This document discusses the management of hypertension in patients with type 2 diabetes. It provides an overview of clinical trials that have evaluated blood pressure targets for reducing cardiovascular risk in this population. The trials have shown that intensive control of blood pressure below 140/80 mmHg reduces microvascular complications, but trials targeting levels under 120/80 mmHg have found no additional cardiovascular benefit and an increased risk of side effects. Current guidelines recommend a systolic blood pressure goal of 130-140 mmHg for most patients with diabetes.
This session will help pharmacists enhance their expertise in managing patients with hypertension through updates on the latest hypertension guidelines, discussion on the role that pharmacists can and should play in the detection and ongoing management of hypertension and hands-on experience with blood pressure measurement devices.
This session will help pharmacists enhance their expertise in managing patients with hypertension through updates on the latest hypertension guidelines, discussion on the role that pharmacists can and should play in the detection and ongoing management of hypertension and hands-on experience with blood pressure measurement devices.
Management of Hypertension and Diabetes in Aging People 2014Nemencio Jr
This module discusses the issues in the management and treatment goals for hypertension and diabetes in the older population based on the most recent guidelines
JNC 8 guideline to Management of HypertensionPranav Sopory
JNC - 8 guidelines to management of Hypertension.
Rencent developments in CKD (Chronic Kidney Disease) and DM (Daibetes Mellitus) management.
Drugs discussed along with doses and side effects.
Compelling indiactions.
2017 AHA/ACC criteria for Hypertension management in brief.
>> Contains animation. Download and view.
This presentation focus on the accurate method of BP measurement as well as the presentation of the latest clinical trials of hypertension management and their impact on recent guidelies
European Society of Hypertension 2013 Hypertension guidelines presentation in...JAFAR ALSAID
Summary of the European Society of Hypertension 2013 Hypertension Guidelines presented during the Eighth Hypertension and Cardiovascular highlight session in Bahrain on Sept. 11th 2013.
Turning into Block , A Case of Complete Heart Block in Turner SyndromeYASIR ALZUBAIDI
A 56 year-old Turner Syndrome (TS) female presented to the emergency room with dyspnea, general weakness and lightheadedness. She had no history of syncope. Heart rate was between 31-42 beats per minute with blood pressure value in the lower normal range.
She received IV atropine with no improvement in her bradycardia. EKG showed complete heart block thus she was transferred to the Intensive care unit for further management. Hypothyroidism and acute coronary syndrome were ruled out. The patient was on verapamil SR 120 mg daily, which was discontinued since presentation. After more than 24 hours off any atrioventricular nodal blocking agents, she remained in complete heart block. Permanent pacemaker was placed and the patient was discharged in stable condition without any more dizziness or lightheadedness.
Management of Hypertension and Diabetes in Aging People 2014Nemencio Jr
This module discusses the issues in the management and treatment goals for hypertension and diabetes in the older population based on the most recent guidelines
JNC 8 guideline to Management of HypertensionPranav Sopory
JNC - 8 guidelines to management of Hypertension.
Rencent developments in CKD (Chronic Kidney Disease) and DM (Daibetes Mellitus) management.
Drugs discussed along with doses and side effects.
Compelling indiactions.
2017 AHA/ACC criteria for Hypertension management in brief.
>> Contains animation. Download and view.
This presentation focus on the accurate method of BP measurement as well as the presentation of the latest clinical trials of hypertension management and their impact on recent guidelies
European Society of Hypertension 2013 Hypertension guidelines presentation in...JAFAR ALSAID
Summary of the European Society of Hypertension 2013 Hypertension Guidelines presented during the Eighth Hypertension and Cardiovascular highlight session in Bahrain on Sept. 11th 2013.
Turning into Block , A Case of Complete Heart Block in Turner SyndromeYASIR ALZUBAIDI
A 56 year-old Turner Syndrome (TS) female presented to the emergency room with dyspnea, general weakness and lightheadedness. She had no history of syncope. Heart rate was between 31-42 beats per minute with blood pressure value in the lower normal range.
She received IV atropine with no improvement in her bradycardia. EKG showed complete heart block thus she was transferred to the Intensive care unit for further management. Hypothyroidism and acute coronary syndrome were ruled out. The patient was on verapamil SR 120 mg daily, which was discontinued since presentation. After more than 24 hours off any atrioventricular nodal blocking agents, she remained in complete heart block. Permanent pacemaker was placed and the patient was discharged in stable condition without any more dizziness or lightheadedness.
Apparently a lengthy presentation actually very good for junior physicians as it covers all aspects of assessment, diagnosis and treatment of pleural effusion
PowerPoint presentation on Intercostal drainage (ICD) or Chest tube drainage. In this this presentation I have included different methods by which a chest tube can be inserted to drain fluid, pus, air from the Pleural cavity. please do mail me your feedback on this presentation at tinkujoseph2010@gmail.com.
newer drug combinations in management of hypertension,esp in presence of CAD, making them more potent anti-hypertensives, with lesser side effects especially pedal edema
Mubashar A Choudry MD | Effects of statin or usual care on outcomesMubashar A Choudry MD
Here, Dr. Mubashar A Choudry MD is explaining about effects of statin or usual care on outcomes. Dr. Mubashar Choudry is a respected cardiologist in Washington.
SGLT2 inhibitors in Heart failure: A prized addition to HF treatment optionsahvc0858
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Chan Wan Xian
Cardiologist, Echocardiologist
Heart Failure Intensivist
Asian Heart & Vascular Centre
www.ahvc.com.sg
Atorvastatin: Statins in CVD management. Is just lipid lowering enough Dr Vivek Baliga
When it comes to management of cardiovascular diseases, are achieving lipid lowering targets sufficient. Here Dr Vivek Baliga, Consultant Internal medicine discusses the additional benefits of statins in CVD in India.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
10. 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
12. 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
13. 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
14. 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
15. 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
16. 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
17. 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
18. Risk reduction (%) in the UKPDS Participants: Initial
results & 10-years follow-up
UKPDS 38: BMJ 1998;317:703–13
NEJM 2008;359:1565-76
19. 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
20. 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
22. 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
23. 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
24. 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
25. 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
26. 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
27. 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
28. SBP
ADVANCE BP reduction in context:
UK Prospective Diabetes Study
UKPDSADV
UK Prospective Diabetes Study
31. “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
33. 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
34. 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
35. 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
36. 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
38. 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
39. 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
40. ACCORD BP INTENSIVE BP
LOWERING
FUTILE IN DIABETES
• No benefit to be gained in diabetes by
intensive lowering (<120mmHg)
41. BP CONTROL IN DIABETES
HOW LOW SHOULD WE GO?
INVEST – Calcium antagonist Vs B Blocker
43. 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
45. CIMT regression better in mean systolic
BP <117 mmHg to
mean <129 mmHg
Haword BV et al
JAMA 2008:299
46. 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
53. • ………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
54. Achieved SBP and CV Event Reduction in trials on
Antihypertensive Treatment in diabetes
J Hypertension 2009;27:923-934
61. 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
62. 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
63.
64.
65. 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)
66. 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
68. 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
73. 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)
74.
75. 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
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 <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 <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 < 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 (<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.