Effects of intensive blood pressure reduction on myocardial infarction and stroke in diabetes: a meta-analysis in 73 913 patients

Physician and patient willingness to pay for electronic cardiovascular disease management

OBJECTIVES

Cardiovascular disease (CVD) is an important target for electronic decision support. We examined the potential sustainability of an electronic CVD management program using a discrete choice experiment (DCE). Our objective was to estimate physician and patient willingness-to-pay (WTP) for the current and enhanced programs.

METHODS

Focus groups, expert input and literature searches decided the attributes to be evaluated for the physician and patient DCEs, which were carried out using a Web-based program. Hierarchical Bayes analysis estimated preference coefficients for each respondent and latent class analysis segmented each sample. Simulations were used to estimate WTP for each of the attributes individually and for an enhanced vascular management system.

RESULTS

144 participants (70 physicians, 74 patients) completed the DCE. Overall, access speed to updated records and monthly payments for a nurse coordinator were the main determinants of physician choices. Two distinctly different segments of physicians were identified - one very sensitive to monthly subscription fee and speed of updating the tracker with new patient data and the other very sensitive to the monthly cost of the nurse coordinator and government billing incentives. Patient choices were most significantly influenced by the yearly subscription cost. The estimated physician WTP was slightly above the estimated threshold for sustainability while the patient WTP was below.

CONCLUSION

Current willingness to pay for electronic cardiovascular disease management should encourage innovation to provide economies of scale in program development, delivery and maintenance to meet sustainability thresholds.

Canadian Society of Nephrology commentary on the 2012 KDIGO clinical practice guideline for the management of blood pressure in CKD

The KDIGO (Kidney Disease: Improving Global Outcomes) 2012 clinical practice guideline for the management of blood pressure (BP) in chronic kidney disease (CKD) provides the structural and evidence base for the Canadian Society of Nephrology (CSN) commentary on this guideline's relevancy and application to the Canadian health care system. While in general agreement, we provide commentary on 13 of the 21 KDIGO guideline statements. Specifically, we agreed that nonpharmacological interventions should play a significant role in the management of hypertension in patients with CKD. We also agreed that the approach to the management of hypertension in elderly patients with CKD should be individualized and take into account comorbid conditions to avoid adverse outcomes from excessive BP lowering. In contrast to KDIGO, the CSN Work Group believes there is insufficient evidence to target a lower BP for nondiabetic CKD patients based on the presence and severity of albuminuria. The CSN Work Group concurs with the Canadian Hypertension Education Program (CHEP) recommendation of a target BP for all non-dialysis-dependent CKD patients without diabetes of ≤140 mm Hg systolic and ≤90 mm Hg diastolic. Similarly, it is our position that in diabetic patients with CKD and normal urinary albumin excretion, raising the threshold for treatment from <130 mm Hg systolic BP to <140 mm Hg systolic BP could increase stroke risk and the risk of worsening kidney disease. The CSN Work Group concurs with the CHEP and the Canadian Diabetic Association recommendation for diabetic patients with CKD with or without albuminuria to continue to be treated to a BP target similar to that of the overall diabetes population, aiming for BP levels < 130/80 mm Hg. Consistent with this, the CSN Work Group endorses a BP target of <130/80 mm Hg for diabetic patients with a kidney transplant. Finally, in the absence of evidence for a lower BP target, the CSN Work Group concurs with the CHEP recommendation to target BP<140/90 mm Hg for nondiabetic patients with a kidney transplant.

The relationships between cardiovascular disease and diabetes: focus on pathogenesis

There is a looming global epidemic of obesity and diabetes. Of all the end-organ effects caused by diabetes, the cardiovascular system is particularly susceptible to the biologic perturbations caused by this disease, and many patients may die from diabetes-related cardiovascular complications. Substantial progress has been made in understanding the pathobiology of the diabetic vasculature and heart. Clinical studies have illuminated the optimal way to treat patients with cardiovascular manifestations of this disease. This article reviews these aspects of diabetes and the cardiovascular system, broadly classified into diabetic vascular disease, diabetic cardiomyopathy, and the clinical management of the diabetic cardiovascular disease patient.

ARB-based single-pill platform to guide a practical therapeutic approach to hypertensive patients

Hypertension is a major modifiable risk for the development of cardiovascular, cerebrovascular and renal diseases. Thus, effective treatment of high blood pressure is an important strategy for reducing disease burden; however, in spite of the availability of numerous effective therapies only 30-40 % of patients with hypertension achieve the recommended blood pressure goals of <140/90 mmHg. Lack of adherence to therapy and reluctance to intensify therapy are cited frequently to explain the discrepancy between potential and attained outcomes. Adherence is closely related to the tolerability, effectiveness and complexity of therapy. Therapeutic inertia may be influenced by concerns over tolerability, as well as the lack of clear preferences for therapies when managing patients with risk factors and comorbidities. Effective and well-tolerated single pill combination therapies are now available that improve adherence and simplify treatment. The combination of a renin-angiotensin system blocker with a calcium channel blocker and a diuretic improves adherence to therapy. We have devised a practical tool for orienting the application of well-tolerated single pill 2/3 drug fixed dose combination therapies in clinical situations commonly encountered when treating hypertensive patients. This approach employs the angiotensin receptor blocker olmesartan alone or in combinations with amlodipine and/or hydrochlorothiazide. This platform is based on clinical evidence, guidelines, best practice, and clinical experience where none of these is available. We believe it will increase the percentage of hypertensive patients who achieve blood pressure control when applied as part of an integrative approach that includes regular follow-up and instruction on lifestyle changes.

