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Slide 1 Welcome to the Canadian Hypertension Society Website Powered By Docstoc
					Hypertension & Diabetes

  Management of hypertension in
      people with diabetes



                                  1
Objectives
By the end of this session you will be able to:
• Explain how to diagnose hypertension
• Discuss the importance of managing
  hypertension for people with diabetes
• Discuss pharmacologic management of
  hypertension in diabetes
• State 5 lifestyle changes to manage
  hypertension in diabetes.

                                                  2
How well is HTN managed?

• In Ontario
  – 2/3 of those with diabetes & hypertension had
    uncontrolled BP
  – ¼ had not been treated for hypertension
• In Newfoundland
  – Physicians knew target level for BP
  – Chart audit people with type 2 diabetes – only
    20% had controlled BP

                               Leenen, CMAJ, 2008;178:1441-49
                                                                3
                               McCrate CMAJ, 2010;56
Making the diagnosis



  Diagnosis of hypertension in diabetes:

  BP > 130/80 mm Hg,

  repeated on 2nd day



                                           4
Target BP for people with diabetes




        < 130/80 mm Hg


                               CDA 2008    5
                               CHEP 2010
How prevalent is hypertension?

• Hypertension (HTN) is the most common chronic
  disease among adults.
• Prevalence increases with age
  – 50% of Canadians over age 65 have HTN
  – Lifetime risk of developing HTN (over 140/90) after age
    55-65 is 90%
  – More common among black and South Asian people
  – People with diabetes are 2 x as likely to have HTN as
    those without diabetes

                                Brown 2007, CHEP 2009, Vasan
                                                                 6
                                2002, Leenen 2008, Sowers 2001
Cardiovascular disease

• 65-80% of people with diabetes will die of
  cardiovascular disease
• Many deaths occur with no prior warning of
  heart disease
  – 1/3 of MIs occur without typical symptoms
• Up to 75% of CVD is caused by hypertension

                            CDA 2008, Campbell 2009
                                                      7
Why manage hypertension?

Meta-analysis of 27 randomized trials showed
  reducing blood pressure by 6 / 4.6 mm Hg
  resulted in:
• 36% reduction in stroke
• 27% reduction in total mortality
• 25% reduction in major cardiovascular events

                            Blood pressure Lowering Treatment
                                                           8
                            Trialists’ Collaboration 2005
 Syst Eur trial
 Systolic Hypertension in Europe Trial

• 492 people with isolated    End point     Relative risk
  systolic hypertension and                  reduction
  diabetes randomized to
                                 CVD            69%
  decrease SBP 20 mm Hg
  or more to SBP <150 mm         CAD            63%
  Hg                            Stroke          73%
                               CV death         76%
• At the end of trial the
  difference was 8.6/3.9 mm   Total death       55%
  Hg
                                               Tuomilehto J 1999
                                                             9
 HOT
 Hypertension Optimal Treatment Trial
• 1501 people with          End point         Relative risk
  hypertension and DM                          reduction
  randomized to
  DBP <90, <85, <80         Major CVD              51%
• End of trial difference       MI                 51%
  144/85 vs. 141/83 vs.      CV death              66%
  140/81 mm Hg
                              Stroke                   NS
• 4/4 mm Hg difference in
  SBP/DBP                   Total death                NS

                                     Hansson L. 1998          10
HOPE trial
Heart Outcomes Prevention Evaluation
 3577 people with DM and normal or high
 blood pressure randomized placebo vs. ACE
 inhibitor

  – Reduction in BP on average 2.2 / 1.4 mm Hg

  – Primary outcome of myocardial infarction, stroke
    or CV death significantly lower in those taking an
    ACE inhibitor (RR 25%)
                                                HOPE, 2000
                                                         11
 Risk reduction from lowering BP

