Htn & Diabetes1


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Htn & Diabetes1

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  • The basic idea concerning good health is: ( click ) Physical Activity, such as running ( click ) Plus Sound Nutrition, such as fruits and grains ( click ) Equal Good Health
  • Now that you know why being healthy is a good idea, lets discuss what you can do to get that way. (click) The first part of our equation, activity, is key. This includes active play and sports. Just get moving with something you enjoy! Ask students What do you like to do? Facilitate responses Do you always make time for activities? (click after all pictures have appeared)
  • Adopting a healthy lifestyle is essential in helping reduce your overall risk of heart disease. If you currently take medications for preventing heart disease, their effectiveness will be enhanced by making these healthy lifestyle changes.
  • Htn & Diabetes1

    1. 1. Management of Hypertension in Diabetes Dr. Awadhesh K Sharma ,MD, Senior Resident, Department of Medicine, M.L.B. Medical College, Jhansi, UP
    2. 3. 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).
    3. 4. Diabetes: History <ul><li>1500 B.C.-Earliest known record of diabetes mentioned on 3rd Dynasty Egyptian papyrus by physician Hesy-Ra; mentions polyuria as a symptom. </li></ul><ul><li>400 B.C.-Indian surgeon Susruta describes ‘honeyed urines’ produced by ‘big eaters of rice and sugar’. </li></ul>
    4. 5. Diabetes: History <ul><li>250 A.D.-Apollinius of Memphis coins the name ‘diabetes’ </li></ul><ul><li>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’ </li></ul>
    5. 6. Diabetes: History <ul><li>1798- John Rollo documents excess sugar in blood and urine </li></ul><ul><li>1813- Claude Bernard links diabetes with glycogen metabolism </li></ul><ul><li>1869- Paul Langerhans (German medical student) finds islets in the pancreas, but is unable to explain function </li></ul><ul><li>1889- von Mehring and Minkowski prove that diabetes develops when they remove the pancreas of dogs </li></ul>
    6. 7. Diabetes: History <ul><li>1910- English physiologist, Sir Edward Albert Sharpey-Schafer, suggested that a single chemical component was missing from the pancreas of diabetics and called it “insulin”. </li></ul><ul><li>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 by abscesses </li></ul>
    7. 8. Diabetes: History <ul><li>1922- Collip refines the extract and re-injects it in the boy with glucose falling from 520 to 120 mg/dl in 24 hours </li></ul>
    8. 9. Diabetes: History Nobel Prize Banting Macleod Collip Best
    9. 10. <ul><li>Hypertension and insulin resistance frequently occur together as part of the dysmetabolic syndrome. </li></ul><ul><li>The addition of hypertension to the clinical picture of diabetes amplifies the already high cardiovascular disease risk in these patients. </li></ul><ul><li>Aggressive blood pressure control prevents more cardiovascular events in diabetics than non-diabetics. </li></ul>
    10. 11. Diagnosis Criteria <ul><li>One test is not enough! </li></ul><ul><li>The diagnosis must be done by a physician. </li></ul>* FBG 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. Normal Pre diabetes Diabetes Fasting Blood Glucose Test (FBG)* Less than 100 Between 100 - 125 More than or equal to 126 Glucose Tolerance Test (GTT) ** Less than 140 Equal to or more than 140 but less than 200 More than or equal to 200
    11. 12. Complications of Diabetes Retinopathy: 25x End-Stage Kidney Disease: 17x Heart Disease: 2-4x Foot/Leg Amputations: 5x Stroke: 2-6x
    12. 13. <ul><li>The Appropriate Blood pressure Control in Diabetes (ABCD) trial investigated the effect of aggressive blood pressure control in type 2 diabetic patients with peripheral arterial disease. </li></ul><ul><li>The intensively treated group (125/75 mm Hg) had no increased risk of cardiovascular events over 4 years of follow up. </li></ul><ul><li>Achieving American diabetes association target blood pressure (130/80 mm Hg) almost always requires more then one agent. </li></ul>
    13. 14. <ul><li>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. </li></ul><ul><li>In the united kingdom prospective diabetes study (UKPDS), each 10 mmHg decrease in mean systolic blood pressure was associated with ----- </li></ul><ul><li>reduction in risk of 12% for any complication related to diabetes. </li></ul><ul><ul><li>15% for deaths related to diabetes. </li></ul></ul><ul><ul><li>11% for myocardial infarction. </li></ul></ul><ul><ul><li>13% for micro vascular complications. </li></ul></ul>
    14. 15. <ul><li>But treatment of hypertension in diabetes mellitus is not always easy and much confusion prevail regarding ------ </li></ul><ul><li>Definition </li></ul><ul><ul><li>Target blood pressure </li></ul></ul><ul><ul><li>Use of specific agents like ACE inhibitors, ARB, thiazide diuretics and beta-blockers and their adverse effects. </li></ul></ul>
    15. 16. Definition, screening and diagnosis According to Joint National Committee – 7 (JNC-7) Staging SBP DBP Normal <120 <80 Prehypertensive 120-139 80-89 Stage 1 hypertension 140-159 90-99 Stage 2 hypertension >160 >100
    16. 17. In 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
