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Managing Hypertension and Diabetes in Patients
- 1. Hypertension & Diabetes: A Family-Centered Approach Third-Year Clerkship in Family Medicine Michael Mendoza, MD, MPH Clinical Assistant Professor Department of Family Medicine Pritzker School of Medicine The University of Chicago
- 9. Benefits of Lifestyle Modification *Strength of recommendation=C, good evidence, but not clinical trials documenting morbidity or mortality benefit Associated Reduction in SBP Nonpharmacologic Intervention* 2 to 4 mmHg Limit daily alcohol consumption (<2 for men, <1 for women) 4 to 9 mmHg Exercise 30 minutes aerobic at least four days per week 2 to 8 mmHg Low sodium diet, < 2.4g Na / day 8 to 14 mmHg “ DASH” diet high in fruits, veggies and low in fat 5 to 20 mmHg Weight loss (BMI < 25)
- 12. Classification of Hypertension > 100 or > 160 Hypertension, Stage 2 90 – 99 or 140 – 159 Hypertension, Stage 1 80 – 89 or 120 – 139 Pre-hypertension <80 and <120 Normal DBP (mmHg) SBP (mmHg)
- 16. Choice of Initial Medication Thiazide + ACE or ARB Yes 160/100 Hypertension, Stage 2 Thiazide Monotherapy Yes 140 / 90 Hypertension, Stage 1 None Yes 120 / 80 Pre-hypertension None Encourage <120/80 Normal Initial Medication (no compelling indications) Lifestyle Modification BP (mmHg)
- 17. Compelling Indications + + CCB + + + + Recurrent stroke prevention + + + + + CKD + + + + + + + + + DM + + + High CAD Risk + + ++ + + + + + + + Post-MI + + + + + + + + + + + + CHF Aldo Antagonist ARB ACE-I B-blocker Thiazide
- 24. HOCM
- 25. Hypertension in Children 75 +/- 15 120 +/- 20 >12 yr 68 +/- 15 112 +/- 20 10-12 yr 65 +/- 15 100 +/- 20 6-9 yr 65 +/- 20 99 +/- 20 4-5 yr 64 +/- 25 99 +/- 25 2-3 yr 66 +/- 25 96 +/- 30 1 yr 60 +/- 10 89 +/- 29 6 month 46 +/- 16 80 +/- 16 1 month 37 +/- 8 60 +/- 10 Newborn DBP SBP Age
- 26. Classification of Pediatric HTN SBP or DBP greater than or equal to 95th percentile Hypertension SBP or DBP greater than 99th percentile plus 5 mm Hg Hypertension, Stage 2 SBP or DBP from 95th percentile to 99th percentile plus 5 mm Hg Hypertension, Stage 1 SBP or DBP greater than or equal to 90th percentile but less than 95th percentile. Blood pressure levels greater than or equal to 120/80 mm Hg for adolescents. Pre-hypertension SBP and DBP less than the 90th percentile Normal
- 35. BREAK
- 37. Adults With Diagnosed Diabetes* *Includes women with a history of gestational diabetes. 1990 No data available Less than 4% 4%-6% Above 6% www.hypertensiononline.org Mokdad AH, et al. Diabetes Care. 2000;23(9):1278-1283 .
- 38. Adults With Diagnosed Diabetes* 2000 www.hypertensiononline.org 4%-6% Above 6% *Includes women with a history of gestational diabetes. Mokdad AH, et al. JAMA. 2001;286(10):1195-1200.