Blood pressure levels and risk of cardiovascular events and mortality in type-2 diabetes: cohort study of 34 009 primary care patients

OBJECTIVE

The optimal blood pressure (BP) in persons with type-2 diabetes is debated. We investigated shapes of the associations of SBP and DBP levels with risk of cardiovascular events and mortality in a large primary care-based sample of diabetic patients.

METHODS

We investigated all 34 009 consecutive cardiovascular disease-free type-2 diabetes patients aged 35 years or older (mean age 64 years) at 84 primary care centers in central Sweden between 1999 and 2008. We followed this cohort until the end of 2009 in national registries for the incidence of major cardiovascular events (a composite endpoint of myocardial infarction, stroke, heart failure, or cardiovascular mortality) or total mortality.

RESULTS

During up to 11 years of follow-up, 6344 patients (18.7%) had a first cardiovascular event, and 6235 died (18.3%). The associations of annually updated SBP and DBP with risk of major cardiovascular events were U-shaped. The lowest risk of cardiovascular events was observed at a SBP of 135-139 mmHg and a DBP of 74-76 mmHg, and the lowest mortality risk at a SBP of 142-150 mmHg and a DBP of 78-79 mmHg, in both antihypertensive drug-untreated and drug-treated persons.

CONCLUSION

In a large primary care-based sample of patients with type-2 diabetes, associations of SBP and DBP with risk of major cardiovascular events and mortality were U-shaped. This may have implications for risk stratification of persons with diabetes.

Differences in health services utilization and costs between antihypertensive medication users versus nonusers in adults with diabetes and concomitant hypertension from Medical Expenditure Panel Survey pooled years 2006 to 2009

OBJECTIVES

To compare population-level baseline characteristics, individual-level utilization, and costs between antihypertensive medication users versus nonusers in adults with diabetes and concomitant hypertension.

METHODS

This longitudinal retrospective observational research used Medical Expenditure Panel Survey household component pooled years 2006 to 2009 to analyze adults 18 years or older with nongestational diabetes and coexistent essential hypertension. Two groups were created: 1) antihypertensive medication users and 2) no antihypertensive pharmacotherapy. We examined average annualized health care costs and emergency department and hospital utilization. Accounting for Medical Expenditure Panel Survey's complex survey design, all analyses used longitudinal weights. Logistic regressions examined the likelihood of utilization and anytihypertensive medication use, and log-transformed multiple linear regression models assessed costs and antihypertensive medication use.

RESULTS

Of the 3261 adults identified with diabetes, 66% (n = 2137) had concomitant hypertension representing 38.7 million individuals during 2006 to 2009. Significantly, the 16% (n = 338) no antihypertensive pharmacotherapy group showed greater mean nights hospitalized (3.6 vs. 1.7, P = 0.0120), greater all-cause hospitalization events per 1000 patient months (41 vs. 24, P = 0.0.007), and lower mean diabetes-related and hypertension-related ambulatory visits. After adjusting for confounders, non-antihypertensive medication users showed 1.64 odds of hospitalization, 29% lower total, and 27% lower average annualized medical expenses compared with antihypertensive medication users.

CONCLUSIONS

In adults with diabetes and coexistent hypertension, we observed significantly greater hospitalizations and lower costs for the non antihypertensive pharmacotherapy group versus those using antihypertensive medications. The short-term time horizon greater hospitalizations with lower expenses among non-antihypertensive medication users with diabetes and concomitant hypertension warrant further study.

Importance of cardiovascular disease risk management in patients with type 2 diabetes mellitus

Type 2 diabetes mellitus (T2DM) is commonly accompanied by other cardiovascular disease (CVD) risk factors, such as hypertension, obesity, and dyslipidemia. Furthermore, CVD is the most common cause of death in people with T2DM. It is therefore of critical importance to minimize the risk of macrovascular complications by carefully managing modifiable CVD risk factors in patients with T2DM. Therapeutic strategies should include lifestyle and pharmacological interventions targeting hyperglycemia, hypertension, dyslipidemia, obesity, cigarette smoking, physical inactivity, and prothrombotic factors. This article discusses the impact of modifying these CVD risk factors in the context of T2DM; the clinical evidence is summarized, and current guidelines are also discussed. The cardiovascular benefits of smoking cessation, increasing physical activity, and reducing low-density lipoprotein cholesterol and blood pressure are well established. For aspirin therapy, any cardiovascular benefits must be balanced against the associated bleeding risk, with current evidence supporting this strategy only in certain patients who are at increased CVD risk. Although overweight, obesity, and hyperglycemia are clearly associated with increased cardiovascular risk, the effect of their modification on this risk is less well defined by available clinical trial evidence. However, for glucose-lowering drugs, further evidence is expected from several ongoing cardiovascular outcome trials. Taken together, the evidence highlights the value of early intervention and targeting multiple risk factors with both lifestyle and pharmacological strategies to give the best chance of reducing macrovascular complications in the long term.

