Cardiovascular Medicine Book

Coronary Artery Disease

Hypertension

  • Hypertension in Diabetes Mellitus

http://www.fpnotebook.com/

Hypertension in Diabetes MellitusAka: Diabetes Mellitus Associated Hypertension

Advertisement

  1. See Also
    1. Diabetes Mellitus
    2. Hypertension
  2. Management: Blood Pressure Goal
    1. Continue adding agents until goal reached (2 or 3 at a time are the norm)
    2. Small differences in Blood Pressure (5 mmHg) have large impact on outcomes
    3. Adults: <130/80 mmHg (ideal Blood Pressure is 115/75)
    4. Child: Average <95th percentile based on height, gender and age
      1. See Pediatric Hypertension
      2. See Hypertension Criteria
      3. NIH Information on Hypertension in Children
        1. http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.pdf
  3. Complications: Hypertension adverse effects in Diabetes Mellitus
    1. Microvascular Complications
      1. Renal insufficiency (and Proteinuria)
        1. ACE Inhibitors beneficial (except renal stenosis)
        2. Calcium Channel Blockers beneficial
        3. Angiotensin Receptor Blockers beneficial
      2. Autonomic Neuropathy (e.g. Impotence)
      3. Diabetic Retinopathy
    2. Macrovascular Complications
      1. Coronary Artery Disease
        1. ACE Inhibitors beneficial
        2. Thiazide Diuretics beneficial
        3. Long-acting Calcium Channel Blockers beneficial
          1. Nondihydropyridines clearly are beneficial
          2. Mixed data on Dihydropyridines (e.g. Verapamil)
        4. Beta Blockers beneficial
      2. Cerebrovascular Disease
        1. ACE Inhibitors beneficial
        2. Thiazide Diuretics beneficial
      3. Peripheral Vascular Disease
  4. Management: Medications
    1. First Choice: ACE Inhibitor
      1. Increase Glomerular Filtration Rate (GFR)
      2. Decrease Proteinuria
    2. Other Medications
      1. Diuretics (esp. Isolated Systolic Hypertension)
      2. Angiotension II Receptor Blockers
      3. Non-Dihydropyridine Calcium Channel Blockers
      4. Dihydropyridine Calcium Channel Blockers
      5. Alpha antagonists (use only as adjunctive agent)
    3. Avoid Beta Blockers until other possibilities exhausted (relative contraindication)
      1. Blunts hypoglycemic response (not seen in studies)
      2. Associated with increased weight gain
      3. Glucose and lipids less affected with Carvedilol
  5. Management: Algorithm
    1. Protocol
      1. Start with 2 medications if goal is >20 mmHg lower than current Blood Pressure
      2. Anticipate needing as many as 3-4 antihypertensives to reach goal
      3. Adjust in specific populations (e.g. Black)
        1. See Antihypertensives for Specific Populations
        2. May require ACE Inhibitor for renal protection, but other agents for Blood Pressure control
    2. Step 1: Start with ACE Inhibitor or Angiotensin Receptor Blocker (ARB)
      1. Proteinuria present: Evidence supports ACE/ARB as first line
      2. Proteinuria absent: No evidence for one antihypertensive class over another
    3. Step 2: Add Diuretic
      1. Serum Creatinine >1.8: Loop Diuretic (e.g. Furosemide)
      2. Serum Creatinine <1.8: Thiazide Diuretic
        1. Hydrochlorothiazide
        2. Chlorthalidone (may be preferred)
          1. Longer half-life (better 24 hour control)
          2. Approaches twice the potency of Hydrochlorothiazide
    4. Step 3: Add long-acting Calcium Channel Blocker
      1. Dihydropyridine Calcium Channel Blocker (e.g. Norvasc, Nifedipine) or
      2. Non-Dihydropyridine Calcium Channel Blocker (e.g. Verapamil, Diltiazem) or
        1. Do not use with Beta Blocker
    5. Step 4: Add Beta Blocker
      1. Use caution if Heart Rate <70-80 bpm
      2. Avoid if on Non-Dihydropyridine Calcium Channel Blocker (e.g. Verapamil, Diltiazem)
    6. Step 5: Add additional antihypertensive
      1. Central Adrenergic Agonist (e.g. Clonidine)
      2. Alpha Adrenergic Antagonist (e.g. Hytrin)
      3. Reserpine (very effective per JNC7, but review drug interactions)
  6. References
    1. Fineberg (1999) Prim Care 26:951
    2. Konzem (2002) Am Fam Physician 66(7):1209
    3. (2003) Diabetes Care 26:S80

Navigation Tree