Are blood pressure and diabetes additive or synergistic risk factors? Outcome in 8494 subjects randomly recruited from 10 populations

Development and validation of nomograms for predicting cardiovascular disease risk in patients with prediabetes and diabetes

This study aimed to develop and validate distinct nomogram models for assessing CVD risk in individuals with prediabetes and diabetes. In a cross-sectional study design, we examined data from 2294 prediabetes and 1037 diabetics who participated in the National Health and Nutrition Examination Survey, which was conducted in the United States of America between 2007 and 2018. The dataset was randomly divided into training and validation cohorts at a ratio of 0.75-0.25. The Boruta feature selection method was used in the training cohort to identify optimal predictors for CVD diagnosis. A web-based dynamic nomogram was developed using the selected features, which were validated in the validation cohort. The Hosmer-Lemeshow test was performed to assess the nomogram's stability and performance. Receiver operating characteristics and calibration curves were used to assess the effectiveness of the nomogram. The clinical applicability of the nomogram was evaluated using decision curve analysis and clinical impact curves. In the prediabetes cohort, the CVD risk prediction nomogram included nine risk factors: age, smoking status, platelet/lymphocyte ratio, platelet count, white blood cell count, red cell distribution width, lactate dehydrogenase level, sleep disorder, and hypertension. In the diabetes cohort, the CVD risk prediction nomogram included eleven risk factors: age, material status, smoking status, systemic inflammatory response index, neutrophil-to-lymphocyte ratio, red cell distribution width, lactate dehydrogenase, high-density lipoprotein cholesterol, sleep disorder, hypertension, and physical activity. The nomogram models developed in this study have good predictive and discriminant utility for predicting CVD risk in patients with prediabetes and diabetes.

Association between brominated flame retardants (PBDEs and PBB153) exposure and hypertension in U.S. adults: results from NHANES 2005-2016

BACKGROUND

Brominated Flame Retardants (BFRs) have attracted widespread concern due to their environmental persistence and potential toxicity. This study aims to examine the association between BFRs exposure and hypertension.

METHODS

We used data from the National Health and Nutrition Examination Survey (NHANES) spanning 2005 to 2016 for the cross-sectional analysis. To evaluate the individual and combined impacts of BFRs exposure on hypertension, we utilized multivariate models, including generalized additive models, weighted quantile sum (WQS) regression, and Bayesian kernel machine regression (BKMR) models.

RESULTS

9882 individuals (48% male) aged ≥ 20 were included in the final analysis, of whom 4114 had hypertension. After controlling for potential covariates, higher serum concentrations of PBDE100 (OR: 1.26; 95% CI: 1.01, 1.57) and PBDE153 (OR: 1.50; 95% CI: 1.18, 1.88) were significantly associated with hypertension. A nonlinear relationship between PBDE28 and hypertension was observed (P = 0.03). Moreover, BFRs mixture were positively associated with the prevalence of hypertension in both the WQS (β:1.09; 95% CI: 1.02, 1.17; P = 0.02) and BKMR models.

CONCLUSION

Our study suggested that BFRs exposure is positively associated with hypertension in the general population. To confirm this association and elucidate the mechanisms, further research is required.

Differences in the impact of newly diagnosed type 2 diabetes on cardiovascular mortality between normotensive and hypertensive individuals

OBJECTIVE

We investigated the interrelationship between hyperglycemia and hypertension on cardiovascular mortality in the middle-aged and elderly people.

METHODS

In this retrospective cohort study that used data from the Hiroshima Study on Glucose Metabolism and Cardiovascular Diseases, we included 16,564 participants without cardiovascular disease (mean age: 65.8 years; 6179 normoglycemic people, 3017 people with newly diagnosed type 2 diabetes, and 7368 people with prediabetes per the 75-g oral glucose tolerance test). Hypertension was defined as the use of antihypertensive medications and/or having a systolic/diastolic blood pressure of at least 140/90 mm Hg.

RESULTS

During a median follow-up period of 12.4 years, a total of 1513 cardiovascular death occurred. Cardiovascular death rates per 1000 participant-years were 4.01, 4.98, 8.33, 8.22, 8.81, and 11.1 among normotensive participants with normal glycemia, prediabetes, and diabetes and hypertensive participants with normal glycemia, prediabetes, and diabetes, respectively. Prediabetes was significantly associated with a high risk of cardiovascular mortality in normotensive individuals [hazard ratio: 1.24, 95% confidence interval (95% CI): 1.02-1.50] but not in hypertensive individuals. Type 2 diabetes was associated with a high risk of cardiovascular mortality in both normotensive (hazard ratio: 1.94, 95% CI: 1.55-2.43) and hypertensive individuals (hazard ratio: 1.35, 95% CI: 1.13-1.62). Stratified analyses revealed no significant impact of type 2 diabetes on cardiovascular mortality in hypertensive individuals aged at least 65 years.

