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Treatment of blood pressure in the patient with hypertension and diabetes in an older population
diabetes remains a challenge. While data extrapo- doubles the risk of stroke, death from cardiovas-
lated from many trials seemed to imply that cular (CV) causes, and all-cause mortality when
lower blood pressures leads to more favorable compared with that of nondiabetic hypertensive
cardiovascular outcomes, this paper reviews patients.4–8 Furthermore, hypertension is a major
newer trials designed to treat to blood pressure risk factor for progression of diabetic nephrop-
targets below 130 ⁄ 80 mmHg in patients with athy,9,10 retinopathy,11 left ventricular hypertro-
long term established diabetes, which showed phy,12 and heart failure.13
that this goal may prove more harmful than
helpful. In clinical practice this may be less rele- BP TREATMENT FOR PERSONS WITH
vant due to the fact that less than half of patients DIABETES: EVIDENCE FOR BENEFIT
are even at the goal of 130 ⁄ 80. The interaction There is considerable evidence that blood pressure
between glucose control and blood pressure (BP) lowering reduces the complications of diabetes.
control are also discussed, emphasizing the One of the first trials to show the effect of lowering
importance of multifactorial treatment. J Clin BP in patients with diabetes was a subtrial of the Uni-
Hypertens (Greenwich). 2011;13:314–318. ted Kingdom Prospective Diabetes Study (UKPDS). A
ª
2011 Wiley Periodicals, Inc. group of 1148 diabetic patients with baseline BP
160 ⁄ 94 mm Hg were randomized to what was at that
time described as tight BP control (<150 ⁄ 85 mm
H ypertension and diabetes are well-known to
go hand in hand, with a 75% prevalence of
hypertension among persons with diabetes.1 Con-
Hg) with b-blockers or angiotensin-converting
enzyme (ACE) inhibitors as baseline therapy, with
addition of other medications as needed, achieving
versely, hypertension is associated with a nearly
mean BP 144 ⁄ 82 mm Hg, or to less tight control
5-fold increase in likelihood of diabetes.2
(<180 ⁄ 105 mm Hg), with mean BP 154 ⁄ 87 mm Hg.
Approximately half of persons with hypertension
Approximately 9 years later, patients assigned to
have insulin resistance,3 with increased likelihood
tight control of BP had a 24% lower risk of all diabe-
of developing diabetes. The combination of both
tes-related end points, a 32% reduction in death
From the Department of Medicine, Mount Sinai School related to diabetes, a 44% decrease in stroke, and a
of Medicine, New York, NY 37% decrease in microvascular disease.14
Address for correspondence: An observational analysis of the UKPDS data
Zachary T. Bloomgarden, MD, Department of showed that the risk of each of the macrovascular
Medicine, Mount Sinai School of Medicine, 35 East and microvascular complications of type 2 diabetes
85th Street, New York, NY 10028 was strongly associated with mean systolic BP. On
E-mail: zbloom@gmail.com average, each 10-mm Hg reduction in systolic BP
Manuscript received December 10, 2010; revised January
was associated with a 12% decrease in the risk of
25, 2011; accepted January 25, 2011
any end point related to diabetes and a 15% reduc-
doi: 10.1111/j.1751-7176.2011.00442.x tion in the risk of death related to diabetes. The