Diabetes and cardiovascular disease: from evidence to clinical practice - position statement 2014 of Brazilian Diabetes Society

There is a very well known correlation between diabetes and cardiovascular disease but many health care professionals are just concerned with glycemic control, ignoring the paramount importance of controlling other risk factors involved in the pathogenesis of serious cardiovascular diseases. This Position Statement from the Brazilian Diabetes Society was developed to promote increased awareness in relation to six crucial topics dealing with diabetes and cardiovascular disease: Glicemic Control, Cardiovascular Risk Stratification and Screening Coronary Artery Disease, Treatment of Dyslipidemia, Hypertension, Antiplatelet Therapy and Myocardial Revascularization. The issue of what would be the best algorithm for the use of statins in diabetic patients received a special attention and a new Brazilian algorithm was developed by our editorial committee. This document contains 38 recommendations which were classified by their levels of evidence (A, B, C and D). The Editorial Committee included 22 specialists with recognized expertise in diabetes and cardiology.

Identification of key nodes of type 2 diabetes mellitus protein interactome and study of their interactions with phloridzin

Network biology-inspired approaches could be used effectively in probing regulatory processes by which small molecules intervene with disease mechanisms. The present study aims at identification of key targets of type 2 diabetes mellitus (T2DM) by network analysis of the underlying protein interactome, and probing for mechanisms by which phloridzin could be critical at altering the disease phenotype. Towards this goal, we constructed a protein-protein interaction network associated with T2DM, starting from candidate genes and systems-level interactions data available. The relevance of the network constructed was verified with the help of gene ontology, node deletion, and biological essentiality studies. Using a network analysis method, MAPK1, EP300, and SMAD2 were identified as the most central proteins of potential therapeutic value. Phloridzin, a known antidiabetic agent, potentially interacts with proteins central to T2DM mechanisms. The structural understanding of interaction of phloridzin with these proteins of relevance to T2DM could provide better insight into its regulatory mechanisms and help in developing better therapeutic agents. The molecular docking results suggest that phloridzin is potentially involved in making critical interactions with MAPK1. These results could further be validated by experimental studies and could be used to design therapeutic agents for T2DM intervention.

Blood pressure control and primary prevention of stroke: summary of the recent clinical trial data and meta-analyses

Stroke is the second most common cause of death worldwide and of adult disability, but in the near future the global burden of cerebrovascular diseases will rise due to ageing and adverse lifestyle changes in populations worldwide. The risk of stroke increases at blood pressure levels above 115/75 mm Hg and high blood pressure (BP) is the most important modifiable risk factor for stroke, associated with 54 % episodes of stroke worldwide. There is strong evidence from clinical trials that antihypertensive therapy reduces substantially the risk of any type of stroke, as well as stroke-related death and disability. The risk attributed to BP is associated not only with absolute values but also with certain parameters describing BP diurnal pattern as well as short-term and long-term variability. Many studies reported that certain features of BP like nocturnal hypertension, morning surge or increased variability predict an increased stroke risk. However, there is no accepted effective modality for correction of these disturbances (chronotherapy, certain classes of antihypertensive drugs). In the elderly, who are mostly affected by stroke, the primary prevention guidelines recommend treatment with diuretics and calcium channel blockers to lower blood pressure to the standard level.

Blood pressure targets for hypertension in people with diabetes mellitus

BACKGROUND

When treating elevated blood pressure (BP), doctors often want to know what blood pressure target they should try to achieve. The standard blood pressure target in clinical practice for some time has been less than 140 - 160/90 - 100 mmHg for the general population of people with elevated blood pressure. Several clinical guidelines published in recent years have recommended lower targets (less than 130/80 mmHg) for people with diabetes mellitus. It is not known whether attempting to achieve targets lower than the standard target reduces mortality and morbidity in those with elevated blood pressure and diabetes.

OBJECTIVES

To determine if 'lower' BP targets (any target less than 130/85 mmHg) are associated with reduction in mortality and morbidity compared with 'standard' BP targets (less than 140 - 160/90 - 100 mmHg) in people with diabetes.

SEARCH METHODS

We searched the Database of Abstracts of Reviews of Effectiveness (DARE) and the Cochrane Database of Systematic Reviews for related reviews. We conducted electronic searches of the Hypertension Group Specialised Register (January 1946 - October 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 9), MEDLINE (January 1946 - October 2013), EMBASE (January 1974 - October 2013) and ClinicalTrials.gov. The most recent search was performed on October 4, 2013.Other search sources were the International Clinical Trials Registry Platform (WHO ICTRP), and reference lists of all papers and relevant reviews.

SELECTION CRITERIA

Randomized controlled trials comparing people with diabetes randomized to lower or to standard BP targets as previously defined, and providing data on any of the primary outcomes below.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed and established the included trials and data entry. Primary outcomes were total mortality; total serious adverse events; myocardial infarction, stroke, congestive heart failure and end-stage renal disease. Secondary outcomes were achieved mean systolic and diastolic BP, and withdrawals due to adverse effects.

