Lower blood pressure goals in high-risk cardiovascular patients: are they defensible?

Current status of aggressive blood glucose and blood pressure control in diabetic hypertensive subjects

Uncontrolled diabetes mellitus (DM) is associated with high cardiovascular morbidity and mortality. The coexistence of hypertension and DM multiplies the diabetic complications manifold. Earlier studies have shown that lowering blood glucose, blood pressure (BP), or both decreases the diabetic complications. On the basis of these results, national and international guidelines have recommended aggressive blood glucose and BP control in patients with DM to glycosylated hemoglobin <7.0% and BP <130/80 mm Hg. However, several recent clinical outcomes trials have demonstrated that lowering glycosylated hemoglobin to <7.0% and BP to <130/80 mm Hg does not add any additional benefit to patients with DM and hypertension and may be detrimental to their health. The consensus of scientific opinion at present is that BP should be reduced to 130 to 139/70 to 80 mm Hg in patients with DM with increased cardiovascular risk. The investigators conducted a Medline search of English-language papers published from 1998 to 2010 regarding aggressive blood glucose and BP control in patients with DM and hypertension, and 15 pertinent reports were selected. In conclusion, a review of recent research findings suggests less aggressive control of glucose and BP, and "the lower the better" may not be defensible at present, until new data become available.

Recognition, pathogenesis, and treatment of different stages of nephropathy in patients with type 2 diabetes mellitus

Nephropathy is a common microvascular complication among patients with type 2 diabetes mellitus and a major cause of kidney failure. It is characterized by albuminuria (≥ 300 mg/d) and a reduced glomerular filtration rate and is often present at the time of diabetes diagnosis after the kidney has been exposed to chronic hyperglycemia during the prediabetic phase. A low glomerular filtration rate (<60 mL/min/1.73 m(2)) is also an independent risk factor for cardiovascular events and death. Detection of diabetic nephropathy during its initial stages provides the opportunity for early therapeutic interventions to prevent or delay the onset of complications and improve outcomes. An intensive and multifactorial management approach is needed that targets all risk determinants simultaneously. The strategy should comprise lifestyle modifications (smoking cessation, weight loss, increased physical activity, and dietary changes) coupled with therapeutic achievement of blood glucose, blood pressure, and lipid goals that are evidence-based. Prescribing decisions should take into account demographic factors, level of kidney impairment, adverse effects, risk of hypoglycemia, tolerability, and effects on other risk factors and comorbidities. Regular and comprehensive follow-up assessments with appropriate adjustment of the therapeutic regimen to maintain risk factor control is a vital component of care, including referral to specialists, when required.