Physicians' Academy for Cardiovascular Education

An aggressive BP lowering strategy lowers BP in hypertensive diabetics, but targets not met in all

Literature - Viana LV, Leitão CB, Grillo MF, et al. - Diabetol Metab Syndr. 2013 Sep 12;5(1):52. [Epub ahead of print]


Hypertension management algorithm for type 2 diabetic patients applied in primary care

 
Viana LV, Leitão CB, Grillo MF, et al.
Diabetol Metab Syndr. 2013 Sep 12;5(1):52. [Epub ahead of print]
 

Background

Type 2 diabetes (T2DM) and hypertension commonly coexist, posing patients at an increased risk of cardiovascular events [1]. The United Kingdom Prospective Diabetes Study (UKPDS) concluded that tight blood pressure control (BP) in patients with T2DM and hypertension can reduce macro- and microvascular diabetic complications [2]. However, it turns out that it is difficult in this population to reach target BP of 130/80 mmHg as advised by several guidelines. Thus, often multiple medications are required [3-5].
In Brazil, the HiperDia System is a program developed to provide antihypertensive and antidiabetic medication in primary care units throughout the country. 81% of participating diabetics had hypertension [6].
This study analysed the possibility to obtain and maintain BP goals with an aggressive BL lowering strategy, according to a stepwise algorithm for BP using the medication supplied by the Brazilian government (HiperDia System). It was a one-year, open-label, non-controlled, single-arm interventional study, consisting of a 3 months run-in period (patients were advised to live a healthy live and take previously prescribed medication), 6 months of drug intervention (patients were given medication in the order of: diuretic, ACE inhibitors, Beta-blocker and then calcium channel blocking as needed, to obtain BP<130/80 mmHg) and a 2-3 months stabilisation period . 78 patients completed the trial.

 
Main results

  • From baseline to the end of the run-in period, there was a significant reduction in both systolic (145.0 ± 22.8 vs. 138.8 ± 21.2mmHg; p = 0.002) and diastolic BP (79.4 ± 11.5 vs. 76.5 ±10.9; p = 0.026), although medication use did not increase over this period.
  • In the intervention period, the amount of medication did increase (3.6 ± 3.5 vs. 5.9 ± 3.5 pills/patient; p <0.001), as well as the number of antihypertensive classes used (1.8 ± 1.0 vs. 2.70 ± 1.2; p < 0.01). Over this period, a further decline in SBP and DBP was seen. SBP dropped with 11 mm Hg (145.0 ± 22.8 vs. 133.7 ± 20.9 mmHg; p < 0.01) and DBP with 5 mmHg (78.7 ± 11.5 vs. 73.7 ± 10.5 mmHg; p = 0.001).
  • The number of patients who reached the BP target almost doubled, from 14 (18.7%) at the first visit to 30 (38.5%, P=0.008) at the end of the study.
  • No changes in BP nor in medication use was seen in the stabilisation period.
  • No differences were seen in age, gender and hypertension duration were seen with regard to response to the intervention.
 

Conclusion

The BP algorithm could lower BP in patients with T2DM and hypertension, although more than half of the patients did not achieve the BP targets.
Clinical inertia importantly contributes to persistently elevated BP. In this study, an aggressive BP lowering strategy doubled the number of patients who reached the BP target. Adherence to lifestyle modification strategies could be another reason for the lack of success in many patients. This study demonstrates the complexity of BP control in this population. Revision of antihypertensive treatment strategies is needed in order to guarantee adequate BP control in T2DM patients.
 

References

1. Mancia G: The association of hypertension and diabetes: prevalence, cardiovascular risk and protection by blood pressure reduction. Acta Diabetol 2005, 42:S17–S25.
2. UK Prospective Diabetes Study Group: Tight blood pressure control and the risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ 1998, 317:703–713.
3. Chobanian AV, Bakris GL, Black HR, et al. National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, National High Blood Pressure Education Program Coordinating Committee: The seventh report of the joint committee on prevention, detection, evaluation, and treatment of high blood pressure. JAMA 2003, 289:2560–2572.
4. American Diabetes Association: Standards of medical care in diabetes, 2010. Diabetes Care 2010, 34:S11–S61.
5. Pinto LC, Ricardo ED, Leitão CB, et al. Control inadecuado de la presion arterial en pacientes con diabetes melito tipo 2. Arq Bras Cardiol 2010, 94:633–637.
6. Ferreira CLRA, Ferreira MG: Características epidemiológicas de pacientes diabéticos da rede pública de saúde: análise a partir do sistema HiperDia. Arq Bras Endocrinol Metab 2009, 53:1.
 

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