MAIN RESULTS

We found five randomized trials, recruiting a total of 7314 participants and with a mean follow-up of 4.5 years. Only one trial (ACCORD) compared outcomes associated with 'lower' (< 120 mmHg) or 'standard' (< 140 mmHg) systolic blood pressure targets in 4734 participants. Despite achieving a significantly lower BP (119.3/64.4 mmHg vs 133.5/70.5 mmHg, P < 0.0001), and using more antihypertensive medications, the only significant benefit in the group assigned to 'lower' systolic blood pressure (SBP) was a reduction in the incidence of stroke: risk ratio (RR) 0.58, 95% confidence interval (CI) 0.39 to 0.88, P = 0.009, absolute risk reduction 1.1%. The effect of SBP targets on mortality was compatible with both a reduction and increase in risk: RR 1.05 CI 0.84 to 1.30, low quality evidence. Trying to achieve the 'lower' SBP target was associated with a significant increase in the number of other serious adverse events: RR 2.58, 95% CI 1.70 to 3.91, P < 0.00001, absolute risk increase 2.0%.Four trials (ABCD-H, ABCD-N, ABCD-2V, and a subgroup of HOT) specifically compared clinical outcomes associated with 'lower' versus 'standard' targets for diastolic blood pressure (DBP) in people with diabetes. The total number of participants included in the DBP target analysis was 2580. Participants assigned to 'lower' DBP had a significantly lower achieved BP: 128/76 mmHg vs 135/83 mmHg, P < 0.0001. There was a trend towards reduction in total mortality in the group assigned to the 'lower' DBP target (RR 0.73, 95% CI 0.53 to 1.01), mainly due to a trend to lower non-cardiovascular mortality. There was no difference in stroke (RR 0.67, 95% CI 0.42 to 1.05), in myocardial infarction (RR 0.95, 95% CI 0.64 to 1.40) or in congestive heart failure (RR 1.06, 95% CI 0.58 to 1.92), low quality evidence. End-stage renal failure and total serious adverse events were not reported in any of the trials. A sensitivity analysis of trials comparing DBP targets < 80 mmHg (as suggested in clinical guidelines) versus < 90 mmHg showed similar results. There was a high risk of selection bias for every outcome analyzed in favor of the 'lower' target in the trials included for the analysis of DBP targets.

AUTHORS' CONCLUSIONS

At the present time, evidence from randomized trials does not support blood pressure targets lower than the standard targets in people with elevated blood pressure and diabetes. More randomized controlled trials are needed, with future trials reporting total mortality, total serious adverse events as well as cardiovascular and renal events.

Aggressive blood pressure reduction and renin-angiotensin system blockade in chronic kidney disease: time for re-evaluation?

Over the past decades, aggressive control of blood pressure (BP) and blockade of the renin-angiotensin-aldosterone system (RAAS) were considered the cornerstones of treatment against progression of chronic kidney disease (CKD), following important background and clinical evidence on the associations of hypertension and RAAS activation with renal injury. To this end, previous recommendations included a BP target of <130/80 mm Hg for all individuals with CKD (and possibly <125/75 mm Hg for those with proteinuria >1 g/day), as well as use of angiotensin-converting-enzyme inhibitors and angiotensin receptor blockers as first-line therapy for hypertension in all CKD patients. However, long-term extensions of relevant clinical trials support a low-BP goal only for patients with proteinuria, whereas recent cardiovascular trials questioned the benefits of low systolic BP for diabetic patients, leading to more individualized recommendations. Furthermore, our previous knowledge of the specific renoprotective properties of RAAS blockers in patients with proteinuric CKD is now extended with data on the use of these agents in patients with less advanced nephropathy and/or absence of proteinuria, deriving mostly from subanalyses of cardiovascular trials. This review discusses previous and recent clinical evidence on the issues of BP reduction and RAAS blockade by type and stage of renal damage, aiming to aid clinicians in their treatment decisions for patients with CKD.

Feasibility and effectiveness in clinical practice of a multifactorial intervention for the reduction of cardiovascular risk in patients with type 2 diabetes: the 2-year interim analysis of the MIND.IT study: a cluster randomized trial

OBJECTIVE

To evaluate the feasibility and effectiveness of an intensive, multifactorial cardiovascular risk reduction intervention in a clinic-based setting.

RESEARCH DESIGN AND METHODS

The study was a pragmatic, cluster randomized trial, with the diabetes clinic as the unit of randomization. Clinics were randomly assigned to either continue their usual care (n = 5) or to apply an intensive intervention aimed at the optimal control of cardiovascular disease (CVD) risk factors and hyperglycemia (n = 4). To account for clustering, mixed model regression techniques were used to compare differences in CVD risk factors and HbA1c. Analyses were performed both by intent to treat and as treated per protocol.

RESULTS

Nine clinics completed the study; 1,461 patients with type 2 diabetes and no previous cardiovascular events were enrolled. After 2 years, participants in the interventional group had significantly lower BMI, HbA1c, LDL cholesterol, and triglyceride levels and significantly higher HDL cholesterol level than did the usual care group. The proportion of patients reaching the treatment goals was systematically higher in the interventional clinics (35% vs. 24% for LDL cholesterol, P = 0.1299; 93% vs. 82% for HDL cholesterol, P = 0.0005; 80% vs. 64% for triglycerides, P = 0.0002; 39% vs. 22% for HbA1c, P = 0.0259; 13% vs. 5% for blood pressure, P = 0.1638). The analysis as treated per protocol confirmed these findings, showing larger and always significant differences between the study arms for all targets.