CONCLUSION

The effect of hyperglycemia on cardiovascular death differed with age and the presence or absence of hypertension, demonstrating the clinical importance of case-specific risk assessments.

Validation of the ANDON KD-595 automated upper-arm blood pressure monitor according to the universal standard

OBJECTIVE

To validate the ANDON KD-595 automated upper-arm blood pressure monitor for clinical use and self-measurement blood pressure measurement according to the Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization (AAMI/ESH/ISO) Universal Standard.

METHODS

Same left-arm blood pressure was sequentially measured in 90 qualified adult participants and compared with a standard mercury sphygmomanometer. A total of 270 comparison pairs were obtained and analyzed according to the universal standard.

RESULTS

For the validation Criterion 1 of the universal standard, the mean ± SD of the differences between the test device and reference blood pressure readings was 0.96 ± 5.35 and 0.82 ± 5.08 mmHg for SBP and DBP, respectively. For Criterion 2, the SDs of the averaged blood pressure differences between the test device and reference blood pressure per subject were 4.84 and 4.64 mmHg (with maximum allowed SDs of 6.87 and 6.89 mmHg) for SBP and DBP, respectively.

CONCLUSION

The ANDON KD-595 automated upper-arm blood pressure monitor passed all the validation requirements according to the AAMI/ESH/ISO Universal Standard and can be recommended for clinical use and self-measurement blood pressure measurement in the general population.

Effect of income level on stroke incidence and the mediated effect of simultaneous diagnosis of metabolic syndrome diseases; a nationwide cohort study in South Korea

BACKGROUND

This study aimed to determine whether a simultaneous diagnosis of main components of metabolic syndrome (MetS) (hypertension, diabetes mellitus, and dyslipidemia) plays a mediator between income level and stroke.

METHODS

We used the National Health Insurance Service National Sample Cohort database from 2006 to 2015. The mediator variables were the number of main MetS components diagnosed simultaneously (two or more/three or more). We used a weighting approach method of causal mediation analysis to apply counterfactual frameworks to the Cox proportional hazards regression model.

RESULTS

A total of 213,526 people were included with 1,690,665.3 person-years of followed up. Compared with the high-income group, the risk of being diagnosed with two or more components of MetS significantly increased in all other income groups [middle-income OR 1.05 (95% CI 1.02-1.08); low-income OR 1.09 (95% CI 1.05-1.12); Medical Aid beneficiaries OR 1.39 (95% CI 1.32-1.47)]. A lower level of income was significantly associated with a higher risk of stroke compared with the high-income group [middle-income HR 1.15 (95% CI 1.07-1.25); low-income HR 1.19 (95% CI 1.10-1.29); Medical Aid beneficiaries HR 1.63 (95% CI 1.48-1.80)]. In the Medical Aid beneficiaries, simultaneous diagnosis of the main metabolic components acted as a significant mediator between income levels and stroke incidence, with 26.6% mediated when diagnosed with two or more diseases and 21.1% when diagnosed with all three.

CONCLUSIONS

Co-diagnosis of MetS components played a significant mediator role between income level and stroke incidence.

Aggregation and combination of cardiovascular risk factors and their association with 10-year all-cause mortality: the PERU MIGRANT Study

OBJECTIVE

To estimate the association between the aggregation and pair-wise combination of selected cardiovascular risk factors (CVRF) and 10-year all-cause mortality.

METHODS

Secondary data analysis of the PERU MIGRANT study, a prospective population-based cohort. Ten-year all-cause mortality was determined for participants originally enrolled in the PERU MIGRANT Study (baseline in 2007) through the National Registry of Identification and Civil Status. The CVRF included hypertension, type 2 diabetes mellitus, hypercholesterolemia, and overweight/obesity. Exposures were composed of both the aggregation of the selected CVRF (one, two, and three or more CVRF) and pair-wise combinations of CVRF. Cox regression models were used to calculate hazard ratios (HR) and 95% confidence intervals (95% CI).

