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Arterial hypertension and diabetes mellitus

Yoto Yotov


The pathogenesis of arterial hypertension in patients with diabetes is a complicated process and involves a complex of biological and ecological factors, as well as genetic predisposition; as a result, the elevated blood pressure (BP) in patients with diabetes mellitus (DM) creates a higher risk of adverse events. Morbidity and mortality increase in diabetic patients who do not effectively control their BP to the targeted values of less than 140/90 (130/80) mm Hg. Large randomized trials and meta-analyses of large randomized controlled studies showed that the pharmacological reduction of BP is the most effective single way for reduction of mortality and of target organs damage in patients with DM, especially the related cardiovascular risk. Frequently, a combination of two or more medications (diuretics, angiotensin converting enzyme inhibitors, β-blockers, calcium channel blockers, angiotensin receptor blockers, spironolactone, etc.) is needed for effective pharmacotherapy, mostly in patients with difficult BP control. However, the costs of the health care to intensively lower BP are significantly lower than the expenditures to treat the hypertension complications, and the latter may be even prevented with BP reduction.


arterial hypertension, diabetes mellitus, pharmacological treatment, cardiovascular diseases

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Public Health Agency of Canada. Report from the Canadian Chronic Disease Surveillance System: hypertension in Canada, 2010. Ottawa, ON: Public Health Agency of Canada; 2010.

Public Health Agency of Canada. Report from the National Diabetes Surveillance System: diabetes in Canada, 2009. Ottawa, ON: Public Health Agency of Canada; 2009.

Cleary PA, Orchard TJ, Genuth S, Wong ND, et al. The effect of intensive glycemic treat- ment on coronary artery calcification in type 1 diabetic participants of the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Study. Diabetes 2006;55:3556 - 3565

Soedamah-Muthu SS, Colhoun HM, Abrahamian H, Chan NN, Mangili R, Reboldi GP, Fuller JH. Trends in hypertension management in Type I diabetes across Europe, 1989/1990 - 1997/1999. Diabetologia 2002;45:1362 - 1371

Nilsson PM, Cederholm J, Zethelius BR, Eliasson BR, Eeg- Olofsson K, Gudbj Rnsdottir S. Trends in blood pressure control in patients with type 2 diabetes: data from the Swedish National Diabetes Register (NDR). Blood Press 2011;20: 348 - 354

Cheung BM. The hypertension-diabetes continuum. J Cardiovasc Pharmacol. 2010; 55: 333-339

Landsberg L, Molitch M. Diabetes and hypertension: pathogenesis, prevention and treatment. Clin Exp Hypertens. 2004;26:621-628

Gress TW, Nieto FJ, Shahar E, et al. Hypertension and antihypertensive therapy as risk factors for type 2 diabetes mellitus. Atherosclerosis Risk in Communities Study. N Engl J Med. 2000;342:905-912

Bild D, Teutsch SM. The control of hypertension in persons with diabetes: a public health approach. Public Health Rep 1987;102(5):522-529

Sowers JR, Epstein M, Frohlich ED. Diabetes, hypertension, and cardiovascular disease: an update. Hypertension 2001;37(4):1053-1059

Brenner BM, Cooper ME, de Zeeuw D, Keane WF, Mitch WE, Parving HH, et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med 2001;345(12):861-869

Lewis EJ, Hunsicker LG, Clarke WR, Berl T, Pohl MA, Lewis JB, et al. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med 2001;345(12):851-860

McInnis NH, Fodor G, Lum-Kwong MM, Leenen FH. Antihypertensive medication use and BP control: a community-based cross-sectional survey (ONBP). Am J Hypertens 2008;21(11):1210-1215. Epub 2008 Sep 4

Leenen FH, Dumais J, McInnis NH, Turton P, Stratychuk L, Nemeth K, et al. Results of the Ontario survey on the prevalence and control of hypertension. CMAJ 2008;178(11):1441-1449

Campbell NR, Brant R, Johansen H, Walker RL, Wielgosz A, Onysko J, et al. Increases in antihypertensive prescriptions and reductions in cardiovascular events in Canada. Hypertension 2009;53(2):128- 134. Epub 2008 Dec 29

McAlister FA, Feldman RD, Wyard K, Brant R, Campbell NR, CHEP Outcomes Research Task Force. The impact of the Canadian Hypertension Education Programme in its first decade. Eur Heart J 2009;30(12):1434-1439. Epub 2009 May 19

Ryden L, Grant P, Anker SD, Berne C, et al. ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD. Eur Heart J 2013; 34: 3035-3087

Redon J, Cifkova R, Laurent S, Nilsson P, Narkiewicz K, Erdine S, Mancia G. Mechanisms of hypertension in the cardiometabolic syndrome. J Hypertens 2009; 27: 441- 451

