Survival of Diabetic Hypertensive Patients

KRISTIAN THYGESEN, MICHAEL STRATE, LISE HANSEN, AND BENT HARVALD

SUMMARY Seventy-nine of 673 patients attending a hypertensive outpatient clinic were classified
as diabetics at the first examination. These patients were age- and sex-matched to two control groups:
nondiabetic hypertensives and the background population. Nondiabetic hypertensive patients had a
significantly poorer survival than expected during a 10-year observation period; the survival of
diabetic hypertensives was even poorer, although not significantly. No sex difference was observed in
the survival rates of hypertensive diabetics, neither was a difference seen between insulin-dependent
and non-insulin-dependent patients. Acute myocardial infarction was the most frequent cause of death
in both diabetic (40%) and nondiabetic (42%) hypertensive persons.
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(Hypertension 7 [Suppl II]: II-14-II-17, 1985)

KEY WORDS • diabetes mellitus • hypertension • mortality • prognosis

T HE association between diabetes mellitus and

hypertension has been well established.1 Pop-
ulation studies indicate that hypertension oc-
curs more frequently in diabetic than nondiabetic sub-
jects,2 3 and the chances of a person with elevated
blood pressure becoming diabetic are increased by
63% compared to those with normal blood pressure.4
Both hypertension and diabetes mellitus are known
contributors to cardiovascular morbidity and mortal-
ity,5-6 and hypertension superimposed on diabetes
seems to produce an additive risk.5 At present, howev-
er, there seems to be some doubt as to the actual effect
of increased blood pressure on the prognosis of diabet-
ic patients. Goodkin7 stated in a report of a 20-year
survey that the mortality is much higher in diabetic
than in nondiabetic patients with comparable degrees
of hypertension, whereas Pell and D'Alonzo8 found no
effect of elevated blood pressure on mortality.
Our study was concerned with the effect of diabetes
on the prognosis of patients with arterial hypertension.
The 10-year survival of diabetic persons with hyper-
tension was compared to that of nondiabetic subjects
with hypertension and the background population.
Methods
The study population was made up of patients with
sustained arterial hypertension (World Health Organi-
zation criteria)9 who were referred to the hypertension
outpatient clinic of the Odense University Hospital
From the Department of Medicine C, Odense University Hospi-
tal, Odense, Denmark.
Address for reprints: Professor Bent Harvald, Department of
Medicine C, Odense University Hospital, DK-5000 Odense C,
Denmark.
11-14
during the years 1970 to 1980. All had been hospital-
ized for assessment, during which blood pressure was
measured three times per day using a cuff 12'/2 x 60
cm; the diastolic pressure was determined from the
fifth Korotkoff sound. The majority of the patients had
been referred to the hospital by their general practition-
er after unsuccessful therapy; the remainder were ad-
mitted as hypertensive emergencies. Treatment was
commenced after this assessment, and the patients at-
tended the outpatient clinic at intervals of 2 to 3
months. The aim of antihypertensive therapy was to
lower the diastolic blood pressure to less than 95 mm
Hg, with due regard for clinical tolerance. A multiple-
drug regimen was employed on an individual basis,
using a diuretic and a beta-adrenergic blocking agent,
combined in some cases with a vasodilator. The dia-
betics were treated with diet and either insulin or oral
antidiabetic drugs aimed at a postprandial plasma glu-
cose level below 10 mmol/L.
Seventy-nine of a total of 673 hypertensive patients
were classified as diabetic at their first examination
based on the criteria laid down by the National Diabe-
tes Data Group10 (Table 1). Seventeen patients had
insulin-dependent diabetes mellitus (IDDM) and 62
non-insulin-dependent diabetes mellitus (NIDDM).10
The IDDM group of 11 men and 6 women had a mean
age of 48.6 years ± 1 3 . 3 (SD). The NIDDM group of
28 men and 34 women had a mean age of 61.5 years ±
8.8 (SD). The mean age of the NIDDM group was
significantly higher than that of the IDDM group [p <
0.001). The duration of diabetes ranged from 0 to 29
years (median 2 years), inasmuch as the median dura-
tion was 0 years for patients with NIDDM and 15 years
for those with IDDM (Figure 1). Sixteen patients (5
NIDDM, 11 IDDM) had diabetic retinopathy and 7 (2
 SURVIVAL OF DIABETIC HYPERTENSIVE PATIENTS/77i;yge.yen et al. 11-15