FINDINGS

Of the 989 participants evaluated at baseline, 976 (98.8%) had information about vital status at 10 years of follow-up (9992.63 person-years), and 63 deaths were recorded. In the multivariable model, adjusting for sociodemographic and lifestyle variables, participants with two CVRF (HR: 2.48, 95% CI: 1.03-5.99), and those with three or more CVRF (HR: 3.93, 95% CI: 1.21-12.74) had higher all-cause mortality risk, compared to those without any CVRF. The pair-wise combinations associated with the highest risk of all-cause mortality, compared to those without such comorbidities, were hypertension with type 2 diabetes (HR: 11.67, 95% CI: 3.67-37.10), and hypertension with overweight/obesity (HR: 2.76, 95% CI: 1.18-6.71).

CONCLUSIONS

The aggregation of two or more CVRF and the combination of hypertension with type 2 diabetes or overweight/obesity were associated with an increased risk of 10-year all-cause mortality. These risk profiles will inform primary and secondary prevention strategies to delay mortality from cardiovascular risk factors.

Evaluation of arterial hypertension by ambulatory blood pressure monitoring in pediatric liver transplant recipients

OBJECTIVE

Many cardiovascular complications, including hypertension, are seen in pediatric liver transplantation. The purpose of this study was to analyze the frequency of arterial hypertension of pediatric liver transplant recipients and also to determine the related risk factors.

METHODS

Thirty-six pediatric liver transplant recipients aged 8-17 years were prospectively studied by manual and ambulatory blood pressure measurement (ABPM) technique.

RESULTS

The mean age of patients was 12.42 ± 2.74 years and the mean ABPM measurement time after transplantation was 2 years (3 months-5.9 years). Only one (2.7%) patient was detected as hypertensive by casual measurement, but 17 (47.2%) patients were found to be hypertensive when measured through ABPM. Of children that were found to be hypertensive as a result of ABPM, 64.7% were observed to have a nondipper pattern. Considering the time passed after the transplantation, patients were found to be more hypertensive in the first 2 years posttransplant although it was not found statistically significant.

CONCLUSIONS

In this study, it has been shown that it is possible to diagnose hypertension at an earlier period of transplantation using ABPM in pediatric liver transplant patients. ABPM is needed to detect masked hypertension that may develop following liver transplantation.

Prevalence of diabetes and hypertension and their interaction effects on cardio-cerebrovascular diseases: a cross-sectional study

BACKGROUND

Hypertension and diabetes mellitus are two of the major risk factors for cardio-cerebrovascular diseases (CVDs). Although prior studies have confirmed that the coexistence of the two can markedly increase the risk of CVDs, few studies investigated whether potential interaction effects of hypertension and diabetes can result in greater cardio-cerebrovascular damage. We aimed to investigate the prevalence of hypertension and diabetes and whether they both affect synergistically the risk of CVDs.

METHODS

A cross-sectional study was conducted by using a multistage stratified random sampling among communities in Changsha City, Hunan Province. Study participants aged > = 18 years were asked to complete questionnaires and physical examinations. Multivariate logistic regression models were performed to evaluate the association of diabetes, hypertension, and their multiplicative interaction with CVDs with adjustment for potential confounders. We also evaluated additive interaction with the relative excess risk ratio (RERI), attribution percentage (AP), synergy index (SI).

RESULTS

A total of 14,422 participants aged 18-98 years were collected (men = 5827, 40.7%). The prevalence was 22.7% for hypertension, 7.0% for diabetes, and 3.8% for diabetes with hypertension complication, respectively. Older age, women, higher educational level, unmarried status, obesity (central obesity) were associated with increased risk of hypertension and diabetes. We did not find significant multiplicative interaction of diabetes and hypertension on CVDs, but observed a synergistic additive interaction on coronary heart disease (SI, 1.43; 95% CI, 1.03-1.97; RERI, 1.94; 95% CI, 0.05-3.83; AP, 0.26; 95% CI, 0.06-0.46).

CONCLUSIONS

Diabetes and hypertension were found to be associated with a significantly increased risk of CVDs and a significant synergistic additive interaction of diabetes and hypertension on coronary heart disease was observed. Participants who were old, women, highly educated, unmarried, obese (central obese) had increased risk of diabetes and hypertension.

