Diabetes mellitis and Hypertension; a sinister alliance; JNC 8 Guidelines

1. Dr. Nadia Shams
Assistant Professor
Medicine

3. Hyperglycemia Dyslipidemia
Hyperinsulinemia
Hypertension
Insulin
resistance
Obesity
Insulin deficiency

4.  Both essential hypertension and diabetes
mellitus affect the same major target organs.
 The common denominator of
hypertensive/diabetic target organ-disease is
the vascular tree.

5.  The tide of diabetes is rising all over the globe and
becoming an increasingly powerful threat to global
health
 The World Health Organization projects that by the
year 2025 > 5% of the world population, i.e. 300
million people will suffer from diabetes.
King H, Donald E, et al. global burden of Diabetes 1995-2025.
Diabetes care, Sept 1998.

6.  Hyperinsulinemia can enhance renal sodium
reabsorption and vascular reactivity
 Angiotensinogen from fat cells can increase
angiotensin II and thus blood pressure
 Both systolic and diastolic blood pressure
increase with increasing body mass index

7. Subcutaneous Fat
Abdominal Muscle
Layer
Intra-abdominal
Fat
Despres JP, Lemieux I, Prud'homme D. Treatment of obesity: need to focus on high risk
abdominally obese patients. BMJ. 2001;322:716-720.

8. Heart DiseaseHeart Disease
Insulin ResistanceInsulin Resistance
Metabolic SyndromeMetabolic Syndrome
↑↑Adipocytokines + Fatty AcidsAdipocytokines + Fatty Acids Liver
Abdominal AdipocytesAbdominal Adipocytes

9.  Hepatic
Insulin
Clearance
Portal
FFA
 Plasma
Insulin
 Renal Na+
Reabsorption
Hypertension
Visceral
Fat Stores
Fat Cell Products and HypertensionFat Cell Products and Hypertension
Vascular
Constriction
Angiotensin I
Angiotensin II
Angiotensinogen
Bray GA. Contemp Diagn Obes. 1998.

10. Chobanian AV, et al. JAMA. 2003;289:2560-2572.
Peripheral
Vascular
Disease Renal Failure,
Proteinuria
LVH, CHD, CHFHemorrhage,
Stroke
Retinopathy
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy
Hypertension
& Diabetes
Hypertension
& Diabetes

11.  Both hypertension and diabetes are well-
identified risk factors for atherogenesis.
 Several mechanisms acting together mediate
damage to vascular tree in diabetic hypertensive
patients.

12.  Elevated lipoprotein levels in diabetics with poor
glycemic control.
 Enhanced foam cell formation.
 Anatomic and functional abnormalities of the
vascular endothelium have been described in
diabetes mellitus and hypertension

13.  Diabetes seems to be a specific risk factor for
small vessel disease.
 In contrast, hypertension, at least in its
nonmalignant form, seems to affect
predominantly the large arteries.
Together, the two disorders
synergistically damage
the arterial tree.

14.  Diabetes, and to a lesser extent hypertension,
may alter the perception of ischemic pain,
leading to a high prevalence of silent ischemia.
 Coronary artery disease is much more common
in diabetic hypertensive patients than in
patients suffering from hypertension or
diabetes alone
Fisman EZ, Tenenbaum A (eds): Cardiovascular Diabetology: Clinical, Metabolic and

15. PROCAM TRIAL
____________________________________________________
Those with none of three risk factors (i.e. HTN, diabetes, or
hyperlipidemia), the coronary artery disease incidence was
6/1,000 in 4 years.
In contrast, the incidence of coronary artery disease in those
participants who were suffering from hypertension or diabetes
was 14 and 15 per 1,000 in 4 years, respectively.
When both risk factors were present in the same patient, the
incidence rate increased to 48 per 1,000
Fisman EZ, Tenenbaum A (eds): Cardiovascular Diabetology: Clinical, Metabolic and
Inflammatory Facets. Adv Cardiol. Basel, Karger, 2008, vol 45, pp 82–106

16.  Melina et al. found a high prevalence of asymptomatic
ST segment depression in diabetic patients with essential
hypertension.
 The number of ST segment depression episodes was
significantly related to glycosylated hemoglobin levels,
left ventricular mass, and ambulatory systolic and
diastolic blood pressure variability and hypertensive
peaks.
Schinzari F, Iantorno M, Melina G, et al. Differences between diabetic and non-diabetic hypertensive
patients with first acute non-ST elevation myocardial infarction predictors of in-hospital
complications. J Med 2008;9:267-72.

17.  The coexistence of diabetes and hypertension
results in more severe cardiomyopathy than
with either hypertension or diabetes mellitus
alone
 The extensive degenerative changes in the
diabetic hypertensive heart may be related to
abnormalities in the microcirculation.

18.  The most striking microscopic findings of the
hypertensive diabetic heart seem to be the
distribution of dense interstitial connective
tissue throughout the myocardium.
 Clinical studies with echocardiography also
showed an increased left ventricular mass in
diabetic hypertensive patients.