CONCLUSIONS

A multifactorial intensive intervention in type 2 diabetes is feasible and effective in clinical practice and it is associated with significant and durable improvement in HbA1c and CVD risk profile.

Blood pressure and stroke risk among diabetic patients

CONTEXT

Blood pressure (BP) control can reduce the risk of stroke among diabetic patients; however, it is not known whether the lowest risk of stroke is among diabetic patients with the lowest BP level.

OBJECTIVE

Our objective was to investigate the race-specific association of different levels of BP with stroke risk among diabetic patients in the Louisiana State University Hospital-based longitudinal study.

DESIGN, SETTING, AND PARTICIPANTS

We prospectively investigated the race-specific association of different levels of BP at baseline and during an average of 6.7 years of follow-up with incident stroke risk among 17,536 African American and 12,618 white diabetic patients within the Louisiana State University Hospital System.

MAIN OUTCOME MEASURE

We evaluated incident stroke until May 31, 2012.

RESULTS

During follow-up, 2949 incident cases of stroke were identified. The multivariable-adjusted hazard ratios of stroke associated with different levels of systolic/diastolic BP at baseline (<110/65, 110-119/65-69, 120-129/70-80 [reference group], 130-139/80-90, 140-159/90-100, and ≥160/100 mm Hg) were 1.88 (95% confidence interval = 1.38-2.56), 1.05 (0.80-1.42), 1.00, 1.05 (0.86-1.27), 1.12 (0.94-1.34), and 1.47 (1.24-1.75) for African American diabetic patients and 1.42 (1.06-1.91), 1.22 (0.95-1.57), 1.00, 0.88 (0.72-1.06), 1.02 (0.86-1.21), and 1.28 (1.07-1.54) for white diabetic patients, respectively. A U-shaped association of isolated systolic or diastolic BP at baseline and during follow-up with stroke risk was observed among both African American and white diabetic patients. The U-shaped association was confirmed in both patients who were and were not taking antihypertensive drugs.

CONCLUSIONS

The current study suggests a U-shaped association between BP and the risk of stroke. Aggressive BP control (<110/65 mm Hg) and high BP (≥160/100 mm Hg) are associated with an increased risk of stroke among both African American and white patients with type 2 diabetes.

Blood pressure targets in the treatment of high blood pressure: a reappraisal of the J-shaped phenomenon

The risk that lowering blood pressure (BP) excessively increases the incidence of cardiovascular disease-the J-shaped phenomenon-has been a matter of concern endorsed by many experts, particularly in patients with coronary heart disease and diabetes. The results of the Action to Control Cardiovascular Risk in Type 2 Diabetes (ACCORD) trial strengthened the idea that it may be futile to lower BP more intensively in patients with diabetes. Nevertheless, there seems to be no direct J-shaped relation between BP-lowering treatment and outcome. Patients with normal or low BP and high or very high cardiovascular risk could have their BP reduced further by treatment. Placebo-controlled clinical trials of BP-lowering agents in patients with BP within normal values and concomitant cardiovascular disease demonstrated consistent reduction of recurrent and newer cardiovascular events. The use of BP agents in such conditions, as in patients with coronary artery disease, heart failure, diabetes and in patients recovered from a stroke has been endorsed by guidelines. Although is likely that there is a J-shaped relationship of BP with outcomes in cohort studies, clinical trials that tested more intensive versus standard goals and clinical trials done with patients with low BP demonstrated that the J-shaped phenomenon should not be a concern in the treatment of high BP.

[Antihypertensive therapy in diabetes mellitus - 2012 guidelines of the Austrian Diabetes Association]

Blood pressure lowering is one of the most important interventions for reducing the vascular complications and mortality in patients with diabetes mellitus. Recent studies indicate that the optimal blood pressure level might be in the range between 130-135 mmHg systolic and 80 mmHg diastolic. Lower blood pressure levels (e.g. 120/80 mmHg) can further reduce the risk for stroke and diabetic nephropathy, but are associated with increased cardiovascular mortality. In particular very low blood pressure levels (< 120 mmHg) should be avoided in patients with coronary heart disease or peripheral arterial disease. Most patients with diabetes mellitus need antihypertensive combination therapies, whereby ACE-inhibitors or Angiotensin-II receptor antagonists should be first line drugs.

Latin American consensus on hypertension in patients with diabetes type 2 and metabolic syndrome

The present document has been prepared by a group of experts, members of cardiology, endocrinology and diabetes societies of Latin American countries, to serve as a guide to physicians taking care of patients with diabetes, hypertension and comorbidities or complications of both conditions. Although the concept of 'metabolic syndrome' is currently disputed, the higher prevalence in Latin America of that cluster of metabolic alterations has suggested that 'metabolic syndrome' is a useful nosographic entity in the context of Latin American medicine. Therefore, in the present document, particular attention is paid to this syndrome in order to alert physicians on a particularly high-risk population, usually underestimated and undertreated. These recommendations result from presentations and debates by discussion panels during a 2-day conference held in Bucaramanga, in October 2012, and all the participants have approved the final conclusions. The authors acknowledge that the publication and diffusion of guidelines do not suffice to achieve the recommended changes in diagnostic or therapeutic strategies, and plan suitable interventions overcoming knowledge, attitude and behavioural barriers, preventing both physicians and patients from effectively adhering to guideline recommendations.

