolic blood pressure <80 mmHg. Multiple drug therapy is generally required to achieve blood pressure targets.

• Initial drug therapy for raised blood pressure should be with a drug class demonstrated to reduce CVD events in patients with diabetes (ACE inhibitors, ARBs, beta-blockers, diuretics, and calcium-channel blockers).

• All patients with diabetes and hypertension should be treated with a regimen that includes either an ACE inhibitor or an ARB.

• In patients with type 1 diabetes, with hypertension and any degree of albuminuria, ACE inhibitors have been shown to delay the progression of nephropathy.

• In patients with type 2 diabetes and microalbuminuria, ACE inhibitors and ARBs have been shown to delay the progression to macroalbuminuria.

• In patients with type 2 diabetes and renal insufficiency, ARBs have been shown to delay the progression of nephropathy.

Lowering of blood pressure with regimens based on antihypertensive drugs, including ACE inhibitors, ARBs, beta-blockers, diuretics, and calcium-channel blockers, has been shown to be effective in lowering cardiovascular events. Several studies suggest that ACE inhibitors may be superior to dihy-dropyridine calcium channel blockers (DCCBs) in reducing cardiovascular events. Additionally, in people with diabetic nephropathy it has been indicated that ARBs may be superior to DCCBs for reducing heart failure but not overall cardiovascular events.

ACE inhibitors have been shown to improve cardiovascular outcomes in patients at high risk for CVD with or without hypertension. In patients with CHF, the addition of ARBs to either ACE inhibitors or other therapies reduces the risk of cardiovascular death or hospitalization for heart failure. However, the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), a large randomized trial of different initial blood pressure pharmacological therapies, found no large differences between initial therapy with a chlorthalidone, amlodipine and lisinopril [24].

During pregnancy, treatment with ACE inhibitors and ARBs is contrain-dicated since they are likely to cause fetal damage. Antihypertensive drugs known to be effective and safe in pregnancy include methyldopa, labetalol, diltiazem, clonidine, and prazosin. Chronic diuretic use during pregnancy has been associated with restricted maternal plasma volume, which might reduce uteroplacental perfusion.

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