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Jab Mein Thaa , Tab Guru Nahin ‚ Aub Guru Hai , Mein Nahin Sab Andhiyara Mit Gaya‚

Jab Mein Thaa , Tab Guru Nahin ‚ Aub Guru Hai , Mein Nahin Sab Andhiyara Mit Gaya‚ Jab Deepak Dekhya Mahin

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Jab Mein Thaa , Tab Guru Nahin ‚ Aub Guru Hai , Mein Nahin Sab Andhiyara Mit Gaya‚

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  1. Jab Mein Thaa, Tab Guru Nahin‚ Aub Guru Hai, Mein NahinSabAndhiyaraMit Gaya‚ Jab Deepak DekhyaMahin When "I“, the Ego, was with me, then I couldn’t realize the almighty within; Now, the Almighty "is" ever with me and there is no place for this Ego. All the darkness (illusion) within me is mitigated, on realizing the light (illumination) within. SK

  2. Diabetic Hypertension Dr. R.V.S.N. Sarma., M.D., M.Sc., (Canada)

  3. The Two Terrorists

  4. The ENORMITY of the problem - compounded

  5. How Common is this Duo? HTN is twice as common in DM New onset DM is 2.5 times in HTN 20 to 40% of IGT pts have HTN 40 to 50% of Type 2 DM have HTN Only 1/4 of HTN in DM is controlled DM + HTN –  CV Risk 3 fold

  6. What Causes HTN in DM • Metabolic Syndrome – Mainly IR, ED,  BG • Excessive RAAS activity is the main mechanism • HTN due to nephropathy in T2DM – GS - KWL • Renal scarring - Recurrent pyelonephritis • Endocrine causes for both HTN & DM • Cushing’s, Conn’s, Pheochromo, Acromegaly • Coincidental – DM on existing HTN • Diabetogenic antihypertensive drugs (D and B) • Drugs causing both HTN & DM – OCP, CS

  7. Each Perpetuates the Other

  8. Relative Risk of DM + HTN Diabetes + HTN versus Diabetes • Neuropathy 1.6 • Nephropathy 2.0 • Retinopathy 2.0 • Stroke 4.0 • CHD 3.0 • Mortality 2.0

  9. Difficulties of HTN in DM • Systolic HTN more common in DM • S-HTN is a stronger predictor of CVE • 65% of T2DM have S-HTN • S-HTN is more difficult to control • Depression is more in DM – Adherence Rx • ‘Clinician Inertia’ is a big problem • Glycemic control only is the focus – No VP

  10. The Compound Jeopardy !! Insulin Resistance Diabetes Obesity MS with HT associated 2 x 4 x CAD, CKD, PAD, CVD – All same Reilly MP et al – Circulation 2003; 108: 1546-1551

  11. The DASAVATARAM andTHE viswa roopam

  12. IR,  Insulin Dyslipidemia IGT, IFG Increased CV Risk ED, Vessel Hypertension Pro Thrombotic Visceral obesity Pro Inflammatory

  13. Perpetuating Circus Diabetes BP CKD ED  Lipids CAD

  14. The Devastating Conspiracy

  15. RF for Nephropathy in DM

  16. Progression of DM - Nephropathy

  17. Nephropathy in DM Years after onset of DM

  18. Outcomes of DM Nephropathy Diabetic Nephropathy

  19. The EVIDENCE BASEDM + HT is dangerous

  20. Top 3 Countries for Diabetes Data from King H et al. Diabetes Care. 1998;21:1414-1431.

  21. CV Mortality Risk Doubles withEach 20/10 mm Hg BP Increment CV Mortality Risk 8 7 6 5 4 3 2 1 0 115/75 135/85 155/95 175/105 SBP/DBP (mm Hg) Lewington S, et al. Lancet. 2002; 60:1903-1913.JNC VII. JAMA. 2003.

  22. SBP & CV Mortality in T2DM 250 Nondiabetic Diabetic CV Mortality rate per 10,000 person-yr 200 150 100 50 0 <120 120-139 140-159 160-179 180-199 ≥200 SBP (mm Hg) Stamler J et al. Diabetes Care. 1993;16:434-444.

  23. 45 40 Men (n=4265) Women (n=4559) 35 30 25 20 15 10 5 0 20-29 30-39 40-49 50-59 60-69 70 ? Metabolic Syndrome and Age 33% of Indian Adults Have Metabolic Syndrome Prevalence, % Age in yr Adapted from: Ford ES, et al. JAMA. 2002;287:356-359.

  24. 25 DM 20 non-DM 15 Events/1000pt-years 10 5 0 <90 <85 <80 Target diastolic BP HOT Study – Imp. of DBP Lancet 1998; 351: 1755–62

  25. SHEP – DM and CVE Rates 35 Active treatment RR .66, 95% Cl .46 - .94 Placebo 30 25 20 5-Year Cumulative Event Rates for All Major Cardiovascular Events (%) RR .66, 95% Cl .55 - .79 15 10 5 0 Nondiabetes Diabetes Curb JD, et al. JAMA. 1996;276:1886-1892.

