Treatment of diabetic hypertension

Stroke in the Patient With Type 2 Diabetes

OBJECTIVE

Persons living with type 2 diabetes mellitus (T2DM) have a significantly greater risk of stroke (1.5 to 3 times higher than normoglycemic individuals). The traditional approach to primary and secondary stroke prevention has been control of risk factors. While this has resulted in prolongation of life in patients with diabetes, the risk for recurrent stroke in these patients still remains higher than in the normoglycemic population, and patients with T2DM post stroke have a poorer quality of life (increases in handicap and death).

METHODS

Multiple publications on the pathophysiology which increases stroke in T2DM were reviewed as well as new publications looking at the effect of traditional and new risk factor modification on stroke are summarized.

RESULTS

Traditional risk factor modification is refined with recommended levels of lipids and blood pressure and methods of anticoagulation. More recently, studies with antidiabetic drugs (glucagon-like peptide 1 RA and pioglitazone) have been shown to prevent both primary and secondary stroke in patients with diabetes.

CONCLUSIONS

Worldwide, stroke is the second leading cause of death and the third leading cause of disability. Both risk and the outcomes are greatly worsened by the presence of T2DM. Newer recommendations can improve these outcomes.

Combine and Conquer: With Type 2 Diabetes Polypharmacy Is Essential Not Only to Achieve Glycemic Control but Also to Treat the Comorbidities and Stabilize or Slow the Advancement of Diabetic Nephropathy

The concept of polypharmacy in the type 2 diabetic patient is both historic and redundant. A combination of three or more medications usually at doses which are less than those utilized for monotherapy is efficacious not only in the therapy of hyperglycemia but also in the therapy of the comorbidities of hypertension and hyperlipidemia. In addition, multiple medications are now accepted as being necessary to reduce albuminuria and decelerate the decline in renal function in the patient with diabetic nephropathy.

Diabetogenic effects of cardioprotective drugs

Drugs that protect against cardiovascular events in the patient with diabetes may also positively or negatively affect glycaemic control in the patient with established diabetes and may induce the development of diabetes in the predisposed patient. Mainly through increasing insulin resistance, beta-blockers, statins and high-dose diuretics have the potential to worsen glycaemic control. Dihydropyridine calcium channel blockers, low-dose diuretics, vasodilating beta-blockers, alpha-blockers and pitavastatin have little or no effect on glycaemic control. Blockers of the renin-angiotensin-aldosterone system, colesevelam, ranolazine and verapamil, through slowing breakdown of bradykinin, vasodilation, increasing cholecystokinin levels, blocking sodium channels and decreasing beta cell apoptosis, may improve glycaemic control and avoid the development of diabetes.

Mechanism of herbal medicine on hypertensive nephropathy (Review)

Hypertensive nephropathy is the most common complication of hypertension, and is one of the main causes of end-stage renal disease (ESRD) in numerous countries. The basic pathological feature of hypertensive nephropathy is arteriolosclerosis followed by renal parenchymal damage. The etiology of this disease is complex, and its pathogenesis is mainly associated with renal hemodynamic changes and vascular remodeling. Despite the increased knowledge on the pathogenesis of hypertensive nephropathy, the current clinical treatment methods are still not effective in preventing the development of the disease to ESRD. Herbal medicine, which is used to relieve symptoms, can improve hypertensive nephropathy through multiple targets. Since there are few clinical studies on the treatment of hypertensive nephropathy with herbal medicine, this article aims to review the progress on the basic research on the treatment of hypertensive nephropathy with herbal medicine, including regulation of the renin angiotensin system, inhibition of sympathetic excitation, antioxidant stress and anti-inflammatory protection of endothelial cells, and improvement of obesity-associated factors. Herbal medicine with different components plays a synergistic and multi-target role in the treatment of hypertensive nephropathy. The description of the mechanism of herbal medicine in the treatment of hypertensive nephropathy will contribute towards the progress of modern medicine.