Intensive blood pressure control in obese diabetic patients: clinical relevance of stroke prevention in the ACCORD trial

In the ACCORD clinical trial, lowering blood pressure (BP) to normal levels, below currently recommended levels, did not significantly reduce the combined risk of fatal or nonfatal cardiovascular (CV) disease events in adults with Type 2 diabetes. A new post hoc analysis of the same trial also suggests that lowering BP in centrally obese diabetic patients is not a useful means for CV prevention. The authors discuss these findings in the light of accumulated evidence on the relationship between the degree of BP reduction and the risk of CV events in patients with diabetes. In particular, the authors focus on trial and systematic review findings, suggesting that a more intensive reduction of BP in Type 2 diabetes effectively protects from stroke.

The lower, the better? : fractional polynomials meta-regression of blood pressure reduction on stroke risk

OBJECTIVE

Lowering systolic blood pressure (BP) (SBP) by 10 mmHg or diastolic BP by 5 mmHg using any of the main classes of BP lowering drugs reduces stroke by about a third. The objective of the present study is to determine whether there is a limit to the extent to which BP should be lowered.

METHODS

From the individual 17 primary-prevention trials of single drug therapy included in a recent meta-analysis, we abstracted reductions in SBP (SBP reduction in the treatment group minus that in the control group [mmHg]) and data regarding incidence of stroke to generate relative risks (RRs). We performed "flexible" (not "linear") unrestricted maximum likelihood meta-regression, using fractional polynomials, of the reduction in SBP on the risk of stroke.

RESULTS

The best-fitting model offered a gain in deviance of 5.71 with respect to the reference linear model, according to the expected inverse J-shaped (nadir at a 13.7-mmHg reduction in SBP) dose-response relation between reductions in SBP and logarithmic RRs for stroke.

CONCLUSIONS

More than 13.7-mmHg SBP reduction with single drug therapy could produce no longer additional reduction in the risk of stroke in a primary-prevention setting.

Type 2 diabetes in older people; the importance of blood pressure control

Diabetes and hypertension often coexist and their coexistence substantially promote cardiovascular disease (CVD) and chronic kidney disease. Control of blood pressure to a level of 140/90 mm Hg in people with diabetes can prevent or at least delay CVD and chronic kidney disease.. In the past many society treatment guidelines have stressed tight blood pressure control (=< 130/80) for people with diabetes. But recommendations for such tight blood pressure control have not been supported by recent large randomized control trials, especially in in elderly. Here we review the recent literature regarding the benefits of blood pressure control in elderly patients with diabetics. We further focus on evidence for specific levels of blood pressure treatment goals, in this population subset..

Masked hypertension in diabetes mellitus: treatment implications for clinical practice

Although distinguishing features of masked hypertension in diabetics are well known, the significance of antihypertensive treatment on clinical practice decisions has not been fully explored. We analyzed 9691 subjects from the population-based 11-country International Database on Ambulatory Blood Pressure in Relation to Cardiovascular Outcomes. Prevalence of masked hypertension in untreated normotensive participants was higher (P<0.0001) among 229 diabetics (29.3%, n=67) than among 5486 nondiabetics (18.8%, n=1031). Over a median of 11.0 years of follow-up, the adjusted risk for a composite cardiovascular end point in untreated diabetic-masked hypertensives tended to be higher than in normotensives (hazard rate [HR], 1.96; 95% confidence interval [CI], 0.97-3.97; P=0.059), similar to untreated stage 1 hypertensives (HR, 1.07; CI, 0.58-1.98; P=0.82), but less than stage 2 hypertensives (HR, 0.53; CI, 0.29-0.99; P=0.048). In contrast, cardiovascular risk was not significantly different in antihypertensive-treated diabetic-masked hypertensives, as compared with the normotensive comparator group (HR, 1.13; CI, 0.54-2.35; P=0.75), stage 1 hypertensives (HR, 0.91; CI, 0.49-1.69; P=0.76), and stage 2 hypertensives (HR, 0.65; CI, 0.35-1.20; P=0.17). In the untreated diabetic-masked hypertensive population, mean conventional systolic/diastolic blood pressure was 129.2 ± 8.0/76.0 ± 7.3 mm Hg, and mean daytime systolic/diastolic blood pressure 141.5 ± 9.1/83.7 ± 6.5 mm Hg. In conclusion, masked hypertension occurred in 29% of untreated diabetics, had comparable cardiovascular risk as stage 1 hypertension, and would require considerable reduction in conventional blood pressure to reach daytime ambulatory treatment goal. Importantly, many hypertensive diabetics when receiving antihypertensive therapy can present with normalized conventional and elevated ambulatory blood pressure that mimics masked hypertension.