- 40. Native Beta Cell Dysfunction
- 44. UKPDS Outcomes by Treatment Group for Patients Randomized to Tight Blood Pressure Control* *The differences between the treatment groups were not statistically significant † For captopril compared to atenolol 1.29 (0.80-2.10) 28 40 Microvascular complications 1.48 (0.35-6.19) 3 5 Peripheral vascular disease 1.12 (0.59-2.12) 17 21 Stroke 1.20 (0.82-1.76) 46 61 Myocardial infarction 1.14 (0.81-1.61) 59 75 All-cause mortality 1.27 (0.82-1.97) 34 48 Diabetes-related death 1.10 (0.86-1.41) Relative Risk † (95% CI) 118 Atenolol (n=358) 141 Captopril (n=400) Any DM-related endpoint
- 55. Goals for Glycemic Control (ADA) <180 Postprandial <8 <7 <6 HbA1c (%) <110 / >180 110 – 150 <120 Bedtime <90 / >150 90 – 130 <110 Preprandial Plasma (venipuncture) <100 / >160 100 – 140 <110 Bedtime <80 / >140 80 – 120 <100 Preprandial Whole blood (“finger stick”) Add’l Action Suggested Goal Normal
- 57. Health Care Maintenance in DM < 130/80 Every visit Blood Pressure Vaccinate very five years Pneumococcal Vaccinate annually Influenza Prevention or identification of neuropathy, infection Baseline then annually Foot Examination Prevention or identification of diabetic retinopathy Baseline, annual if at target glycemic control, quarterly if not Ophthalmologic LDL < 100 (? < 70) Baseline, q3mo until normal, then q6mo Lipids < 6% usually (must tailor to patient) Baseline, q3mo until normal, then q6mo HbA1c Goal Frequency
Editor's Notes
- 50 million – number of votes each received by Gore and Bush in 2000 election, number of people who downloaded Mozilla Firefox
- 5 to 10% of patients in the ambulatory primary care setting A: Accuracy – poor technique, white coat hypertension (20% of elevated results) Apnea - OSA Aldosteronism – primary hyperaldo – Increased urinary excretion of potassium signals hyperaldosteronism, which should be suspected in all hypertensive patients with unprovoked (i.e., not diuretic-induced) hypokalemia. B: Bruits – renovascular HTN (bruit is present in half of patients with this type of HTN) due to fibromuscular dysplasia or atherosclerosis Bad Kidneys – renal parenchymal HTN C: Catecholamines – pheochromocytoma, white coat HTN, decongestants, ma huang Coarctation of the Aorta - congenital narrowing of the aortic lumen, most often occurring just distal to the origin of the left subclavian artery Cushing’s Syndrome D: Drugs – steroids, OCPs, NSAIDs Diet – high sodium intake, low potassium, calcium, and magnesium intake E: Erythropoetin – caused by hypoxia in COPD or iatrogenic Endocrine Disorders – hypo/hyperthyroid, hyperparathyroid, pheo, acromegaly (elevated GH)
- DASH Dietary approaches to stop hypertension High (4-5 servings f/v daily, 7-8 servings fiber daily, 2 servings lean meat), Ca, Mg, K Low in saturated fat, cholesterol, salt
- * vitamin D * combination antioxidant vitamins * vitamin C * vitamin E * potassium * combination of potassium and magnesium * omega-6 fatty acids (olive oil) * dark chocolate * garlic * green coffee bean extract * guava fruit * sour milk (milk fermented with Lactobacillus helveticus, casein hydrosylate) * soy milk (but soy protein supplements had inconsistent results) * Abana * Balsamodendron mukul * grape seed polyphenol (but increased blood pressure when combined with vitamin C) * hawthorn extract * Hibiscus sabdariffa (sour tea) * stevia * L-arginine * coenzyme Q10 * melatonin (but increased blood pressure with concomitant nifedipine)
- Mr. S. returns to your office six weeks later, as you advised, so you can answer any new questions he might have and so you can follow up on his high blood pressure and assess whether he has been able to adhere to your lifestyle modification recommendations. Mr. S. reports that despite his best efforts his diet still consists of doughnuts and beer. His wife is supportive but his kids do nothing to curb his stress. In addition to already being labeled a deadbeat and a slacker, he is worried about being labeled “hypertensive”. How do you want to spend your time during this visit?
- People 130/80 to 139/89 are at twice the risk of progressing to hypertension (Vasan RS, Larson MG, Leip EP, et al. Assessment of frequency of progression to hypertension in nonhypertensive participants in The Framingham Heart Study. Lancet. 2001;358:1682-1686)
- PEDIATRIC HYPERTENSION
- Epidemiology
- People 130/80 to 139/89 are at twice the risk of progressing to hypertension (Vasan RS, Larson MG, Leip EP, et al. Assessment of frequency of progression to hypertension in nonhypertensive participants in The Framingham Heart Study. Lancet. 2001;358:1682-1686)
- PIH
- Adults With Diagnosed Diabetes in 1990 In 1984, The Centers for Disease Control and Prevention (CDC) established the Behavioral Risk Factor Surveillance System (BRFSS), which was designed to collect state-level data, with a number of states from the outset stratifying their samples to allow them to estimate prevalence for regions within their respective states. CDC developed a standard core questionnaire for states to use so that data could be compared across states. The BRFSS is administered and supported by the Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion at the CDC, and is an on-going data collection program in which all states, the District of Columbia, and three territories have been participating since 1994. BRFSS data are collected by telephone surveys and designed to monitor state-level prevalence of the major behavioral risks among adults associated with premature morbidity and mortality. The basic philosophy was to collect data on actual behaviors, rather than on attitudes or knowledge, that would be especially useful for planning, initiating, supporting, and evaluating health promotion and disease prevention programs. To determine diabetes status, respondents were asked, “Have you ever been told by a doctor that you have diabetes?” Classification of diabetes was not assessed. Participants with a BMI 30 were classified as obese. BMI data were derived from self-reported weight and height information. In 1990, there were 81,855 BRFSS participants. Of them, 11.1% were obese. Diabetes prevalence was 4.9%. States with the highest diabetes prevalence were Mississippi (6.9%), Missouri (6.4%), South Carolina (6.3%), and West Virginia (7.5%). States with the lowest prevalence were Colorado (3.1%), Idaho (3.2%), Minnesota (3.2%), Montana (2.8%), and Vermont (3.4%). References: Mokdad AH, Ford ES, Bowman BA, Nelson DE, Engelgau MM, Vinicor F, Marks JS. Diabetes trends in the U.S.: 1990-1998. Diabetes Care. 2000;23(9):1278-1283. Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 1990.
