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
    3. Hypertension Management
    4. Nonpharmacologic Management of Hypertension
    5. DASH Diet
  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-Line Agents
      1. ACE Inhibitor
        1. Increases Glomerular Filtration Rate (GFR)
        2. Decreases Proteinuria
      2. Angiotension II Receptor Blockers
        1. Alternative to ACE Inhibitors
    2. Second-Line Agents
      1. Diuretics (especially in Isolated Systolic Hypertension)
    3. Third-Line Agents
      1. Beta Blockers
        1. Now thought to be a viable option for Hypertension control
        2. Historically has been used only when other options have been exhausted
          1. Blunts hypoglycemic response (not seen in studies)
          2. Associated with increased weight gain
          3. Glucose and lipids less affected with Carvedilol
      2. Calcium Channel Blockers
        1. Non-Dihydropyridine Calcium Channel Blockers
        2. Dihydropyridine Calcium Channel Blockers
    4. Other Medications
      1. Alpha antagonists (use only as adjunctive agent)
  5. Management: Algorithm
    1. General
      1. See Hypertension Management
      2. See Nonpharmacologic Management of Hypertension
      3. See DASH Diet
    2. 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
    3. 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
    4. 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
    5. 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
    6. 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)
    7. 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. (2003) Diabetes Care 26:S80
    2. () Arauz-Pacheco Diabetes Care 27:S65
    3. Fineberg (1999) Prim Care 26:951
    4. Konzem (2002) Am Fam Physician 66(7):1209
    5. Whalen (2008) Am Fam Physician 78(11):1277

Hypertensive disease (C0020538)

Definition (MSH)Persistently high systemic arterial BLOOD PRESSURE. Based on multiple readings (BLOOD PRESSURE DETERMINATION), hypertension is currently defined as when SYSTOLIC PRESSURE is consistently greater than 140 mm Hg or when DIASTOLIC PRESSURE is consistently 90 mm Hg or more.
Definition (CSP)persistantly high arterial blood pressure.
Definition (NCI)Abnormally high blood pressure.
Definition (NCI)Pathological increase in blood pressure; a repeatedly elevated blood pressure exceeding 140 over 90 mmHg.
ConceptsDisease or Syndrome (T047)
ICD9401-405.99, 997.91
MSHD006973
EnglishBLOOD PRESSURE HIGH, BP - High blood pressure, BP+ - Hypertension, HBP - High blood pressure, high blood pressure, High blood pressure disorder, High Blood Pressures, HT - Hypertension, HTN, HTN - Hypertension, Hyperpiesia, Hyperpiesis, Hypertension, HYPERTENSION ARTERIAL, Hypertensive disease, Hypertensive disorder, Hypertensive vascular degeneration, Hypertensive vascular disease, Increased blood pressure, SURG COMP - HYPERTENSION, Systemic arterial hypertension, Systemic hypertension, vascular hypertension, Vascular Hypertensive Disorder
Spanishdegeneracion vascular hipertensiva, enfermedad hipertensiva, enfermedad vascular hipertensiva, hiperpiesia, hiperpiesis, hipertension arterial, presion arterial alta, tension arterial alta, tension arterial elevada
Parent ConceptsHypertensive disease (C0020538), Circulatory system disease NOS (C0728936), Cardiovascular Diseases (C0007222), Blood Pressure Disorders (C0542302), sympathomimetic disorder (C1323099), Complications affecting other specified body systems, NEC in ICD9CM_2008 (C0302415), Vascular Diseases (C0042373), Blood pressure finding (C1271104), Systemic arterial finding (C0577829), Arteriopathic disease (C0852949), Ambiguous concept (C1274012), Duplicate concept (C1274013)
SourcesAOD, CCS, COSTAR, CSP, CST, DXP, ICD9CM, LCH, LNC, MEDLINEPLUS, MSH, MTH, NCI, NDFRT, OMIM, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



Navigation Tree