% risk
reduction
    80
    70
                                                      BP lowered by:
    60
    50                                                    Syst Eur 8.6/3.9
    40
                                                          mmHg
    30                                                    HOT 4/4 mmHg
    20
    10                                                    HOPE 2.2/1.4
     0                                                    mmHg
            CVD   CAD/MI   Stroke CV death    Total
                                              death
                                                                 HOPE, 2000      12
                                             Tuomilehto J 1999 Hansson L. 1998
Benefits of Tight BP & Tight Glucose Control
UKPDS
                                                Any diabetes-          Microvascular         Diabetes-related
                              Stroke          related endpoint          endpoints                deaths
                  0

                -10
                                                     †

                -20
    Risk
 reduction                                                 *                †
    (%)    -30
                                                                                                          *
                -40                                                                *

                -50                *
                                                                                       Tight glucose control
                                                                                       Tight BP control
 *P<0.02, tight BP control (achieved BP 144/82 mm Hg) vs less tight control (achieved BP 154/87 mm Hg).
 †P<0.03, intensive glucose control (achieved HbA 7.0%) vs less intensive control (achieved HbA 7.9%).
                                                 1c                                             1c
 UKPDS Group. BMJ. 1998;317:703-713.
 UKPDS Group. Lancet. 1998;352:837-853.
UKPDS
United Kingdom Prospective Diabetes
Study

• For every 10 mm HG rise in systolic BP
   –Risk of myocardial infarction & death
    rose by 12%
   –Risk of microvascular disease rose by
    13%

                                   Adler 2000
                                                14
Treatment in the elderly

• Treatment of hypertension in those over 80
  years showed significant reduction in
  – Cardiovascular morbidity and mortality
  – Reduction in stroke
  – Reduction in heart failure


• Caution – when treating frail elderly – risk of
  hypotension
                                         Abatetusso, 2008
                                         CHEP 2009       15
Healthcare system benefits

• Treating hypertension is a cost effective
  intervention
• Treatment is less expensive than treating
  complications of retinopathy and nephropathy

• HOT study showed improved quality of life



                         Campbell 2009, CDC 2002, Wiklund 1997
                                                          16
Changes in management of
hypertension in Canada
 CHHS 1985-1992              HSFO 2006
    Canada                    Ontario
                                                      Treated
       13%                                            and
                           12.6%                      Controlled
       (DM 9%)
                        5.4%
                                                      Treated
43%                                                   not
                 21%   13%
                                     69%              Controlled

                                   (DM 37%)           Aware
                                                      Not
      22%                                             Treated
                                                      Not
                                                      Aware
                               Joffres 1997, Leenen 2008   17
Treatment




            18
Nutrition

• Dietary Approach to Stop Hypertension
  (DASH)
  – Reduces blood pressure by 11.4 / 5.5 mm Hg

• DASH emphasizes a diet …
  – Rich in fruits and vegetables
  – Whole grains, dietary and soluble fibre
  – Low fat dairy products
  – Low in saturated fats, cholesterol and salt

                                           Appel 1997   19
Meta analysis: effect of reducing salt
on blood pressure




                             Hypertension 2003;42:1093-1099
                                                       He 2003
                                                                 20
Sodium recommendations

• CHEP (2010) recommends targeting an
  adequate intake of sodium for the
  prevention and control of hypertension.
    Age     Adequate intake Upper limit
            mg/day          mg/day
    19 – 50      1500           2300
    51 – 70      1300           2300
    Over 70      1200           2300
                              CHEP 2010, Health Canada   21
Sources of sodium in our diet

                                77% - processed
                                food – includes
                                restaurant foods
                                12% - naturally
                                present
                                6% - added salt
                                to cooking
                                5% - added salt at
                                the table


                                  Garriguet 2007   22
To reduce sodium intake

• Eat fewer processed canned and instant foods,
• Choose fresh foods more often,
• Limit salted snack foods, such as nuts, chips,
  popcorn
• Read labels and select lower salt options of
  similar foods.
• Do not add salt to home cooking, use spices
  instead,
• Take the salt shaker off the table,

                                                   23
Alcohol

• Heavy drinkers who reduced alcohol intake
  reduced BP by 2-4 / 1-2 mm HG

Recommendations
• No more than 2 standard drinks a day
  – Less than 14 / week for men
  – Less than 9 / week for women

