Hypertension in Patients with Diabetes

Dr. Page is an associate professor of clinical pharmacy and physicalmedicine and a clinical specialist, Division of Cardiology, University ofColorado Health Sciences Center, Schools of Pharmacy and Medicine.

Morning Hypertension and Diabetes: Powerful Predictor for Future Complications

Hypertension frequently coexistswith many cardiovascular disease(CVD) risk factors. In fact,the rate of risk factor clustering isabout 4 times that which would occurby chance alone.¹ In a Canadian studyof hypertensive patients aged 35 yearsor older who were free from clinical evidenceof CVD, 56% were obese with abody mass index of 30 mg/m² or higheror had diabetes or hyperlipidemia.²With their knowledge base and training,pharmacists are very familiar withthe closely related combinations of riskfactors such as hypertension, hyperlipidemia,diabetes, and obesity, whichdefine the metabolic syndrome.

Research suggests that a strong associationbetween hypertension and diabetesexists in which at least 15% ofhypertensive patients have concomitantdiabetes.² Furthermore, patients withhypertension appear to develop diabetesmore frequently than nonhypertensives,independent of any specific treatment.Hypertension occurs approximately twiceas frequently in individuals with diabetesas those without, in which the prevalencehas been estimated to be as high as 70%to 80% in patients with type 2 diabetes.^3,4Nonetheless, a concomitant diagnosis ofhypertension in a patient with diabetescan substantially increase the risk for thedevelopment of both microvascular (eg,neuropathy, nephropathy, and retinopathy)and macrovascular (eg, heart disease,stroke and peripheral vascular disease,and diabetic foot infections) complications.

Impact of Morning Hypertension

When evaluating the specific type ofhypertension and its impact on healthoutcomes, data have suggested a possiblelink between morning hypertension(MH) and an increased risk for complicationsin patients with diabetes. In a studyof 170 patients with both type 2 diabetesand hypertension, Kamoi and colleaguesfound that, compared with those withoutMH, those with MH demonstrated a 4 to 6times higher risk for nephropathy demonstratedas microalbuminuria and clinicalalbuminuria, retinopathy, coronary heartdisease, and CVD (P <.01).⁵ The prevalenceof nephropathy in all study participantswas highly associated with systolic MH(P <.001). In patients with type 1 diabetes,the investigators found similar findings.⁶Based on an evaluation of 53 patients,Kamoi and colleagues demonstrated thatthose with MH had a significantly higherrisk for nephropathy with microalbuminuriaand/or clinical albuminuria as well asretinopathy (P <.01), compared with thosepatients without MH.

Optimal Blood Pressure Control Is Necessary

Finally, large hypertension trials have suggestedthat blood pressure (BP) control isoften suboptimal in diabetic hypertensivepatients.^7-10 The results of the NationalHealth and Nutrition Examination Survey2003?2004 found BP control (<130/80mm Hg) was achieved in only 33.2% oftreated hypertensive diabetic individuals,a percentage substantially lower than theBP control rate for all treated hypertensiveindividuals.¹¹

Based on these findings, it appears thatpatients with diabetes and hypertension,particularly with MH, should be especiallytargeted for more intensive managementof their hypertension. One particular strategythat may benefit this patient populationis home BP monitoring, which couldnot only enhance medication adherencebut assist with classifying hypertensivestatus and better explain the risk for diabeticcomplications.

References

• Schmieder RE, Ruilope LM. Blood pressure control in patients with comorbidities. J Clin Hypertens (Greenwich). 2008;10:624-631.
• Weycker D, Nichols GA, O'Keeffe-Rosetti M, et al. Risk-factor clustering and cardiovascular disease risk in hypertensive patients. Am J Hypertens. 2007;20:599-607.
• Sowers JR, Epstein M, Frohlich ED. Diabetes, hypertension, and cardiovascular disease: an update. Hypertens. 2001;37:1053-1059.
• Mancia G, De Backer G, Dominiczak A, Cifkova R, Fagard R, Germano G. 2007 Guidelines for the management of arterial hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2007;28:1462-1536.
• Kamoi K, Miyakoshi M, Soda S, Kaneko S, Nakagawa O. Usefulness of home blood pressure measurement in the morning in type 2 diabetic patients. Diabetes Care. 2002;25:2218-23.
• Kamoi K, Imamura Y, Miyakoshi M, Kobayashi C. Usefulness of home blood pressure measurement in the morning in type 1 diabetic patients. Diabetes Care. 2003;26:2473-2475.
• Bakris GL, Gaxiola E, Messerli FH, et al. Clinical outcomes in the diabetes cohort of the INternational VErapamil SR-Trandolapril study. Hypertens. 2004;44:637-642.
• Andersen NH, Poulsen PL, Knudsen ST, et al. Long-term dual blockade with candesartan and lisinopril in hypertensive patients with diabetes: the CALM II study. Diabetes Care. 2005;28:273-277.
• Dahlof B, Sever PS, Poulter NR, et al. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomized controlled trial. Lancet. 2005;366:895-906.
• Maahs DM, Kinney GL, Wadwa P, et al. Hypertension prevalence, awareness, treatment, and control in an adult type 1 diabetes population and a comparable general population. Diabetes Care. 2005;28:301-306.
• Nelson RG, Knowler WC, Pettit DJ, et al. Kidney diseases in diabetes. In: Diabetes in America. Bethesda, MD: National Institutes of Health Publication; 1995.