Ambulatory blood pressure monitoring over 24 h: A Latin American Society of Hypertension position paper-accessibility, clinical use and cost effectiveness of ABPM in Latin America in year 2020

Accurate office blood pressure measurement remains crucial in the diagnosis and management of hypertension worldwide, including Latin America (LA). Office blood pressure (OBP) measurement is still the leading technique in LA for screening and diagnosis of hypertension, monitoring of treatment, and long-term follow-up. Despite this, due to the increasing awareness of the limitations affecting OBP and to the accumulating evidence on the importance of ambulatory BP monitoring (ABPM), as a complement of OBP in the clinical approach to the hypertensive patient, a progressively greater attention has been paid worldwide to the information on daytime and nighttime BP patterns offered by 24-h ABPM in the diagnostic, prognostic, and therapeutic management of hypertension. In LA countries, most of the Scientific Societies of Hypertension and/or Cardiology have issued guidelines for hypertension care, and most of them include a special section on ABPM. Also, full guidelines on ABPM are available. However, despite the available evidence on the advantages of ABPM for the diagnosis and management of hypertension in LA, availability of ABPM is often restricted to cities with large population, and access to this technology by lower-income patients is sometimes limited by its excessive cost. The authors hope that this document might stimulate health authorities in each LA Country, as well as in other countries in the world, to regulate ABPM access and to widen the range of patients able to access the benefits of this technique.

Prevalence of hypertension, diabetes, and dyslipidemia, and their additive effects on myocardial infarction and stroke: a cross-sectional study in Nanjing, China

BACKGROUND

This study aimed to investigate the prevalence and risk factors for hypertension, diabetes, and dyslipidemia, and to evaluate their additive effects on myocardial infarction (MI) and stroke in Nanjing in East China.

METHODS

A multistage, stratified random cluster sampling method was used to select representative participants. All eligible participants completed questionnaires, physical measurements, and blood tests. Multivariable and univariable logistic regression analyses were used to identify associated risk factors and evaluate additive effects on cardiovascular events, respectively.

RESULTS

Hypertension was the most prevalent chronic disease among 11,036 participants enrolled (18.5%), followed by dyslipidemia (8.3%) and diabetes (6.0%). The prevalence of hypertension was higher in men than in women while no sex-related difference was observed in the prevalence of diabetes and dyslipidemia. Older age and higher body mass index were risk factors for all three diseases. Sex, central obesity, smoking, number of family members, salt intake, and family history of hypertension were associated with hypertension; central obesity, smoking, alcohol assumption, and family history of diabetes correlated with diabetes; and female sex, higher education, and alcohol assumption were risk factors for dyslipidemia. Hypertension complicated with dyslipidemia conferred more risk of MI and stroke than independent effects. Diabetes also contributed to risk based on hypertension or dyslipidemia.

CONCLUSIONS

The burden of hypertension and diabetes has stopped increasing. However, total cholesterol (TC) concentration in the population has not been well controlled. A more comprehensive approach to managing dyslipidemia, hypertension, and diabetes needs to be developed, especially for individuals with multiple cardiovascular risk factors.

Comparison between newly diagnosed hypertension in diabetes and newly diagnosed diabetes in hypertension

BACKGROUND

Hypertension and diabetes mellitus are often jointly present, especially in early onset cases of either disease. We investigated clinical characteristics of hypertensive patients with newly diagnosed diabetes and diabetic patients with newly diagnosed hypertension.

METHODS

Our study subjects were recruited in a China nationwide multicenter registry of hypertension and diabetes (n = 2510). We performed logistic regression to compare patients seen for hypertension in cardiology, with newly diagnosed diabetes (n = 137) and patients seen for diabetes mellitus in endocrinology, with newly diagnosed hypertension (n = 155). Albuminuria was defined as a urinary albumin-to-creatinine ratio of ≥ 30 mg/g, and left ventricular hypertrophy according to the Cornell product index.

RESULTS

These two groups of patients with both hypertension and diabetes mellitus were similar in most of the characteristics (P ≥ 0.06). However, hypertensive patients with newly diagnosed diabetes, compared to diabetic patients with newly diagnosed hypertension, had a significantly greater body mass index (26.3 vs. 25.4 kg/m², P = 0.03) and slower heart rate (73.7 vs. 78.1 beats/min, P = 0.01). In logistic regression analyses adjusted for sex (48.3% women) and age (mean 60.0 ± 11.5 years), the odds ratio for newly diagnosed diabetes mellitus versus newly diagnosed hypertension was 1.27 (95% CI 1.03-1.56) and 0.80 (95% CI 0.66-0.96) for body mass index (+ 3 kg/m²) and heart rate (+ 10 beat/min), respectively. Hypertensive patients with newly diagnosed diabetes also had a lower prevalence of albuminuria (16.0% vs. 30.1%, P = 0.02) and slightly and non-significantly higher prevalence of left ventricular hypertrophy (5.1% vs. 1.9%, P = 0.14) than diabetic patients with newly diagnosed hypertension.