                                   Mayo Clinic
                                   CDA 2008
                                                 24
Physical Activity

• Previously inactive people reduced BP by
  3.8 / 2.6 mm Hg by engaging in regular
  physical activity

• 30 – 60 minutes moderate intensity,
  dynamic exercise 4 – 7 days a week
  – Brisk walking, jogging, cycling, swimming

                                          Whelton2005
                                          CHEP 2009, CDA 2008
                                                        25
Physical Activity

• If previously sedentary, at risk for
  cardiovascular disease and wishing to start
  more than brisk walking

  – Have a medical check up
  – Exercise ECG

• Start slowly, gradually build duration and
  intensity
                                       CDA 2008   26
Weight

• 4.4 kg loss in weight resulted in
  4.0 / 2.8 mm Hg reduction in BP

• Weight loss of 5-10%
  – Improves insulin sensitivity
  – Improves blood glucose
  – Improves blood pressure
  – Improves blood lipids
                                   Trials of hypertension Prevention
                                   Collaborative Research Group,1997
                                   CDA 2008                     27
Weight recommendations

• BMI should be between 18.5 and 24.9 kg/m2

• International Diabetes Federation recommends
  waist circumference:
   – Less than 94 cms for Europid men
   – Less than 90 cms South Asian, Chinese men
   – Less than 80 cms for women
  For Japanese people
   – Men: less than 85 cms
   – Women: less than 90 cms
                                       CDA 2008, IDF 2006
                                                       28
Smoking

• Risk of CVD reduced by 50% after 1 year
  smoke free




                        American Heart Association
                                                     29
Stress management

• Healthcare professionals should screen for
  psychological distress

• Stress management should be considered
  when stress is a contributing factor to
  hypertension.



                                               30
Steno 2 study: Effect of a Multifactorial Vascular
Protective Strategy on Macro- and Microvascular
Outcomes
                                         60
                                                  P = .007
       Primary Composite End Point (%)



                                         50

                                                             Conventional therapy
                                         40
                                                             Intensive therapy
                                         30

                                         20

                                         10

                                         0
                                              0     12       24     36     48    60   72   84    96



                                                                                                Gaede. 2003   31
Steno 2 study: Extended Follow-up:
Effect of a multi-factorial vascular protective strategy on total
mortality
                        60
                                 HR = 0.54 (0.32-0.88)                       Conventional therapy
                        50       p = 0.015
  Total mortality (%)




                                                             END OF TRIAL
                        40

                        30

                        20

                        10                                                       Intensive therapy




                             0    1    2    3   4    5   6    7   8      9      10   11   12   13

                                                    Years of follow-up
                                                                                               Gaede 2008.
                                                                                                       32
Pharmacotherapy

• When BP more than 130 / 80 mm Hg,
  pharmacotherapy should be started
  concurrently with lifestyle changes.

• If BP 150 / 90 mm Hg or more start with
  combination of medications



                                                       33
                                 CDA 2008, CHEP 2010
Pharmacotherapy

• Normal urinary albumin excretion AND no
  chronic kidney disease AND BP 130/80 mm Hg or
  higher
  –   ACE inhibitor
  –   ARB
  –   DHP CCB
  –   Thiazide diuretic

  Cardioselective beta blocker or non-DHP CCB if above
    are contraindicated or not tolerated

                                             CDA 2008    34
Pharmacotherapy
Persistent albuminuria (ACR > 2 in men or > 2.8
  in women)
• Start with ACE inhibitor or ARB

     ACE inhibitor and ARB should not be used
     in combination in people with
        –Uncomplicated hypertension
        –Diabetes
        –Chronic kidney disease
                                  CDA 2008,CHEP 2010
        –Ischemic heart disease
                                                       35
 Combination Therapy Needed to
 Achieve Target DBP Goals
  Patients with diabetes or renal impairment required an
  average of 3.2 BP medications to reach lower BP goals