  26. Mortality and Morbidity in DM SHEP SYST-EUR SYST-EUR SHEP -25 Rate in Placebo Group* Mortality 45.1 35.6 -55 -34 CV Endpoints 63.0 57.6 -22 -59 26.6 Stroke 28.8 -56 -73 21.3 32.2 Coronary -57 Placebo Better Active Better 50% -100% 0 -50% *Number of endpoints / 1000 patient years

  27. HOT – Diabetic Hypertension 90 mmHg Myocardial Infarction 80 mmHg Major CV Events Stroke CV Mortality Total Mortality | | | | 0 1 2 3 4 Lancet 1998; 351: 1755–62

  28. BP v/s Glucose Control Microvascular Any DM Stroke DM Death Complications End Point 0 - -10 - -20 - Reduction in Risk (%) -30 - Tight Glucose Control -40 - Tight BP Control *P < 0.05 -50 - UKPDS. BMJ. 1998:317;703-712.

  29. Hypertension & DM Mortality Captopril (UKPDS) Atenolol (UKPDS) Diuretic (SHEP) Nitrendipine (Syst-Eur) Nitrendipine (Syst-China) 0% 20% 40% 60% 80% 100%

  30. STENO-2 Study in DM – Event  • Nephropathy  56% • Proliferative retinopathy  55% • Cardiovascular events  59% • Total Mortality  40% %  in Complications with intensive Rx NEJM 2003; 358:580

  31. SOLVD: Enalapril – Reductionin New-Onset Diabetes Absolute risk reduction in development of diabetes No. of New Diabetes Cases P <.0001 Vermes E et al. Circulation. 2003;107:1291-1296.

  32. SOLVD: Enalapril – Reductionin New-Onset Diabetes in IFG Patients With IFG at Baseline (n = 55) 100 Enalapril % Diabetes-Free 45% risk reduction P < 0.0001 75 50 Placebo 25 0 1 2 3 4 5 Time (y) Vermes E et al. Circulation. 2003;107:1291-1296.

  33. LIFE Study: Results P <.05 25% decrease in RR P <.001 Dahlöf B et al. Lancet. 2002;359:995-1003.

  34. ALLHAT: Incidence of New-Onset Diabetes at 4 Years P .001 P = .04 11.6% 9.8% 8.1% % Chlorthalidone Amlodipine Lisinopril ALLHAT Officers and Coordinators. JAMA. 2002;288:2981-2997.

  35. The EVIDENCE BASEMANAGEMENT Guide

  36. Risk Reduction for CAD and CKD Management of Components Dysglycemia Hypertension Dyslipidemia

  37. Risk Reduction for CAD and CKD Management of Components CHO GL Na & K SFA UFA S S O

  38. Mandatory Clinical Actions

  39. HTN – Lifestyle modifications • Regular 30’ of moderately intense exercise • No tobacco and minimizing alcohol • Na restriction to < 6 g of Nacl per day • Avoiding high salt foods – pickles, savouries • Four adult family – 6 x 30 x 4 = 720 g (500 g) • Use of K containing foods – fruits, vegetables • Weight reduction – goal ideal weight • Reducing coffee consumption

  40. HTN – Lifestyle modifications

  41. DASH Diet Plan

  42. Benefit of Quitting Smoking in HTN  CAD incidence (%) over 5 years

  43. BP Targets in DM Ideal Blood Pressure Without proteinuria < 130/80 With proteinuria < 125/75 Goal BP maximum for DM < 130/80 Almost all DM pts require > 1 drug for HTN Identify the co-morbidity – CAD, CKD, CVD

  44. ADA Guidelines on Rx. of HTN with DM Systolic Diastolic Goal (mmHg) <130 <80 Behavioral therapy alone 130–139 80–89 (maximum 3 months) TLC Behavioral therapy + 140 90 pharmacologic treatment Arauz-Pacheco C et al. Diabetes Care. 2003;26(suppl):S80–S82.

  45. The EVIDENCE BASE FORMANAGEMENT OPTIONS

  46. Management Options NDHP - CCBs Diuretics MNT ACEi, ARB Exercise New BB

  47. Choice of Drug Rx for HTN Younger than 55 years Older than 55 years 1 ACEi or ARB (A) Diuretic (D) or CCB (C) 2 A + D or C 3 A + D + C 4 A + D + C + new  or  blocker

  48. Goal BP 130/80 HTN Rx. Algorithm in DM BP > 130/80 (2 readings) >140/90/MAU/TOD No TOD / MAU ACE/ARB + TLC 1 M TLC cont. Yes No Yes Add LD Diuretic 1 Month No Yes Add Verapamil 1 Month No Yes Sub Amlodepine 1 Month No Yes Add new B / 1 Month No ? Diabetes Spectrum 2004, Vol. 5, # 3, 103-108

  49. Physiological RAAS Effects

  50. Renin Angiotensin Aldosterone System

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