CONCLUSIONS

Earlier or later onset of hypertension than diabetes mellitus may have different risk factors and organ damage.

Risk of stroke and coronary heart disease among various levels of blood pressure in diabetic and nondiabetic Chinese patients

OBJECTIVE

To compare the risk of stroke and coronary heart disease (CHD) among various blood pressure (BP) levels in diabetic and people without diabetes Chinese patients.

METHODS

This cross-sectional study was part of Prospective Urban Rural Epidemiology China study. Patients aged 35 to70 years were recruited from 12 provinces of China between 2005 and 2009. The participants were classified into three groups: hypertension (HTN), high normal BP, and normal BP, and also into SBP and DBP quintiles.

RESULTS

A total of 42 959 patients were analyzed with 38 975 (90.7% of total population) people without diabetes and 3984 (9.3% of total population) diabetic patients. Among diabetic patients, the HTN group was associated with an increased risk of stroke (odds ratio, 3.03; 95% confidence interval, 1.47-6.25) and CHD (odds ratio, 2.21; 95% confidence interval, 1.45-3.38), when compared with normal BP group. Similar results were drawn in nondiabetic patients. However, no significant difference in risk of stroke or CHD was found between high normal BP and normal BP groups in either diabetic or nondiabetic patients. Risk of CHD and stroke increased significantly when SBP was above 125 mmHg or DBP above 72 mmHg in people without diabetes, whereas this trend was attenuated in diabetic patients.

CONCLUSION

HTN was associated with a two-fold increased risk of CHD and a three-fold increased risk of stroke compared with normotension irrespective of diabetes status. For diabetic patients with HTN, a more comprehensive method is essential for assessing cardiovascular risk.

Hypertension with diabetes mellitus: significance from an epidemiological perspective for Japanese

The prevalence of both hypertension and diabetes mellitus is increasing worldwide. Both diseases lead to severe complications such as cardiovascular and chronic kidney diseases, which increase the risk of death over a long period of time. Therefore, the prevention and aggravation of hypertension and diabetes mellitus are major challenges. Because few review articles have focused on the epidemiological perspective of hypertension and diabetes mellitus, we reviewed major observational studies mainly from Japan and from Western countries that have reported on the prevalence of hypertension and diabetes mellitus, the binominal risk of hypertension and diabetes mellitus, and the risk of their coexistence. Our investigation found that approximately 50% of diabetic patients had hypertension, and approximately 20% of hypertensive patients had diabetes mellitus. Those with either hypertension or diabetes mellitus had a 1.5- to 2.0-fold higher risk of having both conditions. These results were similar for both Japan and Western countries. Although comparing the results between Japan and Western countries was difficult because the risks were estimated using widely varying statistical analyses, it was revealed that the coexistence of hypertension and diabetes mellitus certainly increased the risk of complications regardless of the country. The definition, prevalence and medical treatment of hypertension and diabetes mellitus will change in the future. For early intervention based on the latest evidence to prevent severe complications, it is important to accumulate epidemiological knowledge of hypertension and diabetes mellitus and to update the evidence for both Japan and other countries.

Prevalence of resistant hypertension and associated factors in Japanese subjects with type 2 diabetes

OBJECTIVE

The prevalence of treatment resistant hypertension (RH) depends on methods used for blood pressure (BP) measurements, goals of BP, and therapeutic efforts in terms of medication and adherence. We focused on diabetic subjects and explored the prevalence of RH in primary care practice.

METHODS

In 1737 subjects with type 2 diabetes who continued regular visits, office BP was evaluated by multiple measurements over one year. RH was defined as using more than four antihypertensive drugs or failure to achieve the goal with three antihypertensive drugs from different classes. The RH prevalence was investigated with BP goals <130/80 and 140/90 mmHg.

RESULTS

The percentage of subjects who achieved BP goals <130/80 and 140/90 were 70.5% and 93.8% with adherence to medication ≥95%, and the corresponding prevalence rates of RH in treated subjects were 28.4% and 21.8%, respectively. Factors independently associated with RH were age (odds ratio 1.02 [95% CI 1.01-1.04]), body mass index (1.10 [1.06-1.13]), variability in systolic BP (1.06 [1.02-1.09]), triglycerides (2.86 [1.34-6.11]), macroalbuminuria (3.33 [2.03-5.48]), estimated glomerular filtration rate (0.98 [0.97-0.99]), retinopathy (1.91 [1.39-2.61]), and family history of hypertension (1.85 [1.23-2.21]). Worsening albuminuria and glomerular filtration rate enhanced the prevalence of RH in a graded manner.

