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Management of Hypertension
Dr. Awadhesh Kumar
Diabetes: The Problem
INDIA, the diabetes capital of world in next
thirty years can also be the hypertension
capital of world. (JAPI 2007)(:55:323-24).
1500 B.C.-Earliest known
record of diabetes
mentioned on 3rd Dynasty
Egyptian papyrus by
mentions polyuria as a
400 B.C.-Indian surgeon
Susruta describes ‘honeyed
urines’ produced by ‘big
eaters of rice and sugar’.
250 A.D.-Apollinius of Memphis
coins the name ‘diabetes’
1674-Thomas Willis publishes ‘The
Diabetes or Pissing Evil’. Writes
‘those laboring with this Disease,
piss a great deal more than they
drink’ asserting that all diabetic
urine ‘was wonderfully sweet as if it
were imbued with Honey or Sugar’
1798- John Rollo documents excess sugar in blood
1813- Claude Bernard links diabetes with glycogen
1869- Paul Langerhans (German medical student)
finds islets in the pancreas, but is unable to explain
1889- von Mehring and Minkowski prove that
diabetes develops when they remove the pancreas
1910- English physiologist, Sir
Edward Albert Sharpey-Schafer,
suggested that a single chemical
component was missing from the
pancreas of diabetics and called it
1922- Banting and Best (a medical
student) isolate insulin (‘ilsetin’ or
‘iletin’) and inject the ‘thick brown
muck’ into a 14 year old boy (7.5
ml into each buttock) producing
some fall in glucose complicated
1922- Collip refines the extract and reinjects it in the boy with glucose falling
from 520 to 120 mg/dl in 24 hours
Hypertension and insulin resistance frequently occur
together as part of the dysmetabolic syndrome.
The addition of hypertension to the clinical picture of
diabetes amplifies the already high cardiovascular
disease risk in these patients.
Aggressive blood pressure control prevents more
cardiovascular events in diabetics than non-diabetics.
Fasting Blood Glucose Test
100 - 125
More than or equal
Glucose Tolerance Test
Equal to or more than
less than 200
More than or equal
blood test is done after fasting 8 hours.
** GTT results are repeated after 2 hours. A person drinks a 75 mg
glucose solution before test. 100 mg for Pregnant women.
One test is not enough!
The diagnosis must be done by a physician.
The Appropriate Blood pressure Control in Diabetes
(ABCD) trial investigated the effect of aggressive blood
pressure control in type 2 diabetic patients with peripheral
The intensively treated group (125/75 mm Hg) had no
increased risk of cardiovascular events over 4 years of
Achieving American diabetes association target blood
pressure (130/80 mm Hg) almost always requires more
then one agent.
Hypertension and diabetes being two important risk
factors for cardiovascular disease, stroke and chronic
kidney disease deserve prime importance in strategy for
control of non-communicable diseases.
In the united kingdom prospective diabetes study
(UKPDS), each 10 mmHg decrease in mean systolic blood
pressure was associated with ----reduction in risk of 12% for any complication related to
15% for deaths related to diabetes.
11% for myocardial infarction.
13% for micro vascular complications.
But treatment of hypertension in diabetes mellitus is not
always easy and much confusion prevail regarding -----Definition
Target blood pressure
Use of specific agents like ACE inhibitors, ARB,
thiazide diuretics and beta-blockers and their adverse
Definition, screening and diagnosis
According to Joint National Committee – 7 (JNC-7)
Stage 1 hypertension
Stage 2 hypertension
Prehypertensive------Life style modification
Stage 1 & 2
Should be treated
But Prehypertensive + diabetes mellitus /CKD
Life style modification,if it fails to redude BP to <130/80
mm Hg then--Start drug therapy
According to ADA
BP should be measured at every routine diabetes
BP should be less than 130/80 mm Hg.
Orthostatic measurement of blood pressure should
be performed to assess for the presence of autonomic
Certain special characteristics of
hypertension in diabetes mellitus
Nocturnal hypertension in diabetes mellitus –
Lack of nocturnal dipping in arterial blood pressure
has been demonstrated both in type 1 and type 2
The lack of nocturnal dipping is associated with
increased risk of stroke and myocardial infarction.
Night time BP control becomes especially
important in diabetics.
Excessive salt sensitivity and increased extracellular
BP of diabetic patients is more sensitive to salt intake
and this sodium sensitivity is found even in absence
A decreased salt intake is important for diabetic
patients with hypertension.