Stroke in the patient with diabetes (part 1) - Epidemiology, etiology, therapy and prognosis

There is a higher incidence of stroke in both the type 2 diabetic and the non-diabetic insulin resistant patient which is accompanied by higher morbidity and mortality. The increase in the frequency of stroke is due to an increase in cerebral infarction, mainly lacunar infarcts, with the incidence of cerebral hemorrhage being less frequent. The major risk factors for stroke in the type 2 diabetic patient are age, hypertension, the number of features of the Metabolic Syndrome, the presence of diabetic nephropathy in both the type 1 and type 2 patient, the presence of peripheral and coronary artery disease and especially the presence of atrial fibrillation. Hyperglycemia is associated with a poor outcome from stroke but is not causative.

Brachial artery responses to ambient pollution, temperature, and humidity in people with type 2 diabetes: a repeated-measures study

BACKGROUND

Extreme weather and air pollution are associated with increased cardiovascular risk in people with diabetes.

OBJECTIVES

In a population with diabetes, we conducted a novel assessment of vascular brachial artery responses both to ambient pollution and to weather (temperature and water vapor pressure, a measure of humidity).

METHODS

Sixty-four 49- to 85-year-old Boston residents with type 2 diabetes completed up to five study visits (279 repeated measures). Brachial artery diameter (BAD) was measured by ultrasound before and after brachial artery occlusion [i.e., flow-mediated dilation (FMD)] and before and after nitroglycerin-mediated dilation (NMD). Ambient concentrations of fine particulate mass (PM2.5), black carbon (BC), organic carbon (OC), elemental carbon, particle number, and sulfate were measured at our monitoring site; ambient concentrations of carbon monoxide, nitrogen dioxide, and ozone were obtained from state monitors. Particle exposure in the home and during each trip to the clinic (home/trip exposure) was measured continuously and as a 5-day integrated sample. We used linear models with fixed effects for participants, adjusting for date, season, temperature, and water vapor pressure on the day of each visit, to estimate associations between our outcomes and interquartile range increases in exposure.

RESULTS

Baseline BAD was negatively associated with particle pollution, including home/trip-integrated BC (-0.02 mm; 95% CI: -0.04, -0.003, for a 0.28 μg/m3 increase in BC), OC (-0.08 mm; 95% CI: -0.14, -0.03, for a 1.61 μg/m3 increase) as well as PM2.5, 5-day average ambient PM2.5, and BC. BAD was positively associated with ambient temperature and water vapor pressure. However, exposures were not consistently associated with FMD or NMD.

CONCLUSION

Brachial artery diameter, a predictor of cardiovascular risk, decreased in association with particle pollution and increased in association with ambient temperature in our study population of adults with type 2 diabetes.

CITATION

Zanobetti A, Luttmann-Gibson H, Horton ES, Cohen A, Coull BA, Hoffmann B, Schwartz JD, Mittleman MA, Li Y, Stone PH, de Souza C, Lamparello B, Koutrakis P, Gold DR. 2014. Brachial artery responses to ambient pollution, temperature, and humidity in people with type 2 diabetes: a repeated-measures study. Environ Health Perspect 122:242-248; http://dx.doi.org/10.1289/ehp.1206136.

Catheter-based arterial sympathectomy: hypertension and beyond

Transluminal ablation of renal artery sympathetic nerves has been shown to provide a significant and durable reduction in blood pressure with very low complication rates. Additional publications have documented improvement in insulin sensitivity, obstructive sleep apnea indices, and frequency and severity of congestive heart failure in subgroups undergoing the procedure. This technology may provide effective management of other diseases in which there is autonomic imbalance. Available data are reviewed with the intent to provoke interest within the interventional radiology community in this novel technology, which may allow minimally invasive treatment of many important chronic medical conditions.

