Your SlideShare is downloading. ×
0
MANAGEMENT OF HYPPERTENSION IN T2DM
TRIALS, TRIBULATIONS, GUIDELINES AND
GOALS
Dr.Dr. RajeevRajeev AgarwalaAgarwala
Jaswan...
Rev. Stephen Hales
(1677-1761)
BP = 8 feet 3 inches of water
April 12, 1945
PROFILE OF THE DISEASE
How Common is this Duo?
HTN is twice as common in DMHTN is twice as common in DM
New onset DM is 2.5 times in HTN
20 to 40...
Relative Risk of DM + HTN
Diabetes + HTN versus Diabetes
• Neuropathy 1.6
• Nephropathy 2.0
• Retinopathy 2.0
• Stroke 4.0...
MRFIT: Association of Systolic BP and
Cardiovascular Death in Type 2 Diabetes
250
225
200
175
150
125
100
75
50
0
25
< 120...
Meta-analysis of 61 prospective, observational studies
One million adults, 12.7 million person-years
2 mmHg
decrease in
me...
UKPDS: Tight blood control and risk of
macrovascular and microvascular complications in
T2DM
 1148 patients randomized to...
UKPDS 38: tight control had a greater
effect on blood pressure
Bloodpressure(mmHg)
Baseline 9 years
0
140
145
150
155
160
...
UKPDS: Results
• Mean blood pressure during follow-up
– Tight control: 144/82 mm Hg
– Less tight control: 154/87 mm Hg
• 1...
UKPDS 38: relative risk reduction
with tight blood pressure control
-60
-50
-40
-30
-20
-10
0
Relativeriskreductiontightvs...
Risk reduction (%) in the UKPDS Participants: Initial
results & 10-years follow-up
UKPDS 38: BMJ 1998;317:703–13
NEJM 2008...
UKPDS 38: Antihypertensive requirements for
tight BP control
UKPDS Study Group. BMJ. 1998;317:703-13.
0
20
40
60
80
100
% ...
HOT: Hypertension Optimal Treatment
• 18,790 patients from 26 countries, age 50 -80, and
diastolic blood pressure 100-115 ...
HOT Trial: Effect of targeted DBP
on CV events over 4 years
Clinical Trials of Blood Pressure Lowering in
Diabetic Patients: Systolic (SBP)
Trial N
Mean SBP,
less intense
Mean SBP,
m...
ADVANCE
215 centers in 20 countries with 11,140 patients with
type 2 diabetes randomized to fixed combination of
perindop...
ADVANCE: a factorial randomised trial
of blood pressure lowering and
intensive glucose control in
11,140 patients with typ...
ADVANCE RESULTS
 4.3 years of follow-up
 Compared to placebo, there was a drop in pressure of
5.6/2.2 mm Hg
 There was ...
ADVANCE: BLOOD PRESSURE REDUCTION
Δ 2.2 mmHg (95% CI 2.0-2.4); p<0.001
Δ 5.6 mmHg (95% CI 5.2-6.0); p<0.001
Diastolic
Syst...
Macrovascular 480 520 8% (-4 to 19)
Microvascular 439 477 9% (-4 to 20)
Combined macro+micro 861 938 9% (0 to 17)
Number o...
SBP
ADVANCE BP reduction in context:
UK Prospective Diabetes Study
UKPDSADV
UK Prospective Diabetes Study
JNC Guideline Recommendations in
Patients with Diabetes
Nat Rev Cardiol 2011;8:42-49
“Usual blood pressure is strongly and directly
related to vascular (and overall) mortality
without any evidence of a thres...
The ACCORD Study Group,(2010) NEJM.362:1575-1585
ACCORD
Hypothesis: Targeting normal systolic blood pressure (
<120 mm Hg) in patients with type 2 diabetes and at
high ris...
Mean Systolic Pressure levels at each study visit
(mean + 95% CI)
Average after 1st
year: 133.5 Standard vs. 119.3 Intensi...
ACCORD Results
• There was no difference between groups, in terms of
reaching the primary outcome composite
• There was a ...
Primary & Secondary Outcomes
Intensive
Events (%/yr)
Standard
Events (%/yr) HR (95% CI) P
Primary 208 (1.87) 237 (2.09) 0....
Kaplan-Meier Analysis of Selected Outcomes
NEJM 2010
SBP
ACCORD BP reduction in context ofACCORD BP reduction in context of
UK Prospective Diabetes Study and ADVANCEUK Prospec...