Diabetes ,hypertension and nephropathy--Increased systolic BP is a significant risk factor for
micro albuminuria and rapid progression of
Isolated systolic hypertension----ISH is strongly related to development of micro and
macrovascular diseases in patients with DM.
Goals of therapy--- American Diabetes Association recommends
target blood pressure levels of <130/80 mm Hg.
In pregnant patients with diabetes and chronic
hypertension, blood pressure target goals of 110129/65-79mm Hg are suggested in the interest of
long term maternal health and minimizing impaired
Loss of weight by 1kg decreases BP by approx 1mm hg.
Decrease in sodium intake from 4.6 gm to 2.3 gm/day
results in reduction of 5mm Hg is SBP and 2-3 mm Hg in
Diabetic patients who are 35 yrs of age or older and are
planning to begin a vigorous exercise programme should
have exercise stress testing or other appropriate noninvasive testing.
At least 150 min of moderate intensity aerobic physical
activity is recommended per week.
Moderation of alcohol intake.
The first part of our
equation is activity
Get moving, find something you
The second part of the
equation is nutrition
Your body needs the right fuel to help it
The ADA Pyramid
SIX FOOD GROUPS:
•Group 1: Bread, grains
and other starches
•Group 2: Vegetables
•Group 3: Fruits
•Group 4: Milk
•Group 5: Meats, meat
substitutes and other
•Group 6: Fats, oils and
Use the pyramid guide to educate people to eat healthy.
General principles of treatment --It has been recommended that all patients should
receive either an ACE inhibitor or ARB.
Multiple drug therapy is generally required to
achieve target blood pressure.
Aspirin therapy is recommended in patients of
diabetes with hypertension.
(ADA position statement diabetes care 30:54541, 2007)
Statin therapy should be given to achieve LDL
cholesterol level <100 mg/dl.
Thiazide diuretic and Beta Blockers
- There have been concerns among physicians as many
studies have shown thiazides and beta blockers
promote glucose intolerance.
Inspite of this both agents have been recommended for
treatment of hypertension in DM, lower doses of shorter
acting thiazides- hydrochlorthiazide instead of
chlorethalidone are generally well tolerated and not
associated with adverse metabolic effects.
Recommendations for beta blockers are-- combined
alpha and beta blocker should be preferable agents.
Carvedilol is the potential agent of choice as it
effectively control blood pressure and improves insulin
sensitivity and decreases HbA1C.
Reduce cardiovascular mortality and progression of
Increases upto 30-35% from baseline serum creatinine
level (creatinine of 3mg/dl or less) that stablize with in the
first 2 months of ACE inhibitors therapy should not deter
use of these agents.(Arch Intern Med 2000).
combination of ACE inhibitors and ARBs causes dual
blockade of RAS and provides superior renoprotection but
serum potassium level should be monitored causitiously.
The UKPDS and systolic hypertension in Europe trial
(Syst-Eur) have shown beneficial effects for both ACE
inhibitors and calcium channel blockers in patients with
Modulation of the renin angiotensin system has
particular importance in diabetic patients.
ACE inhibitors reduces nephropathy and end stage
renal disease in patients with type 1 diabetes, and
angiotensin receptor blockers reduce the risk of these
microvascular disorders in patient with type 2
In the Heart Outcomes and Prevention Evaluation
(HOPE) study, ramipril significantly decreased the
rates of myocardial infarction ,stroke and death in
patients with diabetes and a mean blood pressure of
140/80 mm Hg.
The Losartan Intervention For End point (LIFE)
study enrolled 1195 diabetic subjects as part of the
cohort. Participants had hypertension and evidence of
left ventricular hypertrophy, subjects were randomized
to losartan or atenolol. Despite equivalent blood
pressure lowering, the subjects randomized to
losartan experienced a 39 percent reduction in all
cause mortality, a 37 percent reduction in
cardiovascular mortality, and a 21 percent reduction in
Calcium channel blockers
Modified release nifedipine can be used.
Treatment Program for Patients with
Hypertension and Diabetes
How Can You Help Reduce Your Risk of
Hypertension in Diabetes?
Limit alcohol to
l os e
w e i t,
What are goals to healthy
Diabetes is a growing problem
Hypertension is a growing problem
Hypertension and diabetes are dying
Hypertension is preventable