Early, Optimal Blood Pressure Control for High-risk Patients

Early, Optimal Blood Pressure Control for High-risk Patients

Nilsson Peter M
European Cardiovascular Disease 2006
Published: May 2006
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Some cardiovascular (CV) risk-prone patients are easy to recognise, for example following manifestations of cardiovascular disease (CVD), coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) interventions, and they deserve appropriate risk-factor control for secondary prevention, including blood pressure (BP) lowering. However, many other at-risk patients without prior CVD manifestation are currently undertreated. One group in particular is the large group of patients with abnormalities in glucose metabolism or overt type 2 diabetes. For these patients the benefits of tight BP control, in addition to lipid lowering, smoking cessation and control of hyperglycaemia, have repeatedly been documented. Another risk group is the stroke-prone elderly patient, risking disability and impaired quality of life following stroke, a condition that is often preventable by appropriate BP control. This short review will focus on BP control in these two high-risk groups.

Hypertension Management in Diabetes
Hypertension in diabetes is one of the most widespread, substantial and treatable CV risk factors of importance in clinical practice. As the number of diabetes patients increases on a global scale, so too does the number of patients with concomitant hypertension. Data from randomised trials have increasingly shown the benefits of tight BP control in patients with type 2 diabetes. New international and national guidelines and recommendations have emphasised the screening, evaluation and vigorous treatment of elevated BP if combined with diabetes, especially systolic blood pressure and pulse pressure. Epidemiological data indicate some improving trends in BP control reflecting increased awareness and more appropriate treatment over time, as shown by recent data from the National Diabetes Register (NDR) in Sweden. In reports from the NDR during the last few years, it has been shown that the trend for better BP control is, in fact, improving. In a recent publication it was also shown that markers of insulin resistance (obesity, hyperglycaemia) and lack of microalbuminuria are independent (inverse) predictors of successful longterm BP control in patients with diabetes, implying the need for lifestyle measures and glycaemic control. Long-term successful BP control was also associated with low predicted risks of coronary heart disease (CHD) and stroke at follow-up. Similar quality assessment projects could be applied to other high-risk groups.

Randomised Clinical Trials Including Hypertensive Patients with Diabetes

Several intervention trials have formed the evidence base for treatment of hypertension in diabetes. In the Systolic Hypertension in the Elderly Program (SHEP), low-dose, diuretic-based treatment (chlorthalidone 12.5-25mg with a step up to atenolol 25-50mg or reserpine 0.05-0.1mg daily if needed) was found to be effective compared with placebo in preventing CV complications in elderly patients with type 2 diabetes mellitus (n=583) and isolated systolic hypertension. Similarly, the Systolic Hypertension in Europe (Syst-Eur) trial compared calciumantagonist- based treatment (nitrendipine) with placebo in elderly patients with isolated systolic hypertension and in a rather large subgroup with type 2 diabetes (n=492). In Syst-Eur, treatment for five years prevented 178 major CV events in every 1000 diabetic patients treated, i.e. approximately six patients had to be treated for five years to prevent one major CV event.

The Hypertension Optimal Treatment (HOT) study investigated the intensity of antihypertensive treatment using a calcium antagonist (felodipine) as baseline therapy in hypertensive patients averaging 61.5 years of age and 170/105mmHg in baseline BP, of whom 1,501 also had type 2 diabetes. In HOT the incidence of major CV events was lowered from 24.4 to 18.6 and 11.9 events per 100 patient-years, respectively, in the randomised tertiles of diabetes patients who had achieved 84, 82 and 81mmHg, respectively, in diastolic BP. Approximately 20 patients needed to be treated for five years to prevent one major CV event when BP was further lowered from 84 to 81mmHg in these patients. Tight BP control to prevent macro- and microvascular complications was also successful after more than eight years of follow-up of 1,148 hypertensive patients in the United Kingdom Prospective Diabetes Study (UKPDS), especially for prevention of stroke and retinopathy. No significant difference was found between captopril and atenolol, but patients on atenolol needed significantly more oral anti-glycaemic drugs due to weight increase.

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