New Guidelines Address 7-Fold Increase in Mortality for Hypertensives With Diabetes

Physicians need to aggressively treat high blood pressure as soon as it develops in patients with diabetes if they are to effectively lower the 7-fold higher mortality rate observed in patients with both conditions.

"Physicians are not being as aggressive as they need to be to get blood pressure controlled in the very early stages of the disease process," Dr. George Bakris told the audience. Dr. Bakris, from the University of Chicago School of Medicine, is president-elect of the American Society of Hypertension.
"We have proven antihypertensive therapies that work to reduce complications if patients take them," he added. "But the take-home message – and this is very important – is that good blood pressure control must be continued if the benefits are to be maintained."

Dr. Bakris noted that no one drug appears to be better at reducing complications, and that, on average, diabetic patients will need three antihypertensive medications at high doses to achieve a goal blood pressure of < 130/80 mm Hg.

"We know that mortality increases by more than 7-fold when hypertension is present in patients with diabetes," said George Bakris, MD, president-elect of the American Society of Hypertension, co-author of the Position Paper and professor, University of Chicago School of Medicine. "Because of their increased cardiovascular risk, these patients require an integrated therapeutic intervention that, in addition to blood pressure control, should include glycemic and lipid control and antiplatelet therapy. It is imperative that we attack all risk factors simultaneously and manage the profile of each patient type more vigilantly."
"However, if you are obese and if you lose weight successfully, especially if your BMI is over 30, then you can definitely reduce your antihypertensive pill burden," he continued.

He noted that among people who now have diabetes and have developed kidney disease, blood pressure control has been achieved in only 20%. "If we doubled that, there would be a huge reduction nationwide in the risk of progression to dialysis – which is eating up the Medicare budget — and in the risk of cardiovascular events."

"It’s the physician’s role to educate and empower the patient. We are in the business of buying time by reducing their risk. We’re not curing or preventing anything, but we are changing the natural history of the disease," the physician said. "But it is the patient’s responsibility to take control."

Updated guidelines from the American Society of Hypertension, with an algorithm for treating hypertension in diabetes, are published in the Journal of Clinical Hypertension for October. It is recommended that initial treatment include an ACE inhibitor or an angiotensin receptor blocker coupled with either a thiazide-like diuretic or a calcium channel blocker if systolic blood pressure is more than 19 mm Hg above goal.

More than 75% of adults with diabetes have hypertension or are using antihypertensive medications. If implemented, this new guidance will potentially lead to better control of blood pressure, blood sugar and blood fats, all major risk factors for cardiovascular events if they are not properly managed.

The authors advise physicians to recheck patients 2 to 3 weeks after each medication adjustment, rather than waiting the usual 4 to 8 weeks, and to refer patients to a clinical hypertension specialist if blood pressure is still not at goal after 2 to 3 months.

Updated guidance published in the current issue of the American Society of Hypertension’s (ASH) Journal of Clinical Hypertension.  For more information, please visit https://www.ash-us.org.