ACCORD: Conclusions
“In patients with type 2 diabetes at high risk for
cardiovascular events, targeting a systolic blood
p...
ACCORD BP INTENSIVE BP
LOWERING
FUTILE IN DIABETES
• No benefit to be gained in diabetes by
intensive lowering (<120mmHg)
BP CONTROL IN DIABETES
HOW LOW SHOULD WE GO?
INVEST – Calcium antagonist Vs B Blocker
INVEST Trial:Methods
JAMA 2010;304:61-68
CONCLUSIONS
There is no data that supports the use of ACE inhibitors orThere is no data that supports the use of ACE inhib...
JNC Guideline Recommendations
in Patients with Diabetes
Nat Rev Cardiol 2011;8:42-49
CIMT regression better in mean systolic
BP <117 mmHg to
mean <129 mmHg
Haword BV et al
JAMA 2008:299
Nihilistic Conclusions from the 3 major recent studies
in diabetes or impaired fasting glycemia
• -Blood pressure was sign...
All Cause Mortality
Circulation 2011;123:2799-2810
CV Death
Circulation 2011;123:2799-2810
Overt Nephropathy
Circulation 2011;123:2799-2810
Stroke
Circulation 2011;123:2799-2810
Serious Adverse Events
(SAEs)
Circulation 2011;123:2799-2810
• ………in patients with diabetes a systolic
BP goal of 130-135 mmHg is acceptable.
However, with more aggressive goals (<130...
Achieved SBP and CV Event Reduction in trials on
Antihypertensive Treatment in diabetes
J Hypertension 2009;27:923-934
BP targets in Latest guideline
JNC Guideline Recommendations in
Patients with Diabetes
JNC 7
EuroPrevention
Guidelines
2012
BP TARGETS IN VARIOUS GUIDELINES
WHAT WENT WRONG
RELATIONSHIP BETWEEN CV
THERAPY AND CV RISK
Sleight et al. J Hypertens 27:1360, 2009
DBP: Risk for All-Cause Death
DBP (mm Hg)
INVEST Subanalysis: BP and Risk
Total patients 176 2253 11339 7367 1201 240
70< ...
DBP: Risk for Primary Outcome
DBP (mm Hg)
Total patients 176 2239 11306 7376 1230 248
INVEST Subanalysis: BP and Risk
70< ...
Stroke / MI and DBP Strata
INVEST Subanalysis: BP and Risk
70< to ≤80
60< to ≤70
≤60
80< to ≤90
90< to ≤100
100< to ≤110
1...
CONCLUSIONS
• The preponderance of MIs over strokes at
low diastolic pressures suggests that
excessive diastolic hypotensi...
CHOICE OF AGENTS
A SIMPLER CHOICE
Treatment recommendation by various guidelines
for BP lowering in diabetics
Guidelines First Line antihypertensives
in dia...
HOLISTIC GOALS
BP IS UNCONTROLLED IN MOST
DIABETICS
Risk factors for 335 CHD events in 3055Risk factors for 335 CHD events in 3055
type 2 diabetic patients followed 7.4 years...
CONCLUSIONS
• Hypertension and Diabetes are twin
enemies of heart, kidney and brain.
• Aggressive control of BP is out
• J...
THANK YOU
14.09 bp management in diabetes
14.09 bp management in diabetes
14.09 bp management in diabetes
14.09 bp management in diabetes
14.09 bp management in diabetes
14.09 bp management in diabetes
14.09 bp management in diabetes
14.09 bp management in diabetes
14.09 bp management in diabetes
14.09 bp management in diabetes
14.09 bp management in diabetes
14.09 bp management in diabetes
Upcoming SlideShare
Loading in...5
×

14.09 bp management in diabetes

157

Published on

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
157
On Slideshare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
13
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide
  • Association of Systolic BP and Cardiovascular Death in Type 2 Diabetes In the large cohort of men screened for Multiple Risk Factor Intervention Trial (MRFIT), the relationships of SBP and other cardiovascular risk factors to cardiovascular mortality were compared in men with diabetes (n=5163) and without diabetes (n=342,815). The absolute risk of cardiovascular death was 3- times higher for men with diabetes than for those without diabetes, after adjustment for age, race, income, serum cholesterol, SBP, and cigarette smoking ( p &lt;0.0001). Systolic blood pressure was positively related to the risk of cardiovascular death, with a significant trend in both nondiabetic and diabetic subjects ( p &lt;0.001). At every level of SBP, cardiovascular death was much greater for men with diabetes than for men without diabetes. Moreover, with higher SBP levels, the cardiovascular mortality rate increased more steeply among those with diabetes than among those without diabetes. Thus, the higher the SBP, the greater the absolute excess risk for patients with diabetes, indicating a greater potential for prevention of cardiovascular death among patients with diabetes by control of elevated BP [Stamler et al, 1993].
