Download 140 mmHg

Management of HTN in diabetic patient
Fatemeh saffarian
Assisstant professor of cardiology
at qazvin university of medicine
HTN & DM:
• HTN affecting 60-70% of patients with DM.
• in type 2 diabetes,HTN is often present as part of the
metabolic syn while in type 1 ,HTN may reflect the
onset of diabetic nephropathy.
• HTN increased risk of both macrovascular &
microvascular complication.
• People with DM & HTN have twice the risk of CVE
as non-diabetic people with HTN.
• masked hypertension is not infrequent, so that
monitoring 24-h ambulatory BP in apparently
normotensive patients with diabetes,may be a useful
diagnostic procedure.
• Target level of BP in DM ?
Which drugs prefered ?
Threshold of initiation of therapy?
Hypertension Guidelines 2013-2014
Case
• A 58 year old African-American woman
with diabetes and dyslipidemia has a
BP of 158/94 confirmed on several
office visits. Other than obesity, the
exam is normal. Labs show normal
renal function, well-controlled lipids on
atorvastatin and well-controlled
diabetes on metformin. Urine microalbumin is mildly elevated.
Case Question 1
• What goal BP is most appropriate for
this patient?
1.
2.
3.
4.
5.
<150/90 mmHg
<130/80 mmHg
<140/90 mmHg
<140/80 mmHg
<140/85 mmHg
Case Question 2
• What is the drug of choice to start?
1.
2.
3.
4.
5.
HCTZ
Norvasc
Lisinopril
Losartan
Combination therapy
Classification of BP – JNC 7
Category
Systolic
(mmHg)
Diastolic
(mmHg)
Normal
< 120
and
< 80
Pre-HTN
120-139
or
80-89
Stage I
140-159
or
90-99
Stage II
> 160
or
> 100
Hypertension
2013 ESH/ESC Guidelines for the management of arterial hypertension
Definitions and classification of office BP levels (mmHg)*
Hypertension:
SBP >140 mmHg ± DBP >90 mmHg
Category
Systolic
Diastolic
Optimal
<120
and
<80
Normal
120–129
and/or
80–84
High normal
130–139
and/or
85–89
Grade 1 hypertension
140–159
and/or
90–99
Grade 2 hypertension
160–179
and/or
100–109
Grade 3 hypertension
≥180
and/or
≥110
Isolated systolic hypertension
≥140
and
<90
* The blood pressure (BP) category is defined by the highest level of BP, whether systolic or diastolic. Isolated systolic
hypertension should be graded 1, 2, or 3 according to systolic BP values in the ranges indicated.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
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•
•
•
•
Definitions of hypertension by office and
out-of-office blood pressure levels:
Office : ≥ 140 and/ or ≥ 90
Ambulatory:
• Daytime (or awake): ≥135 and/or ≥85
• Nighttime (or asleep): ≥120 and/or ≥70
• 24-h: ≥130 and/or ≥80
• BP must be remeasured at least 3
times over a period of at least 4 weaks.
• Except:
• BP>180/110 or symptomatic or end
organ damage
JNC 8
• 2014 Evidence-Based Guidelines for
the Management of High Blood
Pressure in Adults
– JAMA. 2014;311(5):507-520
– December 18, 2013
JNC 8: Graded Recommendations
A – Strong evidence
B – Moderate evidence
C – Weak evidence
D – Against
E – Expert Opinion
N – No recommendation
JNC 8: Drug Treatment
Thresholds and Goals
• Age > 60 yo
– Systolic:
• Threshold > 150 mmHg
• Goal < 150 mmHg
– LOE: Grade A
Diastolic:
• Threshold > 90 mmHg
• Goal < 90 mmHg
– LOE: Grade A
JNC 8: Drug Treatment
Thresholds and Goals
• Age < 60 yo
– Systolic:
• Threshold > 140 mmHg
• Goal < 140 mmHg
Diastolic:
• Threshold > 90 mmHg
• Goal < 90 mmHg
– LOE: Grade A for age 30-59; Grade E for ages 1829
• For patients who can tolerate without asdverse symptom,can
target as SBP<130 and DBP<80
JNC 8: Drug Treatment
Thresholds and Goals
• Age > 18 yo with CKD or DM
– JNC 7: < 130/80 (MDRD NEJM 1994)
– Systolic:
• Threshold > 140 mmHg
• Goal < 140 mmHg
Diastolic:
• Threshold > 90 mmHg
• Goal < 90 mmHg
• For patients who can tolerate without
asdverse symptom,can target as
SBP<130 and DBP<80
• For pts with SBP of 130-139 or DBP of
80-89 mmHg should initiate lifestyle
modification alone,for a maximum of 3
months,if after these,BP not
reduced,drug therapy initiated.