Cheung BMY, Li C. Diabetes and Hypertension: Is There a Common Metabolic Pathway? Current Atherosclerosis Reports 2012;14(2):160-166

Stamler J, Vaccaro O, Neaton JD, Wentworth D. Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial. Diabetes Care 1993;16(2):434-444

Dolan E, Stanton A, Thijs L, Hinedi K, Atkins N, McClory S, et al. Superiority of ambulatory over clinic blood pressure measurement in predicting mortality: the Dublin outcome study. Hypertension 2005;46(1):156-161. Epub 2005 Jun 6

UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ 1998;317(7160):703-713

Schrier RW, Estacio RO, Esler A, Mehler P. Effects of aggressive blood pressure control in normotensive type 2 diabetic patients on albuminuria, retinopathy and strokes. Kidney Int 2002;61(3):1086-1097

Estacio RO, Jeffers BW, Gifford N, Schrier RW. Effect of blood pressure control on diabetic microvascular complications in patients with hypertension and type 2 diabetes. Diabetes Care 2000;23(Suppl 2):B54-B64

Patel A, MacMahon S, Chalmers J, Neal B, Woodward M, Billot L, et al. Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomised controlled trial. Lancet 2007;370(9590):829-840

Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Lancet 2000; 355(9200):253-259

Tuomilehto J, Rastenyte D, Birkenhger WH, Thijs L, Antikainen R, Bulpitt CJ, et al. Effects of calcium-channel blockade in older patients with diabetes and systolic hypertension. N Engl J Med 1999;340(9):677-684

Hansson L, Zanchetti A, Carruthers SG, Dahlцf B, Elmfeldt D, Julius S, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet 1998;351(9118):1755-1762

Turnbull F, Neal B, Algert C, Chalmers J, Chapman N, Cutler J, et al. Effects of different blood pressure-lowering regimens on major cardiovascular events in individuals with and without diabetes mellitus: results of prospectively designed overviews of randomized trials. Arch Intern Med 2005;5(12):1410- 1419

Ganesh J, Viswanathan V. Management of diabetic hypertensives. Indian J Endocrd Metab 2011;15(Suppl4): S374-S379

Neutel CI, Morrison H, Campbell NR, de Groh M. Statin use in Canadians: trends, determinants and persistence. Can J Public Health 2007;98(5):412- 416

Cushman WC, Evans GW, Byington RP, Goff DC Jr., et al. Effects of intensive blood-pressure control in type 2 diabe-tes mellitus. N Engl J Med 2010;362:1575 - 1585

Bangalore S, Kumar S, Lobach I, Messerli FH. Blood pressure targets in subjects with type 2 diabetes mellitus/ impaired fasting glucose: observations from traditional and bayesian random-effects meta-analyses of randomized trials. Circulation 2011;123: 2799 - 2810

Cushman WC, Evans GW, Byington RP, Goff DC Jr., Grimm RH Jr., et al., ACCORD Study Group. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med 2010;362(17):1575- 1585. Epub 2010 Mar 14

Weber MA, Bakris GL, Jamerson K, Weir M, Kjeldsen SE, Devereux RB, et al. Cardiovascular events during differing hypertension therapies in patients with diabetes. J Am Coll Cardiol 2010;56(1):77-85

Arguedas JA, Leiva V, Wright JM. Blood pressure targets for hypertension in people with diabetes mellitus. Cochrane Database Syst Rev 2013 Oct 30;10:CD008277. doi: 10.1002/14651858. CD008277.pub2

Moore TJ, Conlin PR, Ard J, Svetkey LP. DASH (Dietary Approaches to Stop Hypertension) diet is effective treatment for stage 1 isolated systolic hypertension. Hypertension 2001;38:155-158

Wallace JP. Exercise in hypertension. Sports Med. 2003;33:585-598

Hackam DG, Khan NA, Hemmelgarn BR, Rabkin SW, Touyz RM, Campbell NR, et al. The 2010 Canadian Hypertension Education Program recommendations for the management of hypertension: part 2-therapy. Can J Cardiol 2010;26(5):249-258

Yusuf S, Teo KK, Pogue J, Dyal L, Copland I, Schumacher H, et al. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med 2008;358:1547-1559

Patel A, MacMahon S, Chalmers J, Neal B, et al. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008; 358: 2560- 2572

Mogensen CE, Neldam S, Tikkane I, Oren S, Viskoper R, Watts RW, et al. Randomised controlled trial of dual blockade of renin-angiotension system in patients with hypertension, microalbuminuria, and non-insulin dependent diabetes: The candesartan and lisinopril microalbuminuria (CALM) study. BMJ 2000;321:1440-1444

Joshi SR, Yeolekar ME, Tripathi KK, Giri J, Maity AK, Chopda M, et al. Evaluation of efficacy and tolerability of Losartan and Ramipril combination in the management of hypertensive patients with associated diabetes mellitus in India (LORD Trial) J Assoc Physicians India 2004;52:189-195