Blood pressure and risk of cardiovascular diseases in type 2 diabetes: further findings from the Swedish National Diabetes Register (NDR-BP II)

OBJECTIVES

Estimate risks of coronary heart disease (CHD), stroke and cardiovascular disease (CVD) with updated mean systolic (SBP) and diastolic (DBP) blood pressure in an observational study of patients with type 2 diabetes.

METHODS

Thirty-five thousand and forty-one patients treated with antihypertensive drugs, and 18 512 untreated patients, aged 30-75 years, without previous heart failure, followed for 6 years until 2009.

RESULTS

In treated patients, nonlinear splines for 6-year risk of fatal/nonfatal CHD, stroke and CVD by BP as a continuous variable showed a progressive increase with higher SBP from 140  mmHg and higher, and with DBP from 80  mmHg, with a J-shaped risk curve at lowest SBP levels, but not obviously at lowest DBP levels. Analysing intervals of SBP with 130-134  mmHg as reference at Cox regression, adjusted hazard ratios (HR) for fatal/nonfatal CHD, stroke and CVD with at least 140  mmHg were 1.22 [95% confidence interval (CI): 1.08-1.39], 1.43 (1.18-1.72), 1.26 (1.13-1.41), all P < 0.001. HR with 115-129 and 135-139  mmHg were nonsignificant, whereas increased with 100-114  mmHg, 1.96 (P < 0.001), 1.75 (P = 0.02), 2.08 (P < 0.001), respectively. With DBP 75-79  mmHg as reference, adjusted HR for fatal/nonfatal CHD, stroke and CVD with DBP 80-84  mmHg were 1.42 (1.26-1.59), 1.46 (1.24-1.72), 1.39 (1.26-1.53), all P < 0.001. Corresponding HR with DBP at least 85  mmHg were 1.70 (1.50-1.92), 2.35 (1.99-2.77), 1.87 (1.69-2.07), all P < 0.001. Corresponding HR with DBP 60-69 and 70-74  mmHg were nonsignificant. The picture was similar in 7059 patients with previous CVD and in untreated patients.

CONCLUSION

BP around 130-135/75-79  mmHg showed lower risks of cardiovascular diseases in patients with type 2 diabetes.

Role of physician gender in drug therapy

There is evidence that female patients receive less intensified drug therapy in many medical conditions than male patients. However, there are only limited data regarding the influence of physician gender on drug therapy. It has been shown, for example, that female physicians tend to adhere more closely to guideline-recommended pharmacotherapy compared to their male counterparts. In some medical conditions where drug therapy is only one among various components of a complex interplay of therapeutic regimes (e.g., diabetes, cardiovascular diseases, depression, pain management), female physicians seem to achieve better overall intermediate outcomes and some studies suggest that "better" drug therapy is provided by female compared to male physicians. The reasons for the overall better outcomes may be superior communication skills of female physicians, participatory decision making, and consequently improved drug adherence in addition to or in combination with more effective non-pharmacologic treatment results. It is impossible to distinguish between the individual contributions of drug- and nondrug-related influence on such improved outcomes and thus to determine whether they are due to unconfounded physician gender effects on drug therapy. There is until now in no area of medicine evidence to suggest that a patient will consistently receive higher quality of drug therapy by switching to a physician of a specific gender.

Biomarkers and surrogate endpoints in clinical trials

One of the most important considerations in designing clinical trials is the choice of outcome measures. These outcome measures could be clinically meaningful endpoints that are direct measures of how patients feel, function, and survive. Alternatively, indirect measures, such as biomarkers that include physical signs of disease, laboratory measures, and radiological tests, often are considered as replacement endpoints or 'surrogates' for clinically meaningful endpoints. We discuss the definitions of clinically meaningful endpoints and surrogate endpoints, and provide examples from recent clinical trials. We provide insight into why indirect measures such as biomarkers may fail to provide reliable evidence about the benefit-to-risk profile of interventions. We also discuss the nature of evidence that is important in assessing whether treatment effects on a biomarker reliably predict effects on a clinically meaningful endpoint, and provide insights into why this reliability is specific to the context of use of the biomarker.

The occurrence rate of cerebrovascular and cardiac events in patients receiving antihypertensive therapy from the post-marketing surveillance data for valsartan in Japan (J-VALID)

It is well known that blood pressure (BP) management reduces the incidence of cerebrovascular and cardiovascular events. However, it is unclear how many of these events occur in hypertensive patients who receive pharmacological treatment. The aim of this survey was to evaluate the occurrence rate of both types of events in patients receiving valsartan-based treatment. Of 30 366 patients treated with valsartan, 28 356 patients were observed for 2.93 years. Antihypertensive drugs other than valsartan were used in 56.8% of patients. After the administration of valsartan, the systolic and diastolic BP significantly decreased from 161.1±19.1/90.4±13.1 to 139.9±18.1/79.6±11.9 mm Hg. Cerebrovascular events were observed in 550 patients (1.94%, 9.29/1000 patient-years), and cardiac events were observed in 576 patients (2.03%, 9.73/1000 patient-years). A comparative analysis of the hazard ratios for cerebrovascular and cardiac events according to the BP level at the endpoint showed a BP-dependent reduction of risk for cerebrovascular events, and the change in risk exhibited a J-curve phenomenon in the relationship between cardiac events and systolic BP. The J-curve phenomenon was not observed in patients aged <75 years, but it was observed for the systolic BP in patients aged 75 years. Adverse drug reactions were observed in 1925 of 28 420 patients (6.77%). This post-marketing surveillance data for valsartan showed the outcomes for treated hypertensive patients in a large population in Japan who were followed for up to 3 years. These data will add important knowledge regarding the treatment of hypertension in Japan.