Women with Diabetes and Hypertension: True "Femmes Fatales"

The worldwide incidence of type 2diabetes continues to increase atan alarming rate with similar findingsreported for blood pressure (BP)and hypertension.^1-3 As part of the metabolicsyndrome, the marriage betweenhypertension and diabetes is a close butcomplex relationship.³ One study in menfound that the risk of developing type 2diabetes rises with the increasing numberof metabolic abnormalities but thatBP per se was not independently associatedwith new-onset diabetes.⁴

This may not be true, however,for women. Data from the Women?sHealth Study suggest that, comparedwith women with optimal BP, thosewith hypertension exhibited a 2.39-foldincreased risk for developing type 2 diabetesindependent of both body massindex and other components of the metabolicsyndrome (P <.0001).⁵

Cardiovascular Disease and Diabetes

Over the last quarter of a century, mortalityassociated with cardiovascular disease(CVD) in the United States has declinedamong men with and without diabetes.⁶For women, however, this decrease hasbeen demonstrated only in those withoutdiabetes.⁷ Furthermore, the relativerisk for fatal diabetes-associated coronaryheart disease is 50% higher in women,compared with men.⁸

These sex-related disparities in CVDmortality may be linked with control ofmodifiable risk factors. Data from theTRIAD (Translating Research Into Actionfor Diabetes) Study found that womenwith type 2 diabetes and CVD were morelikely to have systolic blood pressures(SBP) exceeding 140 mm Hg and lowdensitylipoprotein (LDL) concentrations>130 mg/dL, compared with men.⁹ In across-sectional analysis of 44,893 patientswith type 2 diabetes, Gouni-Berthold andcolleagues found that women with establishedCVD were significantly more likelythan men to have SBP, LDL level, andhemoglobin A1C exceeding 140 mm Hg(P <.0001), 130 mg/dL (P <.0001), and 8%(P = .0009), respectively.¹⁰

Blood Pressure Control Is Vital

Based on these findings, it appears thatthe presence of diabetes negates theprotective effect of female gender on therisk of CVD. In order to improve the genderdisparity in CVD-associated mortality,more aggressive management of CVD inwomen with diabetes will be necessary.One particular modifiable risk factor worthtargeting is tighter BP control in womenwith hypertension. With the advent ofaffordable and accurate home BP monitoringdevices, women with both diabetesand hypertension can more closely monitortheir BP with greater accuracy andconvenience.

Through the use of such technology,patients can take a more active role intheir health care, thus increasing theirchances for adherence to their antihypertensivemedications and improved CVDoutcomes. Because these devices aretypically sold in community pharmacies,pharmacists are in a unique position torecommend an appropriate device and toeducate patients on its proper use.

References

• Zimmet P, Alberti KG, Shaw J. Global and societal implications of the diabetes epidemic. Nature. 2001;414:782-787.
• Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJ. Selected major risk factors and global and regional burden of disease. Lancet. 2002;360:1347-1360.
• Danaei G, Lawes CM, Vander Hoorn S, Murray CJ, Ezzati M. Global and regional mortality from ischaemic heart disease and stroke attributable to higher-than-optimum blood glucose concentration: comparative risk assessment. Lancet. 2006;368:1651-1659.
• Sattar N, Gaw A, Scherbakova O, et al. Metabolic syndrome with and without C-reactive protein as a predictor of coronary heart disease and diabetes in the West of Scotland Coronary Prevention Study. Circulation. 2003;108:414-419.
• Conen D, Ridker PM, Mora S, Buring JE, Glynn RJ. Blood pressure and risk of developing type 2 diabetes mellitus: the Women's Health Study. Eur Heart J. 2007;28:2937-2943.
• Gu K, Cowie CC, Harris MI. Diabetes and decline in heart disease mortality in US adults. JAMA. 1999;281:1291-1297.
• Gregg EW, Gu Q, Cheng YJ, Narayan KM, Cowie CC. Mortality trends in men and women with diabetes, 1971 to 2000. Ann Intern Med. 2007;147:149-155.
• Huxley R, Barzi F, Woodward M. Excess risk of fatal coronary heart disease associated with diabetes in men and women: meta-analysis of 37 prospective cohort studies. BMJ. 2006;332:73-78.
• Ferrara A, Mangione CM, Kim C, et al. Sex disparities in control and treatment of modifiable cardiovascular disease risk factors among patients with diabetes: Translating Research Into Action for Diabetes (TRIAD) Study. Diabetes Care. 2008;31:69-74.
• Gouni-Berthold I, Berthold HK, Mantzoros CS, B?hm M, Krone W. Sex disparities in the treatment and control of cardiovascular risk factors in type 2 diabetes. Diabetes Care. 2008;31:1389-1391.

This communication on the importance of home blood pressure monitoring is supported by OmronHealthcare, Inc. It is intended to help pharmacists and their staff understand the importance of homeblood pressure monitoring.