CONCLUSION

Careful estimation of office BP values over one year with a high achievement of BP goals and adequate adherence revealed that the prevalence of RH in type 2 diabetes is high. RH was characterized by accumulation of cardiovascular genetic and environmental risks.

Amiloride lowers blood pressure and attenuates urine plasminogen activation in patients with treatment-resistant hypertension

In conditions with albuminuria, plasminogen is aberrantly filtered across the glomerular barrier and activated along the tubular system to plasmin. In the collecting duct, plasmin activates epithelial sodium channels (ENaC) proteolytically. Hyperactivity of ENaC could link microalbuminuria/proteinuria to resistant hypertension. Amiloride, an ENaC inhibitor, inhibits urokinase-type plasminogen activator. We hypothesized that amiloride (1) reduces blood pressure (BP); (2) attenuates plasminogen-to-plasmin activation; and (3) inhibits urine urokinase-type plasminogen activator in patients with resistant hypertension and type 2 diabetes mellitus (T2DM).In an open-label, non-randomized, 8-week intervention study, a cohort (n = 80) of patients with resistant hypertension and T2DM were included. Amiloride (5 mg/d) was added to previous triple antihypertensive treatment (including a diuretic and an inhibitor of the renin-angiotensin-aldosterone system) and increased to 10 mg if BP control was not achieved at 4 weeks. Complete dataset for urine analysis was available in 60 patients. Systolic and diastolic BP measured by ambulatory BP monitoring and office monitoring were significantly reduced. Average daytime BP was reduced by 6.3/3.0 mm Hg. Seven of 80 cases (9%) discontinued amiloride due to hyperkalemia >5.5 mol/L, the most frequent adverse event. Urinary plasmin(ogen) and albumin excretions were significantly reduced after amiloride treatment (P < .0001). Urokinase activity was detectable in macroalbuminuric urine, with a tendency toward reduction in activity after amiloride treatment. Amiloride lowers BP, urine plasminogen excretion and activation, and albumin/creatinine ratio, and is a relevant add-on medication for the treatment of resistant hypertension in patients with T2DM and microalbuminuria.

Shared medical appointments for patients with diabetes mellitus: a systematic review

OBJECTIVES

Shared medical appointments (SMAs) are an increasingly used system-redesign strategy for improving access to and quality of chronic illness care. We conducted a systematic review of the existing literature on SMA interventions for patients with diabetes in order to understand their impact on outcomes.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, PsycINFO, and Web of Science from January 1996 through April 2012. PubMed search updated June 2013.

STUDY SELECTION

English-language peer-reviewed publications of randomized controlled trials (RCTs), nonrandomized cluster controlled trials, controlled before-and-after studies, or interrupted time-series designs conducted among adult patients with diabetes. Two independent reviewers used prespecified criteria to screen titles and abstracts for full text review.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two different reviewers abstracted data and rated study quality and strength of evidence. When possible, we used random-effects models to synthesize the effects quantitatively, reporting by a weighted difference of the means when the same scale was used across studies, and a standardized mean difference when the scales differed. We measured heterogeneity in study effects using Forest Plots, Cochran's Q, and I(2), and explored heterogeneity by using subgroup analyses for categorical variables and meta-regression analyses for continuous or discrete variables. Outcomes not suitable to meta-analysis were summarized qualitatively.

RESULTS

Twenty-five articles representing 17 unique studies compared SMA interventions with usual care. Among patients with diabetes, SMAs improved hemoglobin A1c (∆ = -0.55 percentage points [95 % CI, -0.11 to -0.99]); improved systolic blood pressure (∆ = -5.2 mmHg [95 % CI, -3.0 to -7.4]); and did not improve LDL cholesterol (∆ = -6.6 mg/dl [95 % CI, 2.8 to -16.1]). Nonbiophysical outcomes, including economic outcomes, were reported too infrequently to meta-analyze, or to draw conclusions from. The A1c result had significant heterogeneity among studies, likely secondary to the heterogeneity among included SMA interventions.