Whelton PK, Barzilay J, Cushman WC, Davis BR, Iiamathi E, Kostis JB, et al. Clinical outcomes in antihypertensive treatment of type 2 diabetes, impaired fasting glucose concentration, and normoglycemia: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Arch Intern Med 2005;165(12):1401-1409

Curb JD, Pressel SL, Cutler JA, Savage PJ, Applegate WB, Black H, et al. Effect of diuretic-based antihypertensive treatment on cardiovascular disease risk in older diabetic patients with isolated systolic hypertension: Systolic Hypertension in the Elderly Program Cooperative Research Group. JAMA 1996; 276: 1886-1892

Staessen JA, Fagard R, Thijs L, Celis H, Arabidze GG, Birkenhger WH, et al. for the Systolic Hypertension in Europe (Syst-Eur) Trial investigators. Randomised double-blind comparison of placebo and active treatment or older patients with isolated systolic hypertension. Lancet 1997;350:757-764

Black HR, Elliott WJ, Grandits G, Grambsch P, Lucente T, White WB, et al. Principal results of the Controlled Onset Verapamil Investigation of Cardiovascular End Points (CONVINCE) Trial. JAMA 2003;289:2073-2082

Estacio RO, Jeffers BW, Hiatt WR, Biggerstaff SL, Gifford N, Schrier RW. The effect of nisoldipine as compared with enalapril on cardiovascular outcomes in patients with non-insulin-dependent diabetes and hypertension. N Engl J Med 1998;338:645-652

Lindholm LH, Ibsen H, Dahlof B, Devereux RB, Beevers G, de Faire U, et al. Cardiovascular morbidity and mortality in patients with diabetes in the Losartan Intervention For Endpoint Reduction in Hypertension Study (LIFE): A randomised trial against atenolol. Lancet 2002;359:1004-1010

Bakris GL, Fonseca V, Katholi RE. Metabolic effects of carvedilol vs metoprolol in patients with type 2 diabetes mellitus and hypertension: a randomized controlled trial. JAMA, 292: 2004; 2227- 2236

Pool JL. Is it time to move to multidrug combinations? Am J Hypertens 2003;16(11 Pt 2):36S-40S

Mann JF, Schmieder RE, McQueen M, Dyal L, Schumacher H, Pogue J, et al. Renal outcomes with telmisartan, ramipril, or both, in people at high vascular risk (the ONTARGET study): a multicentre, randomised, double-blind, controlled trial. Lancet 2008;372(9638):547-553

Jamerson K, Weber MA, Bakris GL, Dahlf B, Pitt B, Shi V, et al. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. N Engl J Med 2008;359(23):2417-2428

Bakris GL, Williams M, Dworkin L, Elliott WJ, Epstein M, Toto R, et al. Preserving renal function in adults with hypertension and diabetes: a consensus approach. Am J Kidney Dis 2000;36(3):646-661

Taler SJ, Textor SC, Augustine JE. Resistant hypertension: comparing hemodynamic management to specialist care. Hypertension 2002;39(5):982-988

Agarwal R. Hypertension, hypokalemia, and thiazide-induced diabetes: a 3-way connection. Hypertension 2008;52(6):1012-1013. Epub 2008 Nov 3

Franse LV, Pahor M, Di Bari M, Somes GW, Cushman WC, Applegate WB. Hypokalemia associated with diuretic use and cardiovascular events in the Systolic Hypertension in the Elderly Program. Hypertension 2000;35(5):1025-1030

CDC Diabetes Cost-Effectiveness Group. Cost-effectiveness of intensive glycemic control, intensified hypertension control, and serum cholesterol level reduction for type 2 diabetes. JAMA 2002;287(19):2542-2551

Wiklund I, Halling K, Ryden-Bergsten T, Fletcher A. Does lowering the blood pressure improve the mood? Quality-of-life results from the Hypertension Optimal Treatment (HOT) study. Blood Press 1997;6(6):357-364

Antithrombotic Trialists` Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 2002; 324(7329): 71-86. Erratum in: BMJ 2002; 324(7330): 141

Ogawa H, Nakayama M, Morimoto T, Uemura S, Kanauchi M, Doi N, et al. Low-dose aspirin for primary prevention of atherosclerotic events in patients with type 2 diabetes: a randomized controlled trial. JAMA 2008;300(18):2134-2141. Epub 2008 Nov 9

Belch J, MacCuish A, Campbell I, Cobbe S, Taylor R, Prescott R, et al. The prevention of progression of arterial disease and diabetes (POPADAD) trial: factorial randomised placebo controlled trial of aspirin and antioxidants in patients with diabetes and asymptomatic peripheral arterial disease. BMJ 2008;337:a1840

Gaede P, Lund-Andersen H, Parving HH, Pedersen O. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med 2008;358(6):580- 591



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