JNC 8: Initial Drug Choice
• Nonblack, including DM
– Thiazide diuretic, CCB, ACEI, ARB
• LOE: Grade B
• Black, including DM
– Thiazide diuretic, CCB
• LOE: Grade B (Grade C for diabetics)
JNC 8: Initial Drug Choice
• Age > 18 yo with CKD and HTN
(regardless of race or diabetes)
– Initial (or add-on) therapy should include
an ACEI or ARB to improve kidney
outcomes
• LOE: Grade B
JNC 8: Subsequent Management
• Reassess treatment monthly
• Avoid ACEI/ARB combination
• Consider 2-drug initial therapy for
Stage 2 HTN (> 160/100)
• Goal BP not reached with 3 drugs, use
drugs from other classes
Recent HTN Guideline Statements
• 2013 ESH/ESC Guidelines for the
management of arterial hypertension.
• J Hypertnsion 2013;31:1281-1357.
• An Effective Approach to High Blood
Pressure Control: A Science Advisory
From the AHA, ACC, and CDC.
• Hypertension online November 15, 2013.
• Clinical Practice Guidelines for the
Management of HTN in the Community
A Statements by the ASH/ISH.
• J Hypertension 2014;32:3-15
2013 ESH/ESC Guidelines for the management of arterial hypertension
Blood pressure goals in hypertensive patients
Recommendations
SBP goal for “most”
•Patients at low–moderate CV risk
•Patients with diabetes
•Consider with previous stroke or TIA
•Consider with CHD
•Consider with diabetic or non-diabetic CKD
<140 mmHg
SBP goal for elderly
•Ages <80 years
•Initial SBP ≥160 mmHg
140-150 mmHg
SBP goal for fit elderly
Aged <80 years
<140 mmHg
SBP goal for elderly >80 years with SBP
•≥160 mmHg
140-150 mmHg
DBP goal for “most”
<90 mmHg
DB goal for patients with diabetes
<85 mmHg
SBP, systolic blood pressure; CV, cardiovascular; TIA, transient ischaemic attack; CHD, coronary heart disease; CKD, chronic kidney disease;
DBP, diastolic blood pressure.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
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BP goal in the elderly
2013 ESH/ESC Guidelines for the management of arterial hypertension
Hypertension treatment for people with diabetes
Recommendations
Additonal considerations
Mandatory: initiate drug treatment in patients
with SBP ≥160 mmHg
• Strongly recommended: start drug treatment
when SBP ≥140 mmHg
SBP goals for patients with diabetes: <140 mmHg
DBP goals for patients with diabetes: <85 mmHg
All hypertension treatment agents are
recommended and may be used in patients with
diabetes
• RAS blockers may be preferred
• Especially in presence of preoteinuria or
microalbuminuria
Choice of hypertension treatment must take comorbidities into account
• Avoid in patients with diabetes
Coadministration of RAS blockers not
recommended
SBP, systolic blood pressure; DBP, diastolic blood pressure; RAS, renin–angiotensin system.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
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2013 ESH/ESC Guidelines for the management of arterial hypertension
Hypertension treatment for people with nephropathy
Recommendations
Additonal considerations
Consider lowering SBP to <140 mmHg
Consider BP <130/90 mmHg with overt
proteinuria
• Monitor changes in eGFR
RAS blockers more effective to reduce
albuminuria than other agents
• Indicated in presence of microalbuminuria or
overt proteinuria
Combination therapy usually required to reach BP
goals
• Combine RAS blockers with other agents
Combination of two RAS blockers
• Not recommended
Aldosterone antagonist not recommended in CKD
• Especially in combination with a RAS blocker
• Risk of excessive reduction in renal function,
hyperkalemia
SBP, systolic blood pressure; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; RAS, renin–angiotensin system.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Medical Education & Information – for all Media, all Disciplines, from all over the World
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Goal BP
Group
BP Goal (mm Hg)
General
DM*
CKD**
JNC 8:
<60 yr: <140/90
>60 yr: <150/90
< 140/90
< 140/90
ESH/ESC:
< 140/90
< 140/85
< 140/90
Elderly
140-150/90
(<80 yr: SBP<140)
ASH/ISH
< 140/90
>80 yr: <150/90
AHA/ACC
< 140/90
*ADA: < 140/80 or lower
(SBP < 130 if proteinuria)
< 140/90
< 140/90
(Consider < 130/80 if proteinuria)
< 140/90
< 140/90
Canadian D.A:<130/80
Drug therapy of HTN in diabetes
• ACEI:
• prefered in most guidelines
• Favorable effects on glucose metabolism &
neghropathy & CVD outcomes.