- Adults With Diagnosed Diabetes in 2000 In 1984, The Centers for Disease Control and Prevention (CDC) established the Behavioral Risk Factor Surveillance System (BRFSS), which was designed to collect state-level data, with a number of states from the outset stratifying their samples to allow them to estimate prevalence for regions within their respective states. CDC developed a standard core questionnaire for states to use so that data that could be compared across states. The BRFSS is administered and supported by the Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion at the CDC, and is an on-going data collection program in which all states, the District of Columbia, and three territories have been participating since 1994. BRFSS data are collected by telephone surveys and designed to monitor state-level prevalence of the major behavioral risks among adults associated with premature morbidity and mortality. The basic philosophy was to collect data on actual behaviors, rather than on attitudes or knowledge, that would be especially useful for planning, initiating, supporting, and evaluating health promotion and disease prevention programs. To determine diabetes status, respondents were asked, “Have you ever been told by a doctor that you have diabetes?” Classification of diabetes was not assessed. Participants with a BMI 30 were classified as obese. BMI data were derived from self-reported weight and height information. In 2000, there were 184,450 BRFSS participants from 50 states. By 2000, obesity and diabetes prevalence had increased to 19.8% and 7.3%, respectively. The prevalence of diabetes and obesity combined was 2.9%. States with the highest diabetes prevalence were Alabama (8.0%), California (8.4%), Maryland (8.0%), Mississippi (8.8%), and South Carolina (8.5%). Several of these states had an obesity prevalence of 22.0%, including Alabama (23.5%) and Mississippi (24.3%), in addition to Arkansas (22.6%), Kentucky (22.3%), Louisiana (22.8%), Tennessee (22.7%), Texas (22.7%), and West Virginia (22.8%). The lowest rate of diabetes was in Alaska (4.4%); the lowest rate of obesity was in Colorado (13.8%). References: Mokdad AH, Bowman BA, Ford ES, Vinicor F, Marks JS, Koplan JP. The continuing epidemics of obesity and diabetes in the United States. JAMA. 2001;286(10):1195-1200. Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2000.
- UKPDS Outcomes by Treatment Group for Patients Randomized to Tight Blood Pressure Control In the UK Prospective Diabetes Study (UKPDS), a total of 1,148 patients aged 25 to 65, with newly diagnosed diabetes, were randomized to a tight blood pressure control group [(n=758) goal of <150/85 mmHg] or a less tight control group [(n=390) goal of <180/105 mmHg]. Of the 758 patients in the tight control group, 400 were randomized to receive the ACE inhibitor, captopril, as initial therapy, and 358 to receive the beta-blocker, atenolol, as initial therapy. Primary outcomes, including any diabetes-related endpoint (myocardial infarction, heart failure, angina, sudden death, stroke, amputation, retinal photocoagulation, renal failure, vitreous hemorrhage), death-related to diabetes, and death from all causes, as well as secondary outcomes that included myocardial infarction, stroke, amputation or death from peripheral vascular disease, and microvascular complications, were compared in patients randomized to each therapeutic group. Captopril and atenolol were equally effective in reducing blood pressure to a mean of 144/83 mmHg and 143/81 mmHg, respectively, over a median of 8.4 years of follow-up. There were no significant differences in either the primary or secondary outcomes when the captopril-treated and atenolol-treated groups were compared. Reference: Efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 39. UK Prospective Diabetes Study Group. BMJ. 1998;317(7160):713-720.
- Mrs. S is SYMPTOMATIC (and so you are no longer screening)
- What do you order?
- TREATMENT
- Oral hypoglycemic agents have limited effectiveness when plasma glucose is very high (i.e., >300)
- Oral hypoglycemic agents have limited effectiveness when plasma glucose is very high (i.e., >300)
- STARTING INSULIN
- DKA case You’ve started Mrs. S on insulin, NPH 10 units subcutaneously at bedtime.