Hypertension vigilance called for in diabetics

Patient-centered management and early, aggressive treatment of hypertension are necessary in patients with diabetes to address the sevenfold mortality increase in this patient population, according to an updated guidance from the American Society of Hypertension.

Physicians need to take a more integrated, individualized approach to treating hypertension in patients with diabetes by “treating the intricacies of each patient profile, rather than focusing on the disease in isolation,” according to a statement by ASH.

The guidance does not alter the fundamental treatment of blood pressure goals for this patient population, but it does emphasize that early detection of risk factors unique to each patient is needed and that earlier, more aggressive treatment should be implemented, including the identification and reduction of proteinuria.

Once high blood pressure is identified, initiation of ACE inhibitors or angiotensin receptor blocker therapy along with either thiazide-like diuretics or calcium antagonists is needed to maintain a target blood pressure of 130/80mm Hg. More frequent patient follow-up also is needed, according to the guidance.

Specifically, follow-up visits after each medication adjustment should occur within 2-2 weeks rather than 4-8 weeks as was previously recommended, and immediate referral to a specialist is necessary if repeated attempt to achieve blood pressure goals fail, according to the guidance.

Previous studies shows that, compared with conventional treatment, aggressive blood pressure control is associated with far fewer cardiovascular events in diabetic patients, a professor of medicine at the University of Chicago, said during a press briefing sponsored by the society. Yet physicians are not being as aggressive as necessary to get blood pressure under control. Physicians also need to empower patients to take control and they need to focus on the goal of reducing morbidity.

Patients who make the necessary lifestyle changes and who comply with aggressive therapy will prolong their lives and improve their quality of life by reducing morbidity.

Physicians need to emphasize that the need for treatment is not transient but is lifelong. Obese patients who lose weight can successfully reduce their antihypertensive pill burden.

These patients require an integrated therapeutic intervention that, in addition to blood pressure control, should include glycemic and lipid control and antiplatelet therapy. It is imperative that all risk factors be attacked simultaneously to manage the profile of each patient more vigilantly.

The challenges of identifying and treating hypertension are not limited to adults.

Nearly a third of obese teens also have high blood pressure, a nephrologist at Thomas Jefferson University, Philadelphia said during the briefing.

Obesity has become such a significant problem among adolescents that the prevalence of premature heart disease in young adults is expected to more than triple from 5 percent to 16 percent when currently obese adolescents reach age 35.

The president of ASH said at the briefing that immediate action is needed to address the problem of childhood obesity and the associated risks.

Overall, about 3.5 percent of children have hypertension and another 3.5 percent have pre-hypertension. It is likely that these children have — or will develop — blood pressure levels that require therapy and that they will become hypertensive young adults. According to an author of pediatric hypertension guidelines published in 2004.

Additional clinical research, involving adolescents is needed to define the disease pathway, to improve detection and treatment methods, and to determine the most beneficial time point for interventions.

For now, the recommendations given are:

• Blood pressure be measured as part of routine health care beginning at age 3 years.

• Blood pressure be measured as part of a medical exam in those younger than 3 years with chronic disease or unexplained symptoms.

• An appropriate evaluation be conducted in patients with detected and verified hypertension.