LIMITATION

Heterogeneity among the components of diabetes SMAs leads to uncertainty about what makes a particular SMA successful.

CONCLUSION

SMA interventions improve biophysical outcomes among patients with diabetes. There was inadequate literature to determine SMA effects on patient experience, utilization, and costs.

Effects of fasting blood glucose levels and blood pressure and treatment of diabetes and hypertension on the incidence of cardiovascular disease: a study of 740 patients with incident Type 2 diabetes with up to 30 years' follow-up

AIMS

To analyse the effects of hyperglycaemia and hypertension and treatment of diabetes and hypertension on cardiovascular disease incidence in patients with Type 2 diabetes with up to 30 years of follow-up.

METHODS

A total of 740 patients with incident Type 2 diabetes were registered at the Laxå Primary Health Care Centre, Sweden between 1972 and 2001. Annual data on mean fasting blood glucose, systolic, diastolic and mean arterial blood pressure, and type of diabetes and hypertension treatment were obtained from patient records, and information on cardiovascular disease, myocardial infarction and stroke events was obtained from national registers.

RESULTS

During the follow-up period, cumulative cardiovascular disease incidence increased significantly with male sex (hazard ratio 1.48, 95% CI 1.21-1.82), number of previous cardiovascular disease events (hazard ratio 1.13, 95% CI 1.08-1.18), age, per year (HR 1.05, 95% CI 1.04-1.07), mean fasting blood glucose, per mmol/l (hazard ratio 1.05, 95% CI 1.00-1.10) BMI (hazard ratio 1.04, 95% CI 1.01-1.06), mean arterial blood pressure, per mmHg (hazard ratio 1.02, 95% CI 1.01-1.03), and decreased significantly with metformin treatment (hazard ratio 0.58, 95% CI 0.38-0.90) and sulfonylurea (hazard ratio 0.73, 95% CI 0.55-0.97). Cumulative myocardial infarction incidence increased significantly with male sex, number of previous myocardial infarction events, mean fasting blood glucose level, BMI, age and mean arterial blood pressure, and decreased with metformin treatment. Cumulative stroke incidence increased with number of previous stroke events, age and mean arterial blood pressure.

CONCLUSIONS

The cumulative incidence of cardiovascular disease and myocardial infarction increased with number of previous events and presence of hyperglycaemia and hypertension and decreased with pharmacological treatment of diabetes. A higher number of previous stroke events increased the cumulative incidence of stroke but no protective effect of pharmacological treatment was observed.

Low dose spironolactone reduces blood pressure in patients with resistant hypertension and type 2 diabetes mellitus: a double blind randomized clinical trial

BACKGROUND

The increased risk of cardiovascular morbidity and mortality associated with arterial hypertension is particularly pronounced in patients with type 2 diabetes mellitus. Blood pressure control is, therefore, decisively important but often not sufficiently achieved.

OBJECTIVE

The primary objective of this study was to evaluate the antihypertensive effect of low dose spironolactone added to triple therapy for resistant hypertension in patients with type 2 diabetes measured by ambulatory monitoring. Secondary objectives were to evaluate the effects on glycaemic control and urinary albumin excretion as well as adverse effects.

METHODS

In a multicentre, double-blind, randomized, placebo-controlled study 119 patients with blood pressure at or above 130/80 mmHg despite triple antihypertensive therapy were included. One tablet of 25 mg spironolactone or placebo was added to previous treatment and increased to two if blood pressure below 130/80 mmHg was not achieved after 4 weeks. Blood pressure was measured by ambulatory monitoring at baseline and after 16 weeks.

RESULTS

The study was completed by 112 patients, 57 randomized to spironolactone and 55 to placebo. Average daytime placebo-corrected blood pressure was reduced by 8.9 (4.7-13.2)/3.7 (1.5-5.8) mmHg. Also office blood pressure, night-time, 24-h and pulse pressures were reduced significantly. Urinary albumin/creatinine ratio was significantly reduced in the spironolactone group. Glycaemic control remained unchanged. Hyperkalemia was the most frequent adverse event leading to dose reduction in three cases and discontinuation in one, whereas gynaecomastia was not reported.

CONCLUSION

Low dose spironolactone exerts significant BP and urinary albumin creatinine ratio lowering effects in high-risk patients with resistant hypertension and type 2 diabetes mellitus.

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.