19.  Grossman et al. found increased septal and
posterior wall thickness in patients with
hypertension and diabetes compared with non-
diabetic hypertensive patients.
 Prevalence of LVH was 72% in diabetic
hypertensive patients and only 32% in
nondiabetic hypertensive patients who had a
similar degree of hypertension
Grossman E, Messerli FH.: Diabetic and hypertensive heart
disease. Ann Intern Med 1996; 125: 304– 310.

20.  When hypertension is superimposed on
diabetes mellitus it accelerates the decline in
renal function.
 Blood pressure control with levels below
130/80mm Hg can slow the progression of
renal disease in diabetic patients
Franz H, Messerli, et al. Combination therapy and target organ protection in
hypertension and diabetes mellitis. Am J Hypertens (1997) 10 (S6):198S-
201S.

21.  The combined presence of hypertension and
diabetes concomitantly affects glomerular
filtration rate and renal blood flow, thereby
greatly accelerating a decrease in renal
function.
Franz H, Messerli, et al. Combination therapy and target organ protection in
hypertension and diabetes mellitis. Am J Hypertens (1997) 10 (S6):198S-
201S.

22.  Hypertension accelerates the development of diabetic
retinopathy; hypertensive/diabetic cerebral disease
leads to vascular dementia, transient ischemic attacks,
and strokes.
Franz H, Messerli, et al. Combination therapy and target organ protection in
hypertension and diabetes mellitis. Am J Hypertens (1997) 10 (S6):198S-201S.

23. A decrease in the hemodynamic and glycemic
burden is the primary goal in the management
of the hypertensive diabetic patients
__________________________________________

24. Category Systolic (mmHg) Diastolic (mmHg)
Normal <120 <80
prehypertension 120-139 80-89
Stage 1 HYPERTENSION 140-159 90-99
Stage 2 HYPERTENSION >160 >100

25. Category Sydtolic (mmHg) Diastolic( mmHg)
optimal <120 <80
normal 120-129 80-84
High normal 130-139 85-89
Grade 1 hypertension 140-159 90-99
Grade 2 hypertension 160-179 100-109
Grade3 hypertension >180 >110
Isolated hypertension >140 <90

26. JNC 8 guidelines (2013)
(James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the
management of high blood pressure in adults: report from the panel members
appointed to the Eighth Joint National Committee (JNC 8). JAMA. Dec 18 2013)

39. For patients aged >18 years with diabetes JNC 8 recommends
initiating treatment at
 Systolic blood pressure (BP) levels of >140 mmHg
 or at diastolic BP levels of > 90 mm Hg
 Treat to a goal BP below 140/90 mm Hg.
(The JNC 7 and the 2011 American Diabetes Association (ADA)
standard of medical care recommended BP control in diabetic
individuals < 130/80 mm Hg)
(James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the
management of high blood pressure in adults: report from the panel members
appointed to the Eighth Joint National Committee (JNC 8). JAMA. Dec 18 2013)

40.  In general, patients with diabetes type 1 or type
2 and hypertension have shown clinical
improvement with diuretics, ACE inhibitors,
beta-blockers, ARBs, and calcium antagonists
(Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. Seventh report of the Joint National Committee
on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.Hypertension. Dec 2003;42(6):1206-52.)

41.  Two or more antihypertensive drugs at
maximal doses should be used to achieve
optimal BP targets in patients with diabetes
and hypertension.
(
American Diabetes Association. Standards of medical care in
diabetes--2011. Diabetes Care. Jan 2011;34 Suppl 1:S11-61)

42.  Either an ACE inhibitor or an ARB is usually required in
patients with diabetes and hypertension.
 If the patient cannot tolerate one class of drugs, the other
should be tried.
 If needed to achieve BP goals,
 a thiazide diuretic is indicated for those patients with an estimated
GFR of >30 mL/min/1.73 m2
or greater
 and a loop diuretic is indicated for those with an estimated GFR of <
30 mL/min/1.73 m2
.
 Regardless of which antihypertensive drugs are used, kidney
function and serum potassium levels should be monitored.
(
American Diabetes Association. Standards of medical care in diabetes--
2011. Diabetes Care. Jan 2011;34 Suppl 1:S11-61)

44. • Hypertension occurs in 75% of patients with type 2
diabetes
• Diabetes, the metabolic syndrome and hypertension
constitute a particularly dangerous combination as
regards cardiovascular morbidity and mortality
• Hypertension is a promoter of macro- and
microvascular disease
• There is evidence to link the RAAS with
hypertension in patients with obesity, metabolic
syndrome, and patients with type 2 diabetes

45.  Target b;ood pressure in diabetic hypertensive
patients < 140/90 mmHg
 In patients with diabetes, the drug of choice
should be a drug that blocks the RAAS (ACE
inhibitor or ARB)
 It is common to use more than 2 agents in order
reach blood pressure goals in patients with
type 2 diabetes

46. Learning is the beginning of health
Learning is the beginning of wealth
Learning is the beginning of spirituality
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