    17. 18. <ul><li>According to ADA </li></ul><ul><ul><li>BP should be measured at every routine diabetes visit. </li></ul></ul><ul><ul><li>BP should be less than 130/80 mm Hg. </li></ul></ul><ul><ul><li>Orthostatic measurement of blood pressure should be performed to assess for the presence of autonomic neuropathy. </li></ul></ul>
    18. 19. Certain special characteristics of hypertension in diabetes mellitus
    19. 20. <ul><li>Nocturnal hypertension in diabetes mellitus – </li></ul><ul><ul><li>Lack of nocturnal dipping in arterial blood pressure has been demonstrated both in type 1 and type 2 diabetes. </li></ul></ul><ul><ul><li>The lack of nocturnal dipping is associated with increased risk of stroke and myocardial infarction. </li></ul></ul><ul><ul><li>Night time BP control becomes especially important in diabetics. </li></ul></ul>
    20. 21. <ul><li>Excessive salt sensitivity and increased extracellular volume: </li></ul><ul><ul><li>BP of diabetic patients is more sensitive to salt intake and this sodium sensitivity is found even in absence of nephropathy. </li></ul></ul><ul><ul><li>A decreased salt intake is important for diabetic patients with hypertension. </li></ul></ul>
    21. 22. Diabetes ,hypertension and nephropathy--- Increased systolic BP is a significant risk factor for micro albuminuria and rapid progression of nephropathy. Isolated systolic hypertension----- ISH is strongly related to development of micro and macrovascular diseases in patients with DM.
    22. 23. <ul><li>Goals of therapy---- </li></ul><ul><ul><li>American Diabetes Association recommends target blood pressure levels of <130/80 mm Hg. </li></ul></ul><ul><ul><li>In pregnant patients with diabetes and chronic hypertension, blood pressure target goals of 110-129/65-79mm Hg are suggested in the interest of long term maternal health and minimizing impaired fetal growth. </li></ul></ul>
    23. 24. Non-pharmacological management of hypertension in diabetes
    24. 25. Weight loss Loss of weight by 1kg decreases BP by approx 1mm hg. Sodium restriction 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 DBP. Exercise 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 non-invasive testing. At least 150 min of moderate intensity aerobic physical activity is recommended per week. Smoking cessation Moderation of alcohol intake.
    25. 27. Health <ul><li>Physical Activity </li></ul><ul><li>+ </li></ul>Sound Nutrition Good Health
    26. 28. Health <ul><li>The first part of our equation is activity </li></ul><ul><li>Get moving, find something you enjoy </li></ul>
    27. 30. Health The second part of the equation is nutrition Your body needs the right fuel to help it work well.
    28. 31. The ADA Pyramid <ul><li>SIX FOOD GROUPS : </li></ul><ul><li>Group 1: Bread, grains and other starches </li></ul><ul><li>Group 2: Vegetables </li></ul><ul><li>Group 3: Fruits </li></ul><ul><li>Group 4: Milk </li></ul><ul><li>Group 5: Meats, meat substitutes and other proteins(like cheese, eggs, tofu). </li></ul><ul><li>Group 6: Fats, oils and sweets </li></ul>
    29. 32. Encourage people to change habits . Use the pyramid guide to educate people to eat healthy.
    30. 33. Pharmacological therapy
    31. 34. <ul><li>General principles of treatment --- </li></ul><ul><ul><li>It has been recommended that all patients should receive either an ACE inhibitor or ARB. </li></ul></ul><ul><ul><li>Multiple drug therapy is generally required to achieve target blood pressure. </li></ul></ul><ul><ul><li>Aspirin therapy is recommended in patients of diabetes with hypertension. </li></ul></ul><ul><li>(ADA position statement diabetes care 30:54- 541, 2007) </li></ul><ul><ul><li>Statin therapy should be given to achieve LDL cholesterol level <100 mg/dl. </li></ul></ul>
    32. 35. Pharmacological therapy 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.
    33. 36. <ul><li>ACE inhibitors </li></ul><ul><li>Reduce cardiovascular mortality and progression of renal disease. </li></ul><ul><li>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). </li></ul><ul><li>combination of ACE inhibitors and ARBs causes dual blockade of RAS and provides superior renoprotection but serum potassium level should be monitored causitiously. </li></ul>
    34. 37. <ul><li>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 diabetes. </li></ul><ul><ul><li>Modulation of the renin angiotensin system has particular importance in diabetic patients. </li></ul></ul><ul><ul><li>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 diabetes. </li></ul></ul>
    35. 38. <ul><ul><li>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. </li></ul></ul><ul><ul><li>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 stroke. </li></ul></ul>
    36. 39. <ul><li>Calcium channel blockers </li></ul><ul><li>Amlodipine </li></ul><ul><li>Modified release nifedipine can be used. </li></ul>
    37. 40. Treatment Program for Patients with Hypertension and Diabetes
    38. 41. How Can You Help Reduce Your Risk of Hypertension in Diabetes ? Eat foods low in fat & calories. If overweight, lose weight.  Physical activity Stop smoking! Limit alcohol to 1-2 drinks per day. Take your medications regularly.
    39. 42. What are goals to healthy living? Be SMART S pecific M easurable A chievable R elevant T ime
    40. 43. Summary <ul><li>Diabetes is a growing problem </li></ul><ul><li>Hypertension is a growing problem </li></ul><ul><li>Hypertension and diabetes are dying problems </li></ul><ul><li>Hypertension is preventable </li></ul>