• In patient with H.F& post MI ACEI was superior to
ARB (OPTIMAL & ELITE II trials)
• ARB:
• Similar level of recommendation in guidelines.
• Prefered in pts with LVH
Drug therapy of HTN in diabetes
• Dihydropyridine CCB : (amlodipine)
• Shown superiority to HCT when added to ACEI
• Beta blockeres:
•
•
•
•
Masking hypoglycemia symptoms
Adverse effects on glucose & lipid metabolism
Carvedilol prefered
May be in IHD patient but no first line.
Drug therapy of HTN in diabetes
• Thiazide diuretics:
• Advers glycemic & triglyceridemic effect
• ALHHAT trial:compared with lisinopril & amlodipine
were similar CVE effect on diabetic patients.
• In USA ,chlorthalidone prefered(longer duration of
action,more potent ,
Beta-blocker / Diuretic Combination
• Despite trial evidence of outcome
reduction, the BB / diuretic combination
favours development of diabetes and
should thus be avoided, unless
required for other reasons,
ACEI / ARB Combination
• An ACEI / ARB combination presents a
dubious potentiation of benefits with a
consistent increase of serious side
effects
• Specific benefits in nephropathic
patients with proteinuria (because of a
superior antiproteinuric effect) expect
confirmation in event based trials
ACEI / CA Combination
• Tested or widely used combination therapy in
Syst-Eur / Syst-China / HOT / ASCOT / INVEST /
ACCOMPLISH
• Greater CV protection than placebo in Syst-Eur /
Syst-China
• Equal (INVEST) or greater (ASCOT) CV protection
than D/BB
• Greater CV protection than ACEI/D in
ACCOMPLISH
2013 ESH/ESC Guidelines for the management of arterial hypertension
Lifestyle changes for hypertensive patients
Recommendations to reduce BP and/or CV risk factors
Salt intake
Restrict 5-6 g/day
Moderate alcohol intake
Limit to 20-30 g/day men,
10-20 g/day women
Increase vegetable, fruit, low-fat dairy intake
25 kg/m2
BMI goal
Waist circumference goal
Men: <102 cm (40 in.)*
Women: <88 cm (34 in.)*
≥30 min/day, 5-7 days/week
(moderate, dynamic exercise)
Exercise goals
Quit smoking
* Unless contraindicated. BMI, body mass index.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Medical Education & Information – for all Media, all Disciplines, from all over the World
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Most guidelines have raised the office BP
treatment threshold in DM to
140/90mmHg
,except :
2013 ESH/ESC recommended 140/85
if proteinuria;130/90
2013 ADA which recommended
140/80mmHg
&2013 canadian guidelines that
recommended 130/80mmHg
Treatment of risk factors associated with
hypertension
• *It is recommended to use statin in moderate to high
CV risk :>40 Y or <40 Y & LDL >100
(target:LDL<100,HDL>50,TG<150)
•
in DM aspirin(75-162mg/day) recommended if
man>50 y & woman >60 y
• In hypertensive patients with DM , a HbA1c target of
<7.0%
Thank you for your attention