Potential drug interactions associated with treatments for type 2 diabetes and its comorbidities: a clinical pharmacology review

Type 2 diabetes is a disease of glucose metabolism that commonly involves multiple comorbidities, including lipid dyscrasias and hypertension. Each concurrent disorder contributes some risk of complications and requires therapeutic intervention. The simultaneous management of so many coexisting illnesses can be complex and commonly results in patients being prescribed multiple medications--referred to as polypharmacy--which may further complicate treatment. To ensure the best patient outcomes, the treating physician must be aware of all the therapeutic agents that a patient is taking to assess possible drug interactions that such a plethora of medications may confer. This article addresses the underlying comorbidites, the drugs commonly used to treat them and the interactions that may arise from concomitant administration.

Prevalence and control of hypertension in iraqi diabetic patients: a prospective cohort study

OBJECTIVES

Diabetes and hypertension are major risk factors for cardiovascular disease, a leading cause of death in humans. The aim of our study was to determine the prevalence of hypertension, and hypertension control among adults with diabetes in Basrah (Southern Iraq).

METHODS

A prospective cohort study was conducted at Al-Faiha Diabetes and Endocrine Center in Basrah. It was started in August 2008 to April 2011. The total number of recruited patients with diabetes was 5578.

RESULTS

Hypertensive diabetic patients constituted 89.6% of this study cohort, with 45.3% of them newly discovered in the center. From hypertensive patients, 48.2% achieved the target blood pressure of less than 130/80 mmHg. The results of the multivariate analyses showed that the factors independently associated with the hypertension were aged > 50 years (odds ratio, 0.4; 95% CI, 0.3 to 0.5; p < 0.001), body mass index equal or more than 25 (odds ratio, 0.5; 95% CI, 0.4 to 0.6; p < 0.001), insulin use (odds ratio, 0.6; 95% CI, 0.5 to 0.8; p < 0.001) and duration of diabetes > 5 years (odds ratio, 0.6; 95% CI, 0.5 to 0.7; p < 0.001) .

CONCLUSION

This study confirmed that hypertension was seen in ~90% of diabetic patients in Iraq, and approximately half of them were achieving target blood pressure level.

Glycated hemoglobin and risk of hypertension in the atherosclerosis risk in communities study

OBJECTIVE

Diabetes and hypertension often co-occur and share risk factors. Hypertension is known to predict diabetes. However, hyperglycemia also may be independently associated with future development of hypertension. We investigated glycated hemoglobin (HbA(1c)) as a predictor of incident hypertension.

RESEARCH DESIGN AND METHODS

We conducted a prospective analysis of 9,603 middle-aged participants in the Atherosclerosis Risk in Communities Study without hypertension at baseline. Using Cox proportional hazards models, we estimated the association between HbA(1c) at baseline and incident hypertension by two definitions 1) self-reported hypertension during a maximum of 18 years of follow-up and 2) measured blood pressure or hypertension medication use at clinic visits for a maximum of 9 years of follow-up.

RESULTS

We observed 4,800 self-reported and 1,670 visit-based hypertension cases among those without diagnosed diabetes at baseline. Among those with diagnosed diabetes at baseline, we observed 377 self-reported and 119 visit-based hypertension cases. Higher baseline HbA(1c) was associated with an increased risk of hypertension in subjects with and without diabetes. Compared with nondiabetic adults with HbA(1c) <5.7%, HbA(1c) in the prediabetic range (5.7-6.4%) was independently associated with incident self-reported hypertension (hazard ratio 1.14 [95% CI 1.06-1.23]) and visit-detected hypertension (1.17 [1.03-1.33]).

CONCLUSIONS

We observed that individuals with elevated HbA(1c), even without a prior diabetes diagnosis, are at increased risk of hypertension. HbA(1c) is a known predictor of incident heart disease and stroke. Our results suggest that the association of HbA(1c) with cardiovascular risk may be partially mediated by the development of hypertension.

Opposing effects of particle pollution, ozone, and ambient temperature on arterial blood pressure

BACKGROUND

Diabetes increases the risk of hypertension and orthostatic hypotension and raises the risk of cardiovascular death during heat waves and high pollution episodes.

OBJECTIVE

We examined whether short-term exposures to air pollution (fine particles, ozone) and heat resulted in perturbation of arterial blood pressure (BP) in persons with type 2 diabetes mellitus (T2DM).