TABLE 1. The Demographics ofDiabetic Patients and Nondia- Number

D Hypertensives without DM
betic Controls at Entry to the Hypertension Outpatient Clinic 200 E3 Hypertensives with DM
Demographic data Diabetics Nondiabetics
n 79 564 175
Age (mean ± SD) (yr) 58.7±11.2 56.4 ±11.4
Weight (mean ± SD) (kg) 79.2± 14.3* 74.6±28.5t 150

Sex (M/F) (n) 39:40 281:283

Primary/secondary hyper- 12S
tension (n) 69:10 468:96
WHO stages 1/2/3 (n) 27:22:20 193:106:160* 100
Risk factors! (n) 49 288
75
•Calculated from 77 patients.
tCalculated from 560 patients.
^Staging not available from nine patients. 50
§Chronic lung disease, hyperlipidemia, hyperuricemia, and pre-
vious myocardial infarction.
25
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Number 0
X 40 50 60 70 80 Years

• NIDDM (Medtan.0year»)
FIGURE 2. Age distribution of hypertensive patients with and
0 IDOM (Median. 15 years) without diabetes mellitus (DM).

Follow-up was carried out on January 1, 1981. At

this time no patients in the diabetic group and six
patients in the nondiabetic control group were lost
from observation. Survival was assessed by the ac-
tuarial method, employing 95% confidence limits of
the curves obtained by means of Greenwood's esti-
mate.12-15 The t distribution was used for comparison of
3 -
the expected and observed survival rates, and the log
rank test was employed for comparison of the observed
survival rates. "• " The relative survival rate, calculat-
0 2 6 10 U 18 22 28 30
ed as the observed survival rate divided by the expect-
ed survival rate, reflects survival of a population
with the disease in question as the only cause of
FIGURE 1. Duration of diabetes on entrance to the study. death. 1 2 1 3 1 8 Differences were considered as signi-
ficant when p was less than 0.05.

NIDDM, 5 IDDM) diabetic nephropathy (proteinuria Results

and elevated serum creatinine concentration). Sixty-
nine diabetics were classified as having primary and 10
as having secondary hypertension; all the latter were
nephrogenic.
A representative control group (see Table 1) was
selected from the nondiabetic hypertensive patients in
such a manner that no statistical difference existed with
regard to age distribution (Figure 2) or risk factors
(chronic lung disease, hyperlipidemia, hyperuricemia,
and previous myocardial infarction). Neither was there
any difference in the frequency of primary and second-
ary hypertension or body weight. Furthermore, no sig-
nificant difference was present in the frequencies of
WHO stages of primary hypertension in the two
groups. Another sex- and age-matched control group
was obtained from the life tables of the Danish
population."
The 10-year survival of diabetic and nondiabetic
hypertensive patients as compared to the background
population is shown in Figure 3. Survival of diabetic
hypertensive patients was significantly reduced (p <
0.01), with a 5-year survival of 75% (expected 91%)
and a 10-year observed survival of 49% (expected
81%). The survival of nondiabetic hypertensive pa-
tients was in between, with a 5-year observed survival
of 81% and a 10-year survival of 6 1 % (p < 0.001).
The difference between the groups was not significant.
The relative survival rates for men and women with
both hypertension and diabetes are shown in Figure 4.
No significant difference was observed between the
sexes.
Figure 5 depicts the relative survival rates for hyper-
tensive patients with IDDM and NIDDM respectively.
Only the 5-year survival rate of patients with IDDM
 11-16 DIABETES AND HYPERTENSION SUPPL II HYPERTENSION, VOL 7, No 6, NOV-DEC 1985

