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Blood Pressure and Diabetes

Blood Pressure and Diabetes. Colin M. Dayan University of Bristol/UBHT. Causes of Death in People With Diabetes. Percent of deaths. All other. Diabetes. Malignant neoplasms. Other heart disease. Pneumonia/ influenza. Cerebrovascular disease. Ischemic heart disease.

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Blood Pressure and Diabetes

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  1. Blood Pressure and Diabetes Colin M. Dayan University of Bristol/UBHT

  2. Causes of Death in People With Diabetes Percent of deaths All other Diabetes Malignant neoplasms Other heart disease Pneumonia/ influenza Cerebrovascular disease Ischemic heart disease Geiss LS, et al. In: Diabetes in America. National Institutes of Health;1995. www.hypertensiononline.org

  3. risk reduction24% p=0.0046 Any diabetes-related endpoints

  4. 0 -10 -20 -30 -40 -50 Benefits of Tight BP and Tight Glucose Control UKPDS Microvascular endpoints Diabetes-related deaths Any diabetes- related endpoint Stroke † Risk reduction (%) * † * * 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 HbA1c 7.0%) vs. less intensive control (achieved HbA1c 7.9%). UKPDS Group. BMJ. 1998;317:703-713. UKPDS Group. Lancet. 1998;352:837-853.

  5. Case 1 • 61 yr old man • Type 2 diabetes diagnosed last year • Albumin/creatinine ratio = 13.5 • Creatinine = 103 • BP = 155/90 • Cholesterol = 5.5 • HbA1c = 7.2% on Metformin

  6. European Guidelines on hypertension in T2DM 2002 • Review BP if single reading >140/85 (130/75 if microalb) • Consider HBPM or ABPM (cut-off ?130/75) 12-20/8-12mmHg less. • Address all CV risk factors - statin, ASA • NB Statins also reduce microalb excretion • Target 140/85 • Drugs

  7. European Guidelines on hypertension in T2DM 2002 - Drugs • Nephropathy - ACE, A2RA, CCBs, indapamide • Hyperkalaemia - Loop diuretics or thiazides • Angina - Beta block or CCB • MI or LV dsyfunction - beta block and ACE • ISH - thiazides and CCBs • Not alpha blockers as first line • Use once daily dosing to aid compliance

  8. HbA1c cross-sectional, median values

  9. Blood Pressure : Tight vs Less Tight Control cohort, median values Less tight control Tight control

  10. Bristol Integrated Care Pathway • 140/80 • In the presence of nephropathy: 135/75 or lower.

  11. Bristol Integrated Care Pathway • Step 1 Lifestyle • Step 2 ACE (or A2RA if cough) • Step 3 Diuretic (BFZ, Frusemide) • Step 4 beta blocker

  12. PANDIPP

  13. Case 2 • 69 yr old woman with Type 2 diabetes diagnosed 7 years ago • BMI = 33 • Proteinuria ++ on 3 occasions • BP = 160/95 • Creatinine = 135 • K+ = 5.9 • HbA1c = 9.0% on Glibenclamide and Metformin

  14. Case 3 • 28 yr old woman with Type 1 diabetes since age 12 • Retinopathy - laser 2 years ago • BP = 144/88 • Alb/creat = 5.4 • HbA1c = 10.1% • Cholesterol = 5.3

  15. Microalbuminuria can disappear in 58% of cases Perkins, B. A. et al. N Engl J Med 2003;348:2285-2293

  16. Case 4 • 74 yr old man with T2DM diagnosed 4 years ago • BP = 140/80 • Proteinuria + on 2 occasions • Cholesterol = 4.9 • HbA1c = 7.3%

  17. The British Hypertension Society recommendations for combining Blood Pressure Lowering drugs Younger (e.g.<55yr)and Non-Black Older (e.g.55yr) or Black Step 1 C or D A or B Step 2 A (or B) + C or D Step 3 A + C + D Step 4Resistant Hypertension Add: either -blocker or spironolactone or other diuretic A: ACE Inhibitor or angiotensin receptor blocker B: b - blockerC: Calcium Channel Blocker D: Diuretic (thiazide) Adapted from : ‘Better blood pressure control: how to combine drugs’Journal of Human Hypertension (2003) 17, 81-86

  18. Treating Hypertension in Nephropathy Lewis et al 2001

  19. Is home blood pressure monitoring useful?

  20. Home BP vs clinic BP

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