  • A meta-analysis of 61 prospective, observational studies has shown that a 10 mmHg lower S BP is associated over the long term with a 40% lower risk of stroke death and a 30% lower risk of death from ischaemic heart disease (IHD) or other vascular causes. 1 Even a small, 2 mmHg fall in mean S BP was associated with large reductions in premature deaths and disabling strokes. 1 There was no evidence of a J-curve (i.e. a threshold of reduction beyond which risk begins to increase). 1 The reduction in risk associated with a given reduction in mean blood pressure is approximately constant down to at least an SBP of 115 mmHg and a DBP of 75 mmHg – well beyond what is normally achieved. 1 The reduction in risk holds for all age groups assessed from 40 up to 89 years old. 1 Lewington S, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002;360:1903–1913.
  • Following the 9 years of treatment, tight control was significantly more effective than less tight control in reducing both systolic and diastolic blood pressure: 144/82 vs 154/87 (p &lt; 0.0001).
  • Compared to blood pressure reduction during less tight control, the reduction of blood pressure due to tight control was associated with a significant decrease in the risk of clinical endpoints including any diabetes endpoint (by 24% p = 0.0046), diabetes-related death (by 32%, p = 0.019), stroke (by 44%, p = 0.013), and microvascular disease (by 37%, p = 0.0092).
  • The UK Prospective Diabetes Study (UKPDS) Group reported on the proportion of hypertensive patients with T2DM who required combination therapy over the 9 years of the trial. As shown, over time there was an increasing number of antihypertensive agents required to maintain BP at target levels (&lt;150/85 mm Hg).
  • Investigators of the international Hypertension Optimal Treatment (HOT) trial evaluated optimum BP levels and the benefit of including aspirin when treating hypertension to minimize CV complications. Patients aged 50-80 years with hypertension (N = 18,790) were randomly assigned to 1 of 3 diastolic BP (DBP) targets: 90 mm Hg or less (n = 6264) 85 mm Hg or less (n = 6264) 80 mm Hg or less (n = 6262) Baseline therapy consisted of felodipine; dosage was titrated and other agents added as needed to approach target DBP levels. Participants were also randomized to 75 mg/day of aspirin (n = 9399) or placebo (n = 9391). After a mean 3.8-year follow-up, DBP was reduced by an average of 20.3, 22.3, and 24.3 mm Hg in the 3 groups, respectively. There was no significant difference in the incidence of major CV events (all MIs, all strokes, and all other CV deaths) among the 3 groups. The incidences of major CV events per 1000 patient-years in patients with diabetes (n = 1501) were 24.4, 18.6, and 11.9 in the 3 groups, respectively (P for trend = 0.005). The relative risk (RR) for a major CV event in diabetic patients was 2.06 for the 80 mm Hg compared with the 90 mm Hg group. Compared with placebo, aspirin reduced major CV events by 15% (P = 0.03) and MI by 36% (P = 0.002), but had no effect on stroke incidence.
