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FIGURE 2 Effects of intensified blood pressure lowering on cardiovascular events in patients with and without diabetes. Source: From Ref. 23.

significance. Interestingly, losartan was significantly more effective than atenolol in reversing LVH (p < 0.0001).

The Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack Trial (ALLHAT) is the largest comparative CV outcomes trial, which compared chlorthalidone, amlodipine and lisinopril in 33,357 patients, including 12,063 T2DM patients, over a 4-8-year follow-up period (33). In the diabetic subgroup, no significant differences were found between the treatment arms in the incidences of the primary outcome (non-fatal myocardial infarction plus coronary heart disease), all-cause mortality, stroke, coronary heart disease or overall CVD. There was a significant benefit in favor of chlorthalidone in the incidence of heart failure, but this result is controversial, as the diagnosis of heart failure was largely based on signs and symptoms and not extensively confirmed by external, independent validation. In addition, compared to the other drugs, diuretics might have had a masking effect on the major clinical signs of heart failure.

In the ASCOT (Anglo-Scandinavian Cardiac Outcomes Trial) blood pressure lowering arm (34) the effect of two different antihypertensive combination therapies (atenolol plus thiazide versus amlodipine plus perindopril) on non-fatal myocardial infarction and fatal coronary heart disease was analyzed in 19,257 hypertensive patients (age range: 40-79 years) who had at least three other CV risk factors. After a follow-up period of 5.5 years, fewer patients treated with the newer drug combination (Fig. 3) reached a primary endpoint (429 vs 474; HR: 0.90; p = 0.1052), fatal and non-fatal stroke (327 vs 422; HR: 0.77; p = 0.0003), total CVD events and procedures (1362 vs 1602; HR: 0.84; p < 0.0001), and all-cause mortality (738 vs 820; HR: 0.89; p = 0.0247). In the ASCOT 5345 patients had diabetes, however, risk reduction was not different in diabetic and nondiabetic patients. The incidence of developing diabetes in the nondiabetic patients at baseline was significantly less in the amlodipine-perindopril group compared to the atenolol-thiazide group (567 vs 799; HR: 0.70; p < 0.0001).

Table 1 summarizes data for primary outcome of CVD and all-cause mortality in several large placebo-controlled trials, in which representative numbers of diabetic and nondiabetic patients were included. A consistent finding is the marked reduction of the risk for subsequent CV events among diabetic patients on active treatment compared with those on placebo. This finding is consistent for all types of BP-lowering drugs that have been studied. In some studies (SHEP, Syst-Eur and HOT) the risk reduction was much more expressed in the diabetic cohort versus nondiabetic patients. Chosen as the initial drug, the beneficial effect of diuretics, beta-blockers, CCB, and ACEi are well documented. More recently, different antihypertensive drugs have been compared with each other (Table 2). It appears that blockade of the renin-angiotensin-system (RAS) seems to be of particular value, especially when treating hypertension in patients with diabetes at particularly high CV risk.

Primary Fatal and non- Total CV events All cause Incidence of endpoint fatal stroke and procedures mortality new diabetes

Primary Fatal and non- Total CV events All cause Incidence of endpoint fatal stroke and procedures mortality new diabetes

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Blood Pressure Health

Blood Pressure Health

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...

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