 AASK (MAP <92)


  HOT (DBP <80)


MDRD (MAP <92)


 ABCD (DBP <75)


UKPDS (DBP <85)


                  0   0.5   1   1.5   2    2.5   3
                                                 3   3.5     4
                                # of BP meds
                                                     Bakris 2000
 XII. Treatment of Hypertension in association
 with Diabetes Mellitus: Summary
 Threshold equal or over                                               A combination of 2 first
 130/80 mm Hg and TARGET                 ACE Inhibitor                 line drugs may be
 below 130/80 mm Hg                      or ARB                        considered as initial
                                                                       therapy if the blood
                                                                       pressure is >20 mm Hg
                   with                     1. ACEInhibitor            systolic or >10 mm Hg
                   Nephropathy                or ARB                   diastolic above target
                                            or
  Diabetes
                                            2. Thiazide
                   without                                                > 2-drug
                                              diuretic or                  combinations
                   Nephropathy
                                              DHP-CCB

  More than 3 drugs may be needed to reach target values for diabetic patients
  If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop
  diuretic should be substituted for a thiazide diuretic if control of volume is desired
Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB
Combinations of an ACEI with an ARB are specifically not recommended in the absence of proteinuria
Self-management of blood pressure

Patient education should include
• Monitor blood pressure using
  – CHS approved home devices
  – Pharmacy devices
• Record results
• Report results
• Ask for blood pressure assessment at every
  visit to a healthcare professional
                                               38
References
•   Abatetusso C, Lupo A, Ortalda V et al. treating elderly people with diabetes and stages 3 and 4 kidney
    disease. Am Soc Nephro 2008;3:1185-94
•   Adler AI, Stratton IM, Neil HA, et al. Association of systolic blood pressure with macrovascular and
    microvascular complications of type 2 diabetes (UKPDS 36): prospective observational study. BMJ
    2000;321:412-419.
•   American Diabetes Association. Clinical practice Guidelines 2010. Diabetes care 2010; 33(Suppl 1):S29.
•   Appel LJ, Moore TJ, Obarzanek E et al. A clinical trial of the effects of dietary patterns on blood pressure. N
    Engl J Med 1997;336:1117-1124.
•   Bakris G, et al. Preserving renal function in adults with hypertension and diabetes: a consensus approach.
    National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group. Am J
    Kidney Dis 2000;36(3):646-61
•   Blood Pressure Lowering Treatment Trialists’ Collaboration. Effects of different blood pressure-lowering
    regimens on major cardiovascular events in individuals with and without diabetes mellitus. Arch Intern
    med 2005;165:1410-1419
•   Brown, V., Bartholomew, L., & Naik, A. Management of chronic hypertension in older men: An exploration
    of patient goal-setting. Patient Education and Counseling. 2007; 70:93-99. doi:10.1016/j.pec.2007.07.006
•   Campbell NRC, Leiter LA, Larochelle P, et al. hypertension in diabetes: A call to action. Can J Cardiol.
    2009;25(5):299-302
•   Canadian Diabetes Association Clinical practice Guidelines Expert Committee. Canadian Diabetes
    Association Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J
    Diab. 2008;32(suppl 1):S115-118
                                                                                                                 39
References cont’d
•   American Heart Association. (2010). Smoking cessation.Why quit? AHA Scientific Position. available from
    http://www.americanheart.org/presenter.jhtml?identifier=4731
•   Canadian Diabetes Association. Reducing salt intake. Available from
    http://www.diabetes.ca/documents/about-diabetes/Healthy_Eating_-_Reducing_salt_intake.pdf
•   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;287:2542-
    2551.
•   CHEP 2010 Canadian Hypertension Education Program recommendations: The Short Clinical Summary –
    An Annual Update. Available from http://www.hypertension.ca/chep
•   CHEP 2009 Canadian Hypertension Education Program recommendations: The Short Scientific Summary –
    An Annual Update. Available from http://www.hypertension.ca/chep
•   Gaede P*, Vedel P, Larsen N, Jensen GV, Parving HH, Pedersen O. Multifactorial intervention and
    cardiovascular disease in patients with type 2 diabetes. PMID: 12556541 [PubMed - indexed for MEDLINE]
•   Gaede P, Lund-Andersen H, Parving HH, Pedersen O. Steno Diabetes Center, Copenhagen, Denmark.
•   PMID: 18256393 [PubMed - indexed for MEDLINE]
•   Garriguet D. Sodium consumption at all ages. Statistics Canada catalogue 82-003. Health Reports
    2007;18(2).
•   Hansson L, Zanchetti A Carruthers SG, et al. for the HOT study group. Effects of intensive blood pressure
    lowering and low dose aspirin in patients with hypertension: principle results of the Hypertension Optimal
    treatment (HOT) randomized trial. Lancet 1998;13(352):1755-62.