  • Transcript of "14.09 bp management in diabetes"

    1. 1. MANAGEMENT OF HYPPERTENSION IN T2DM TRIALS, TRIBULATIONS, GUIDELINES AND GOALS Dr.Dr. RajeevRajeev AgarwalaAgarwala Jaswant Rai Speciality Hospital Meerut.Jaswant Rai Speciality Hospital Meerut. Email : rajeev_jrsh@yahoo.co.inEmail : rajeev_jrsh@yahoo.co.in
    2. 2. Rev. Stephen Hales (1677-1761) BP = 8 feet 3 inches of water
    3. 3. April 12, 1945
    4. 4. PROFILE OF THE DISEASE
    5. 5. How Common is this Duo? HTN is twice as common in DMHTN is twice as common in DM New onset DM is 2.5 times in HTN 20 to 40% of IGT pts have HTN20 to 40% of IGT pts have HTN 40 to 50% of Type 2 DM have HTN40 to 50% of Type 2 DM have HTN Only 1/4 of HTN in DM is controlledOnly 1/4 of HTN in DM is controlled DM + HTN –  CV Risk 3 foldDM + HTN –  CV Risk 3 fold
    6. 6. Relative Risk of DM + HTN Diabetes + HTN versus Diabetes • Neuropathy 1.6 • Nephropathy 2.0 • Retinopathy 2.0 • Stroke 4.0 • CHD 3.0 • Mortality 2.0
    7. 7. MRFIT: Association of Systolic BP and Cardiovascular Death in Type 2 Diabetes 250 225 200 175 150 125 100 75 50 0 25 < 120 120– 139 140–159 160–179 180–199 ≥ 200 Systolic blood pressure (mm Hg) Cardiovascular mortality rate/10,000 person-yr Nondiabetic Diabetic Stamler J et al. Diabetes Care. 1993;16:434-444./ hypertensiononline.org
    8. 8. Meta-analysis of 61 prospective, observational studies One million adults, 12.7 million person-years 2 mmHg decrease in mean SBP 10% reduction in risk of stroke mortality 7% reduction in risk of ischaemic heart disease mortality Lowering BP reduces cardiovascular risk Lewington et al. Lancet. 2002;360:1903–1913 Small SBP reductions yield significant benefit Lesson learned …… Community based approach & Individual Approach
    9. 9. UKPDS: Tight blood control and risk of macrovascular and microvascular complications in T2DM  1148 patients randomized to right control or less tight control  Tight control defined as < 150/85 mm Hg  Less tight control defined as < 180/105 mm Hg  Half of tight control to ACE inhibitors (captopril) and half to beta blockers (atenolol)  Mean follow-up of 8.4 years  Part of larger UKPDS with follow-up every 3-4 months
    10. 10. UKPDS 38: tight control had a greater effect on blood pressure Bloodpressure(mmHg) Baseline 9 years 0 140 145 150 155 160 165 Tight Less tight Systolic BP 0 78 80 82 84 86 88 90 92 94 96 Baseline 9 years Diastolic BP UKPDS 38: BMJ 1998;317:703–13
    11. 11. UKPDS: Results • Mean blood pressure during follow-up – Tight control: 144/82 mm Hg – Less tight control: 154/87 mm Hg • 1/3 patients in tight control group required 3 or more medications • 24% decrease in diabetes-related endpoints • 32% decrease in deaths related to diabetes • 37% decrease in microvascular endpoints – Mostly related to reduced risk of laser treatment • 44% decrease in strokes BMJ 317: 703, 1998
    12. 12. UKPDS 38: relative risk reduction with tight blood pressure control -60 -50 -40 -30 -20 -10 0 Relativeriskreductiontightvs lesstightBPcontrol(%) M icrovascular endpoint D iabetes death M I All-cause m ortality Stroke Peripheralvascular disease Any diabetes endpoint ** * p < 0.05 ** p < 0.01 ** * * UKPDS 38: BMJ 1998;317:703–13
    13. 13. Risk reduction (%) in the UKPDS Participants: Initial results & 10-years follow-up UKPDS 38: BMJ 1998;317:703–13 NEJM 2008;359:1565-76
    14. 14. UKPDS 38: Antihypertensive requirements for tight BP control UKPDS Study Group. BMJ. 1998;317:703-13. 0 20 40 60 80 100 % of patients Number of antihypertensive agents ≥3 2 1 0 Mean BP in “tight” control group: 144/82 mm Hg 1 2 3 4 5 6 7 8 Years from randomization