Survival (V.) was calculated, due to the limited number of patients in

100
this group. No difference in survival was demonstrated
90
within the 5-year observation period between the types
of diabetes.
80 Among 23 deaths in the diabetic hypertensives (5
IDDM, 18 NIDDM), 9 (40%) were due to acute myo-
70
r cardial infarction, 1 to stroke, 1 to renal failure
u (IDDM), and 12 to various other causes. These figures
60
\ ^^ ] compared well with the causes of death in nondiabetic
50
- - "Background population
"\ hypertensives, in whom 46 of 110 deaths (42%) oc-
curred from myocardial infarction, 8 from stroke, 8
40 —o—Hypertensivt population from renal failure, and 48 from other causes.
30 ;
—•—Hypertensive patitnts with d n b t t t s
• 95 V. confidence limits L
6 7 8 9 10 Discussion
Observation time (years)
This investigation demonstrated a steadily decreas-
ing life expectancy in hypertensive patients compared
FIGURE 3. Survival curve of hypertensive patients with diabe- to the background population during the 10 years of
tes mellitus compared to those of matched hypertensive and observation. A further reduction in life expectancy was
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background populations. observed in diabetic hypertensives; however, there

was no significant difference in the survival of diabetic
and nondiabetic hypertensive patients. The most obvi-
ous explanation of this is effective treatment and con-
Relative survival trol of diabetes, thus delaying serious complications
1 00 giving rise to increased mortality. Although other ex-
—o planations are also possible, first, the duration of dia-
0 90 \
\
betes was too short to demonstrate an added risk, and
0.80
second, there may have been too few patients in the
study to reveal a significant effect. In this context it
0.70 - # _ .
should be noted that there was no difference in the
-r—* severity of hypertension or the aim of antihypertensive
0.60 treatment in the diabetic and nondiabetic groups, inas-
\
\ much as the frequency of primary and secondary hy-
0 50 pertension as well as of WHO stages did not differ.
- - o - - Male
Furthermore, all patients were treated with the object
0.40 . — • — Female
of achieving normalization of blood pressure, as far as
0 1 2 3 1 5 6 7 8 9 10
possible.
Observation time (ysars )
A recent Danish study of the mortality of insulin-
treated diabetic patients' 9 showed that men have a
FIGURE 4. Relative survival ofpatients with hypertension and
higher mortality than comparable women, whereas our
diabetes mellitus according to sex. study, based on a cohort from the same region, was
unable to demonstrate any sex difference in the surviv-
al of diabetic hypertensive persons.
Our material consisted of a major group of patients
Relative survival
1.00 with newly diagnosed non-insulin-dependent diabetes
and a smaller group of patients with long-standing
0.90 insulin-dependent diabetes (median 15 years). When
corrected for differences in age, the two types of pa-
0.80 tients had the same prognosis, at least during a 5-year
observation period.
0.70
Elevated arterial blood pressure is frequently pres-
0.60 ent in insulin-dependent diabetic patients with diabetic
nephropathy,20 and renal failure due to diabetic ne-
0.50 phropathy is a major cause of death in these patients.21
~ ° — Hypertensive patients with IDOM
In the present series, only one insulin-dependent pa-
0.40 — • — Hypertensive patients with NIDDM
tient died from renal failure; this may have been due to
the fact that antihypertensive treatment postponed the
0 1 2 3 4 5 6 7 8 9 10
Observation time (years) end stage of renal insufficiency.22-23
The dominant cause of death in both diabetic and
FIGURE 5. Relative survival ofpatients with hypertension and nondiabetic hypertensive patients was myocardial in-
diabetes mellitus according to insulin dependency. farction, 40% and 42% respectively. These figures
 SURVIVAL OF DIABETIC HYPERTENSIVE PATIENTS/Thygesen et al.
correspond well to that reported by Goodkin,7 where
41.5% of the deaths of diabetics were due to arterio-
sclerotic heart disease. Thus diabetes mellitus associ-
ated with hypertension does not appear to change the
mortality pattern seen in each of the disorders.
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 Survival of diabetic hypertensive patients.
K Thygesen, M Strate, L Hansen and B Harvald

Hypertension. 1985;7:II14
doi: 10.1161/01.HYP.7.6_Pt_2.II14
Hypertension is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 1985 American Heart Association, Inc. All rights reserved.
Print ISSN: 0194-911X. Online ISSN: 1524-4563
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