Association of systolic and diastolic blood pressure and all cause mortality in people with newly diagnosed type 2 diabetes: retrospective cohort study

OBJECTIVE

To examine the effect of systolic and diastolic blood pressure achieved in the first year of treatment on all cause mortality in patients newly diagnosed with type 2 diabetes, with and without established cardiovascular disease.

DESIGN

Retrospective cohort study.

SETTING

United Kingdom General Practice Research Database, between 1990 and 2005.

PARTICIPANTS

126,092 adult patients (age ≥ 18 years) with a new diagnosis of type 2 diabetes who had been registered with participating practices for at least 12 months.

MAIN OUTCOME MEASURE

All cause mortality.

RESULTS

Before diagnosis, 12,379 (9.8%) patients had established cardiovascular disease (myocardial infarction or stroke). During a median follow-up of 3.5 years, we recorded 25,495 (20.2%) deaths. In people with cardiovascular disease, tight control of systolic (<130 mm Hg) and diastolic (<80 mm Hg) blood pressure was not associated with improved survival, after adjustment for baseline characteristics (age at diagnosis, sex, practice level clustering, deprivation score, body mass index, smoking, HbA(1c) and cholesterol levels, and blood pressure). Low blood pressure was also associated with an increased risk of all cause mortality. Compared with patients who received usual control of systolic blood pressure (130-139 mm Hg), the hazard ratio of all cause mortality was 2.79 (95% confidence interval 1.74 to 4.48, P<0.001) for systolic blood pressure at 110 mm Hg. Compared with patients who received usual control of diastolic blood pressure (80-84 mm Hg), the hazard ratios were 1.32 (1.02 to 1.78, P=0.04) and 1.89 (1.40 to 2.56, P<0.001) for diastolic blood pressures at 70-74 mm Hg and lower than 70 mm Hg, respectively. Similar associations were found in people without cardiovascular disease. Subgroup analyses of people diagnosed with hypertension and who received treatment for hypertension confirmed initial findings.

CONCLUSION

Blood pressure below 130/80 mm Hg was not associated with reduced risk of all cause mortality in patients with newly diagnosed diabetes, with or without known cardiovascular disease. Low blood pressure, particularly below 110/75 mm Hg, was associated with an increased risk for poor outcomes.

Are there new threshold and goals in the treatment of arterial hypertension?

BACKGROUND

About half of the global burden of cardiovascular disease has been attributed to high blood pressure (BP). Worldwide, 7·6 million premature deaths (about 13·5% of the global total), 54% of strokes, and 47% of cases of ischemic heart disease were caused by high BP in 2001.

METHODS AND RESULTS

All guidelines agree that pharmacological treatment of patients with hypertension should be initiated as soon as BP rises >140/90 mmHg. Available data support the reduction of BP to values to <140/90 mmHg, but do not favor a reduction to <130/80 mmHg in patients with diabetes or a history of cardiovascular disease because of the absence of evidence obtained in prospective studies.

CONCLUSIONS

This review updates the controversies and challenges involved in the treatment of patients with established arterial hypertension, such as the progression of high-normal BP to overt hypertension, the choice of appropriate threshold and goal BP levels, the adequate number of drugs to be used since the early stages of hypertension, and which type of combination therapy offers most advantages to the patient.

Long-term changes of the prevalence and control rate of hypertension among Korean adults with diagnosed diabetes: 1998-2008 Korean National Health and Nutrition Examination Survey

AIMS

We investigated the long-term changes in the prevalence and the control rate of hypertension among Korean adults diagnosed with diabetes.

METHODS

Using data from the Korean National Health and Nutrition Examination Survey (1998-2008), including 1384 adults diagnosed with diabetes, we analyzed changes in the prevalence of hypertension (mean SBP ≥ 140 mmHg, DBP ≥ 90 mmHg, or use of antihypertensive medication) and the control rate of hypertension (BP < 130/80 mmHg).

RESULTS

The prevalence of hypertension in diabetic adults was 50.9% in 1998 and 51.7% in 2008 (P = 0.563). The mean blood pressure decreased from 138.1 ± 1.1/80.0 ± 0.6 mmHg to 124.7 ± 0.8/76.0 ± 0.5 mmHg (P < 0.001); awareness (37.4 to 85.2%, P < 0.001), treatment (37.4 to 81.8%, P < 0.001), and the control rate (20.1 to 34.7%, P = 0.001) steadily increased. The prevalence of hypertension increased significantly more in the obese group compared with the non-obese group (53.3% vs. 49.0% in 1998, P = 0.784; 64.3% vs. 42.0% in 2008, P < 0.0001, respectively, P for trend = 0.0001).

CONCLUSIONS

Although the rates of hypertension treatment have significantly improved, the control rate remains inadequate, and intensive intervention is urgently needed.