    15. 15. HOT: Hypertension Optimal Treatment • 18,790 patients from 26 countries, age 50 -80, and diastolic blood pressure 100-115 mm Hg were recruited • Patients were randomized to 3 groups based on diastolic pressure goal (< 90, < 85, and < 80 mm Hg) • Primary endpoint was composite macrovascular outcome of non-fatal MI, non-fatal stroke, or CV death • Major finding was that patients with diabetes had a 51% reduction in primary endpoint • No increase in side effects. Hansson et al. Lancet 351:1755, 1998
    16. 16. HOT Trial: Effect of targeted DBP on CV events over 4 years
    17. 17. Clinical Trials of Blood Pressure Lowering in Diabetic Patients: Systolic (SBP) Trial N Mean SBP, less intense Mean SBP, more intense CVD Risk Reduction SHEP 583 155* 146* 22-56% Syst-Eur 492 162 153 62-69% HOT 1,501 148 144 30-67% UKPDS 1,148 154 144 32-44% ABCD 470 138 132 No CVD reduction Cushman, et al. Am J Cardiol 2007;99:44i- 55i
    18. 18. ADVANCE 215 centers in 20 countries with 11,140 patients with type 2 diabetes randomized to fixed combination of perindopril and indapamide or matching placebo, Primary endpoints were composites of major macro- and microvascular events Death from CV disease, non-fatal stroke or non-fatal MI New or worsening renal or diabetic eye disease
    19. 19. ADVANCE: a factorial randomised trial of blood pressure lowering and intensive glucose control in 11,140 patients with type 2 diabetes Effects of a fixed combination of the ACE inhibitor, perindopril, and the diuretic, indapamide on major vascular events Lancet 2007 Sept 8;370:829-40 Presented at European society of Cardiology, Vienna, 9/2/07
    20. 20. ADVANCE RESULTS  4.3 years of follow-up  Compared to placebo, there was a drop in pressure of 5.6/2.2 mm Hg  There was not a significant decrease in macrovasular (p = 0.16) events or microvascular events (p = 0.16) separately  There was a 9% decrease in combination(p=0.04)  There was a decrease in CV death (p = 0.03) and death from any cause (p = 0.03) Lancet 370:829, 2007
    21. 21. ADVANCE: BLOOD PRESSURE REDUCTION Δ 2.2 mmHg (95% CI 2.0-2.4); p<0.001 Δ 5.6 mmHg (95% CI 5.2-6.0); p<0.001 Diastolic Systolic Placebo Perindopril-Indapamide MeanBloodPressure(mmHg) 65 75 85 95 105 115 125 135 145 155 165 Follow-up (Months) R 6 12 18 24 30 36 42 48 54 60 140.3 mmHg 134.7 mmHg Average BP during follow-up 77.0 mmHg 74.8 mmHg BP = 145/81 mm Hg @ baseline Lancet 2007;370:829-40
    22. 22. Macrovascular 480 520 8% (-4 to 19) Microvascular 439 477 9% (-4 to 20) Combined macro+micro 861 938 9% (0 to 17) Number of events Per-Ind Placebo (n=5,569) (n=5,571) Relative risk reduction (95% CI) Favours Per-Ind Favours Placebo Hazard ratio 0.5 1.0 2.0 * *2P=0.04 Primary outcomes Major macro or microvascular event Lancet 2007;370:829-40
    23. 23. SBP ADVANCE BP reduction in context: UK Prospective Diabetes Study UKPDSADV UK Prospective Diabetes Study
    24. 24. JNC Guideline Recommendations in Patients with Diabetes Nat Rev Cardiol 2011;8:42-49
    25. 25. “Usual blood pressure is strongly and directly related to vascular (and overall) mortality without any evidence of a threshold down to at least 115/75 mmHg.” Prospective Studies Collaboration Lancet 2002;360:1903-1913
    26. 26. The ACCORD Study Group,(2010) NEJM.362:1575-1585
    27. 27. ACCORD Hypothesis: Targeting normal systolic blood pressure ( <120 mm Hg) in patients with type 2 diabetes and at high risk for cardiovascular events reduces major cardiovascular events 4733 patients were randomized to intensive therapy (systolic BP < 120 mm Hg) or standard therapy (systolic BP < 140 mm Hg) Primary composit outcome was nonfatal MI, nontatal storke, or death from CV causes Mean follow-up time was 4.7 years
