How is hypertension defined in DM and what are the targets of therapeutic intervention

Hypertension in the general (non-diabetic) population is defined as the presence of arterial blood pressure (BP) levels above 140/90 mmHg. These limits were set based on large epidemiological studies (e.g. Framingham Study, Multiple Risk Factor Intervention Trial, etc), which revealed that the risk of cardiovascular complications is considerably increased above these levels, while the risk for lower BP levels, although existent, is not significant enough to justify therapeutic interventions, apart from lifestyle advice. For DM, however, the data from large, controlled, randomized, clinical studies showed that the reduction of BP should be more aggressive in order to decrease the risk of cardiovascular complications. Thus, the UKPDS 36 study (Adler, et al. 2000) showed that the reduction of BP levels from 154/87 mmHg (for the control group) to 144/82 mmHg (for the treatment group) decreased considerably the chance of micro- and macro-vascular complications. The HOT (Hypertension Optimal Treatment) Study (Hansson, et al., 1998) showed the benefit of a target diastolic BP reduction to under 80 mmHg for diabetic patients. A later analysis of the data from the UKPDS 38 study examined the risk of cardiovascular complications in relation exclusively to systolic BP and led to the conclusion that the risk in diabetics is smallest for arterial pressures near 120mmHg for the systolic BP.

Thus, based on the above studies the guidelines of the Hypertension and Diabetes Executive Working Group of the National Kidney Foundation of the USA include a reduction of BP < 130/80 mmHg. These guidelines were also adopted by the American Diabetes Association. BP levels > 130/80 mmHg in a diabetic individual are considered as hypertension and treatment is recommended. Moreover, in the event of diabetic nephropathy coexistence, with proteinuria of > 1g24 hours, more aggressive control of BP for the protection of the diabetic kidney is recommended, with target BP levels of < 120/ 75 mmHg.

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