                                                                                                            40
References cont’d
•   He FJ, MacGregor GA. How far shold salt intake be reduced? Hypertension 2003;42:1093-1099.
•   Health Canada. Food and Nutrition. The Issue of sodium. Available from, http://www.hc-sc.gc.ca/fn-
    an/nutrition/sodium/index-eng.php
•   Health Canada. Canadian Guidelines for Body Weight classification in Adults. Ottawa, ON: Health Canada;2003.Publication
    H49-179/2003E
•   Heart Outcomes prevention Evaluation (HOPE) Study Investigators. 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.
•   International Diabetes Federation. The IDF consensus worldwide definition of the metabolic syndrome.
    Brussels:IDF communications; 2006. Available at:
    http://www.idf.org/webdata/docs/IDF_Meta_def_final.pdf
•   Joffres MR, Ghadirian P, Fodor JG et al, Awareness, treatment and control of hypertension in Canada. Am J
    Hypertension 1997;10:1097-1102.
•   Leenen FH, Dumais J, McInnis NH et al. Results of the Ontario survey on the prevalence and control of
    hypertension. CMAJ 2008;178:1441-1449.
•   MayoClinic.com. Does drinking alcohol affect your blood pressure? Available from:
    http://www.mayoclinic.com/health/blood-pressure/AN00318
•   McCrate F, Godwin M, Murphy L. Attainment of Canadian Diabetes Association recommended targets in
    patients with type 2 diabetes. Can Family Physician. 2010;56: January


                                                                                                                              41
References cont’d
•   Sowers JR, Epstein M, Frohlich ED. Diabetes, hypertension, and cardiovascular disease: an update.
    Hypertension. 2001;37:1053-10594.
•   The Trials of Hypertension Prevention Collaborative Research Group. Effects of weight loss and sodium
    reduction intervention on blood pressure and hypertension incidence in overweight people with high-
    normal blood pressure. The Trials of Hypertension Phase II. Arch Intern Med 1997;157:657-667.
•   Tuomilehto, J, Rastenyte D, Birkenhager WH e al. Effects of calcium channel blockade in older patients with
    diabetes and systolic hypertension. Systolic Hypertension in Europe Trial Investigators. N Eng J Med
    1999;340:677-684.
•   UKPDS study group. Tight blood pressure control and risk of macrovascular and microvascular
    complications in type 2 diabetes and UKPDS 38. BMJ 1998;317:703-713.
•   UKPDS Study group. Effect of intensive blood-glucose control with metformin on complications in
    overweight patients with type 2 diabetes (UKPDS 34). Lancet 352; 854-865.
•   Vasan RS, Beiser A Seshadri S, et al. Residual lifetime risk for developing hypertension in middle aged men
    and women: The Framingham Heart Study. JAMA 2002;287(8) 1003-10.
•   Whelton PK, Barzilay J, Cushman WC 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 Me.d 2005;165:1401-1409.
•   Wiklund I, Halling K, Ryden-Bergsten T, et al. Does lowering blood pressure improve the mood? Quality of
    life results from the hypertension optimal treatment (HOT) study. Blood Pressure. 1997;6:357-64.


                                                                                                             42

				
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