    28. 28. Mean Systolic Pressure levels at each study visit (mean + 95% CI) Average after 1st year: 133.5 Standard vs. 119.3 Intensive, Delta = 14.2 Mean # Meds Intensive: 3.2 3.4 3.5 3.4 Standard: 1.9 2.1 2.2 2.3
    29. 29. ACCORD Results • There was no difference between groups, in terms of reaching the primary outcome composite • There was a decrease in rates of stroke and lesser rates of progression of albuminuria • Benefit to those who have HbAIC >6% N Engl J Med 362: 1575, 2010
    30. 30. Primary & Secondary Outcomes Intensive Events (%/yr) Standard Events (%/yr) HR (95% CI) P Primary 208 (1.87) 237 (2.09) 0.88 (0.73-1.06) 0.20 Total Mortality 150 (1.28) 144 (1.19) 1.07 (0.85-1.35) 0.55 Cardiovascular Deaths 60 (0.52) 58 (0.49) 1.06 (0.74-1.52) 0.74 Nonfatal MI 126 (1.13) 146 (1.28) 0.87 (0.68-1.10) 0.25 Nonfatal Stroke 34 (0.30) 55 (0.47) 0.63 (0.41-0.96) 0.03 Total Stroke 36 (0.32) 62 (0.53) 0.59 (0.39-0.89) 0.01 Also examined Fatal/Nonfatal HF (HR=0.94, p=0.67), a composite of fatal coronary events, nonfatal MI and unstable angina (HR=0.94, p=0.50) and a composite of the primary outcome, revascularization and unstable angina (HR=0.95, p=0.40) NEJM 2010
    31. 31. Kaplan-Meier Analysis of Selected Outcomes NEJM 2010
    32. 32. SBP ACCORD BP reduction in context ofACCORD BP reduction in context of UK Prospective Diabetes Study and ADVANCEUK Prospective Diabetes Study and ADVANCE UKPDSADV UK Prospective Diabetes Study ACCORD
    33. 33. ACCORD: Conclusions “In patients with type 2 diabetes at high risk for cardiovascular events, targeting a systolic blood pressure of less than 120 mm Hg, as compared with less than 140 mmHg, did not reduce the rate of a composite outcome of fatal and nonfatal major cardiovascular events.” Cushman et al. NEJM 2010
    34. 34. ACCORD BP INTENSIVE BP LOWERING FUTILE IN DIABETES • No benefit to be gained in diabetes by intensive lowering (<120mmHg)
    35. 35. BP CONTROL IN DIABETES HOW LOW SHOULD WE GO? INVEST – Calcium antagonist Vs B Blocker
    36. 36. INVEST Trial:Methods JAMA 2010;304:61-68
    37. 37. CONCLUSIONS There is no data that supports the use of ACE inhibitors orThere is no data that supports the use of ACE inhibitors or ARBs prior to the development of hypertension (BP >ARBs prior to the development of hypertension (BP > 130/80 mm Hg) or microalbuminuria130/80 mm Hg) or microalbuminuria Further lowering of blood pressure to values < 120/80 mmFurther lowering of blood pressure to values < 120/80 mm Hg is not associated with an improvement in cardiovascularHg is not associated with an improvement in cardiovascular events and is associated with increased side effectsevents and is associated with increased side effects
    38. 38. JNC Guideline Recommendations in Patients with Diabetes Nat Rev Cardiol 2011;8:42-49
    39. 39. CIMT regression better in mean systolic BP <117 mmHg to mean <129 mmHg Haword BV et al JAMA 2008:299
    40. 40. Nihilistic Conclusions from the 3 major recent studies in diabetes or impaired fasting glycemia • -Blood pressure was significantly lower by 2.8/1.4 mm Hg in the valsartan arm when compared with placebo”… but it did not reduce the rate of cardiovascular events…” NAVIGATOR • The use of ramipril for 3 years did not significantly reduce the incidence of diabetes or death…” nor did it “reduce the risk of the cardiorenal composite outcome.” DREAM • In 4,733 patients with type 2 diabetes targeting systolic BP to <120 mm Hg as compared with <140 mmHg “did not reduce the rate of a composite outcome of fatal and nonfatal major cardiovascular events.” ACCORD JACC 2011;57:114-115
    41. 41. All Cause Mortality Circulation 2011;123:2799-2810
    42. 42. CV Death Circulation 2011;123:2799-2810
    43. 43. Overt Nephropathy Circulation 2011;123:2799-2810