METHODS

We conducted a panel study in 70 subjects with T2DM, measuring BP by automated oscillometric sphygmomanometer and pulse wave analysis every 2 weeks on up to five occasions (355 repeated measures). Hourly central site measurements of fine particles, ozone, and meteorology were conducted. We applied linear mixed models with random participant intercepts to investigate the association of fine particles, ozone, and ambient temperature with systolic, diastolic, and mean arterial BP in a multipollutant model, controlling for season, meteorological variables, and subject characteristics.

RESULTS

An interquartile increase in ambient fine particle mass [particulate matter (PM) with an aerodynamic diameter of ≤ 2.5 μm (PM2.5)] and in the traffic component black carbon in the previous 5 days (3.54 and 0.25 μg/m3, respectively) predicted increases of 1.4 mmHg [95% confidence interval (CI): 0.0, 2.9 mmHg] and 2.2 mmHg (95% CI: 0.4, 4.0 mmHg) in systolic BP (SBP) at the population geometric mean, respectively. In contrast, an interquartile increase in the 5-day mean of ozone (13.3 ppb) was associated with a 5.2 mmHg (95% CI: -8.6, -1.8 mmHg) decrease in SBP. Higher temperatures were associated with a marginal decrease in BP.

CONCLUSIONS

In subjects with T2DM, PM was associated with increased BP, and ozone was associated with decreased BP. These effects may be clinically important in patients with already compromised autoregulatory function.

Efficacy and safety of triple-combination therapy with olmesartan, amlodipine, and hydrochlorothiazide in study participants with hypertension and diabetes: a subpopulation analysis of the TRINITY study

BACKGROUND

Most patients with hypertension and diabetes require two or more antihypertensive agents to achieve the recommended blood pressure (BP) goal of <130/80 mm Hg. This prespecified subgroup analysis from the TRIple Therapy with Olmesartan Medoxomil, Amlodipine, and Hydrochlorothiazide in HyperteNsIve PatienTs StudY assessed the efficacy and safety of triple-combination treatment (olmesartan medoxomil 40/amlodipine besylate 10/hydrochlorothiazide 25 mg) versus the component dual-combination treatments according to diabetes status (diabetes; non-diabetes).

METHODS

Participants received dual-combination treatment for 4 weeks or placebo for 2 weeks. Participants receiving placebo switched to dual-combination treatment from week 2 to week 4. At week 4, participants switched to triple-combination treatment or continued on dual-combination treatment until week 12.

RESULTS

The prespecified changes in BP from baseline for the diabetes subgroup receiving triple-combination treatment were greater than the respective dual-combination treatments (P ≤ .0013). Also, more participants with diabetes receiving triple-combination treatment reached BP goal (<130/80 mm Hg) versus those receiving dual-combination treatments (P ≤ .0092). In a post hoc analysis, significantly greater proportions of study participants with diabetes achieved BP targets with triple-combination treatment compared with each dual-combination treatment. Most treatment-emergent adverse events were mild to moderate in severity.

CONCLUSIONS

In participants with hypertension and diabetes, triple-combination treatment led to greater BP reductions and enabled greater proportions of participants to reach BP goal versus the dual-combination treatments. Triple-combination treatment was well tolerated in both diabetes and non-diabetes subgroups.

Why does quick-release bromocriptine decrease cardiac events?

A placebo-controlled prospective safety study of quick-release bromocriptine in patients with type 2 diabetes has shown a 40% reduction in cardiovascular events. Possible explanations for this decrease are that through re-establishing diurnal variation a decrease in insulin resistance and its associated risk factors occurs. In addition, a decrease in the activity of the sympathetic nervous and renin-angiotensin systems and re-establishment of diurnal variations in the pituitary-adrenal axis may play a role. However, the most probable explanation is that because of the lowering of insulin resistance there are decreases in hepatic glucose production and an increased uptake of glucose leading to decreased levels of postprandial glucose, free fatty acids and triglycerides, which cause decreases in inflammation, oxidative stress and accumulation of atheroma.