September 04, 2017
Standing blood pressure (BP) should be measured in patients with diabetes at every routine clinic visit to assess both autonomic function as well as potential volume depletion, according to new recommendations from the American Diabetes Association (ADA).
There is "unequivocal evidence" that supports targeting BP goal to <140/90 mm Hg in most adults with diabetes, as it reduces cardiovascular events as well as some microvascular complications, write Ian H de Boer, MD, from the University of Washington, Seattle, and colleagues from the ADA Professional Practice Committee.
The new report, published online on August 22 in Diabetes Care, is the ADA's first updated guidance on hypertension treatment since 2003.
In patients with a high risk of cardiovascular disease, a lower blood-pressure target of <130/80 or <120/80 mm Hg is recommended, if these targets can be met "without undue treatment burden," the report authors suggest. "Such intensive blood-pressure control has been evaluated in landmark clinical trials and meta-analyses of clinical trials."
The updated recommendations are based on review of 137 clinical trials and meta-analyses including the Action to Control Cardiovascular Risk in Diabetes-Blood Pressure (ACCORD BP) trial; the Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation-Blood Pressure (ADVANCEBP) trial; the Hypertension Optimal Treatment (HOT) trial; and the Systolic Blood Pressure Intervention Trial (SPRINT).
Individualized treatment must be based on the comorbidities of each patient as well as "their anticipated benefit for reduction in [atherosclerotic cardiovascular disease] ASCVD, heart failure, progressive diabetic kidney disease, and retinopathy events and their risk of adverse events," Dr de Boer and colleagues write. "This conversation should be part of a shared decision-making process between the clinician and the individual patient."
BP measurement needs to be carried out with "much more care than has been given," senior author George Bakris, MD, from the University of Chicago Medicine, told Medscape Medical News. He emphasized that all personnel measuring blood pressure should adhere to American Heart Association guidelines.
In addition, BP goals should be achieved through lifestyle — "the least intrusive means possible," he emphasized. "You need to make sure the patient understands the clear importance of salt restriction and good sleep hygiene as the base for lowering BP. This is will take more time from you and [requires] a dietitian."
When asked to comment, Sverre E Kjeldsen, MD, PhD, of the division of cardiovascular medicine at the University of Michigan, Ann Arbor, and the department of cardiology at Oslo University Hospital, Norway, said he found the position paper "very well written" but noted that results from the ACCORD trial suggest that the target for standing BP should be 120 to 140 mm Hg (N Engl J Med. 2010; 362:1575-1585).
"Reaching a standing blood pressure of less than 120 mm Hg is in no way needed," Dr Kjeldsen told Medscape Medical News. "It may be easier to avoid orthostatic hypotension by keeping [standing blood pressure] above 120 mm Hg."
In fact, the authors of the new ADA recommendations note that in ACCORD, a target systolic blood pressure of <120 mm Hg "resulted in no significant difference in the primary composite outcome of [myocardial infarction] MI, stroke, or cardiovascular death." And while there was a 41% decreased rate of stroke, there was also a significantly increased incidence of hypotension, electrolyte abnormalities, and elevated serum creatinine.
Dr Kjeldsen also said that findings from SPRINT should not have been included in the report since the study excluded patients with diabetes. "We do not believe in the SPRINT study in Europe," he said.
In Europe, measurements of 24-hour BP are sometimes included along with measurements of standing BP and BP measurements taken by patients at home because "home BP is not always reliable," he explained. Patients who experience increases in nocturnal BP may benefit from antihypertensive medication taken in the evening, he added.
Results from a single randomized clinical trial show that a small number of cardiovascular events were significantly reduced when at least one antihypertensive medication was taken at bedtime, the report authors say.
"In the past 2 decades, we have seen a decrease in ASCVD morbidity and mortality in people with diabetes, and evidence indicates that advances in blood-pressure control are likely the key to such improvements," said William T Cefalu, MD, chief scientific, medical, and mission officer for the ADA, in a statement. "As medical and pharmacological developments occur, it is imperative that medical providers, diabetes educators, and patients stay abreast of the most current care recommendations that can lead to improved cardiovascular health for people with diabetes and will ultimately result in better overall health and fewer diabetes-related complications."
The report "strongly recommends" that home BP monitoring be carried out by all hypertensive patients with diabetes with periodic reporting to a nurse to identify white-coat hypertension. Standing BP measures are recommended during initial evaluation as well as at follow-up and when symptoms of orthostatic hypotension are present. Regular BP monitoring is recommended following a diagnosis of orthostatic hypotension. "It is particularly important to make and average repeated measurements of blood pressure for the diagnosis of hypertension and titration of antihypertensive treatment," the report authors point out.
Other new recommendations provide lifestyle management plans for lowering BP that include suggestions for weight loss, a Dietary Approaches to Stop Hypertension (DASH)–style food plan, and increased physical activity.
The recommendations include an algorithm for the treatment of confirmed hypertension in patients with diabetes and detail specific information on pharmacologic treatment based on initial BP, renal sufficiency, response to treatment, and adverse effects. For the first time, it is also recommended that a diastolic BP <60 mm Hg be avoided.
In addition to lifestyle therapy, treatment for patients with confirmed office-based blood pressure between 140/90 mm Hg and 159/99 mm Hg can be initiated with a single drug. Patients who are at least 20/10 mm Hg above the BP goal should be given single-pill combinations of either renin-angiotensin system [RAS] blockers/calcium-channel blockers or RAS blockers/diuretics. A combination of ACE inhibitors and angiotensin-receptor blockers (ARBs) is not recommended as multidrug therapy to achieve blood-pressure targets.
"RAS blockers are not a panacea for those with diabetes and should be used appropriately based on data," Dr Bakris cautioned.
In patients with diabetes and either urine albumin-to-creatinine ratio ≥300 mg/g creatinine or 30 to 299 mg/g creatinine, the recommended first-line treatment for hypertension is an ACE inhibitor or ARB, at the maximum tolerated dose for blood-pressure treatment. In the event that one drug class is not tolerated, the other should be substituted. Serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored in patients treated with an ACE inhibitor, ARB, or diuretic.
Microalbuminuria is not an indicator of diabetic kidney disease but a cardiovascular risk marker and prognosticator for cardiovascular risk, Dr Bakris pointed out, noting that progression to >300 mg/day in spite of therapy indicates nephropathy.
The authors also emphasize that patients who are pregnant and have preexisting hypertension or mild gestational hypertension (BP <160/105 mm Hg) and no evidence of end-organ damage should not be treated with antihypertensive medications. There is no benefit that clearly outweighs the potential risks, Dr Bakris said.
The guideline also lists BP targets and potential medication guidelines to optimize long-term maternal health and fetal growth in pregnant patients with diabetes who don't need to be treated for hypertension.
In patients with resistant hypertension — defined as BP ≥140 mm Hg despite conventional drug therapy with lifestyle management plus a diuretic and two other antihypertensive drugs — referral to a certified hypertension specialist is recommended.
Dr Bakris reports relationships with Bayer, Janssen, AbbVie, Merck, Relypsa, Vascular Dynamics, and GlaxoSmithKline. Disclosures for the coauthors are listed in the paper. Dr Kjeldsen reports relationships with AstraZeneca, Bayer, Boehringer-Ingelheim, Leo, Medtronic, Nycomed and Takeda, and Pronova.