    44. 44. Stroke Circulation 2011;123:2799-2810
    45. 45. Serious Adverse Events (SAEs) Circulation 2011;123:2799-2810
    46. 46. • ………in patients with diabetes a systolic BP goal of 130-135 mmHg is acceptable. However, with more aggressive goals (<130 mmHg) we observed target organ heterogeneity in that risk of stroke continued to fall, but there was no benefit regarding the risk of other macro/microvascular (cardiac, renal and retinal) events and the risk of serious adverse events increased…….. Circulation 2011;123:2799-2810
    47. 47. Achieved SBP and CV Event Reduction in trials on Antihypertensive Treatment in diabetes J Hypertension 2009;27:923-934
    48. 48. BP targets in Latest guideline
    49. 49. JNC Guideline Recommendations in Patients with Diabetes JNC 7 EuroPrevention Guidelines 2012
    50. 50. BP TARGETS IN VARIOUS GUIDELINES
    51. 51. WHAT WENT WRONG
    52. 52. RELATIONSHIP BETWEEN CV THERAPY AND CV RISK
    53. 53. Sleight et al. J Hypertens 27:1360, 2009
    54. 54. DBP: Risk for All-Cause Death DBP (mm Hg) INVEST Subanalysis: BP and Risk Total patients 176 2253 11339 7367 1201 240 70< to ≤8060< to ≤70≤60 80< to ≤90 90< to ≤100 100< 0 2 4 6 EstimatedHazardRatio Hazard Ratio Nadir = 85.8 mm Hg 1 3 5
    55. 55. DBP: Risk for Primary Outcome DBP (mm Hg) Total patients 176 2239 11306 7376 1230 248 INVEST Subanalysis: BP and Risk 70< to ≤80 60< to ≤70 ≤60 80< to ≤90 90< to ≤100 100< 0 1 2 3 4 5 6 EstimatedHazardRatio Hazard Ratio Nadir = 84.1 mm Hg
    56. 56. Stroke / MI and DBP Strata INVEST Subanalysis: BP and Risk 70< to ≤80 60< to ≤70 ≤60 80< to ≤90 90< to ≤100 100< to ≤110 110< to ≤120 DBP (mm Hg)
    57. 57. CONCLUSIONS • The preponderance of MIs over strokes at low diastolic pressures suggests that excessive diastolic hypotension associated with antihypertensive therapy increased CAD risk INVEST Subanalysis: BP and Risk
    58. 58. CHOICE OF AGENTS A SIMPLER CHOICE
    59. 59. Treatment recommendation by various guidelines for BP lowering in diabetics Guidelines First Line antihypertensives in diabetic Other Recommended antihypertensives JNC -7(1) ACE inhibitor or ARB or HCTZ ACEI, ARB, BB, CCB, or combination NICE(2) ACE inhibitor or ARB. Calcium-channel blocker (CCB),Thiazide-like diuretic ESH(3) ACEI, ARB diuretics, CA Canadian Hypertension 2012(4) ACE Inhibitor or ARB Long-acting CCB or Thiazide diuretic Japanese Society of Hypertension (5) ACE inhibitors or ARBs Ca channel blockers, diuretics ICMR(6) ACE inhibitors and ARB CCBs, Beta blockers ADA(7) ACE inhibitor or an ARB diuretics 1.JNC –7, 2.Hypertension: NICE guideline Feb,2011, 3.Journal of Hypertension 2007, 25:1751–1762 4. 2012 Canadian Hypertension Education Program Recommendations 5. Hypertension Research 32, 40-50 (January 2009), 6. Indian J Med Res 132, November 2010, pp 531-542 7. Diabetes Care January 2012; l( 35). Supplement 1 S11-S63
    60. 60. HOLISTIC GOALS
    61. 61. BP IS UNCONTROLLED IN MOST DIABETICS
    62. 62. Risk factors for 335 CHD events in 3055Risk factors for 335 CHD events in 3055 type 2 diabetic patients followed 7.4 yearstype 2 diabetic patients followed 7.4 years UKPDS, BMJ 1998 ∆ risk of CHD HbA1c (1 %) x 1.11 (1.02 to 1.20) SBP (10 mmHg) x 1.15 (1.02 to 1.20) LDL-chol (1 mmol/l) x 1.57 (1.37 to 1.79) HDL-chol (0.1 mmol/l) x 0.15 (0.08 to 0.22) (Smoking vs. no smoking: x 1.6)
    63. 63. CONCLUSIONS • Hypertension and Diabetes are twin enemies of heart, kidney and brain. • Aggressive control of BP is out • J curve is defining diastolic BP bottom • Choice of agent is simple ACEI/ARBS
    64. 64. THANK YOU
    1. A particular slide catching your eye?

      Clipping is a handy way to collect important slides you want to go back to later.

    ×