Effects of fasting blood glucose, diabetes treatment, blood pressure and anti-hypertension treatment on cardiovascular disease incidence: a 30-year follow-up study of 740 incident patients with Type 2 diabetes

AIMS

To analyse the effects of hyperglycaemia and blood pressure, diabetes and anti-hypertension treatment on total and various types of cardiovascular disease incidence in patients with Type 2 diabetes followed for 30 years.

METHODS

A total of 740 incident patients with Type 2 diabetes were registered at the Laxå Primary Health Care Centre, Sweden between 1972 and 2001. Information on systolic, diastolic, and mean arterial blood pressure, mean fasting blood glucose, type of diabetes and anti-hypertension treatment was obtained from the patient records, and information on cardiovascular disease, myocardial infarction and stroke events from National Registers.

RESULTS

During the follow-up period the cumulative incidence of cardiovascular disease increased significantly with male sex (HR 1.52, 95% CI 1.25-1.85), age (HR 1.05, 95% CI 1.04-1.07), year of diabetes onset (HR 1.03, 95% CI 1.01-1.05), BMI, (HR 1.04, 95% CI 1.02-1.07), mean arterial blood pressure (HR 1.04, 95% CI 1.02-1.05) and number of previous cardiovascular disease events (HR 1.15, 95% CI 1.10-1.21), and decreased significantly with sulfonylurea treatment (HR 0.64, 95% CI 0.49-0.84), insulin (HR 0.57, 95% CI 0.33-0.98) and calcium channel blocker treatment (HR, 0.69, 95% CI 0.48-0.99). Cumulative incidence of myocardial infarction increased significantly with male sex, age, BMI, mean arterial blood pressure, number of previous myocardial infarction events and diuretic treatment, and decreased with metformin treatment. Cumulative incidence of stroke increased with age, year of diabetes onset, mean arterial blood pressure, and previous number of stroke events.

CONCLUSIONS

Cumulative cardiovascular disease, myocardial infarction and incidence of stroke increased with number of previous events and presence of hypertension and decreased with pharmacological anti-diabetic treatment and, to a lesser extent, with anti-hypertension treatment.

Impact of noninsulin-dependent type 2 diabetes on carotid wall 18F-fluorodeoxyglucose positron emission tomography uptake

OBJECTIVES

In this study, the impact of noninsulin-dependent type 2 diabetes mellitus on carotid wall (18)F-fluorodeoxyglucose (FDG) uptake in patients with documented or suspected cardiovascular disease was evaluated.

BACKGROUND

Inflammation is a pivotal process in the progression of atherosclerosis, which can be noninvasively imaged by FDG positron emission tomography (FDG-PET).

METHODS

Carotid artery wall FDG uptake was quantified in 134 patients (age 60.2 ± 9.7 years; diabetic subjects, n = 43). The pre-scan glucose (gluc) level corrected mean of the maximum standardized uptake value (SUV) values ((mean)SUV(gluc)), mean of the maximum target-to-background ratio ((mean)TBR(gluc)), and single hottest segment (SHS(gluc)) of FDG uptake in the artery wall were calculated. Associations between FDG uptake, the presence of risk factors for atherosclerosis, and diabetes were then assessed by multiple regression analysis with backward elimination.

RESULTS

The study demonstrated a significant association between diabetes and FDG uptake in the arterial wall (diabetes (mean)SUV(gluc) β = 0.324, (mean)TBR(gluc) β = 0.317, and SHS(gluc) β = 0.298; for all, p < 0.0001). In addition, in diabetic patients, both body mass index ≥ 30 kg/m(2) ((mean)SUV(gluc) β = 0.4, (mean)TBR(gluc) β = 0.357, and SHS(gluc) β = 0.388; for all, p < 0.015) and smoking ((mean)TBR(gluc), β = 0.312; SHS(gluc), β = 0.324; for all, p < 0.04) were significantly associated with FDG uptake.

CONCLUSIONS

Type 2 diabetes was significantly associated with carotid wall FDG uptake in patients with known or suspected cardiovascular disease. In diabetic patients, obesity and smoking add to the risk of increased FDG uptake values.

Safety and efficacy of low blood pressures among patients with diabetes: subgroup analyses from the ONTARGET (ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial)

OBJECTIVES

We sought to determine whether the blood pressure (BP) levels at which cardiovascular (CV) protection is achieved differ between diabetic and nondiabetic patients from the ONTARGET (ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial).

BACKGROUND

Greater absolute benefits of BP reductions have been claimed for diabetic as compared with nondiabetic patients.

METHODS

A total of 25,584 patients (9,603 diabetic), older than 55 years, at high CV risk were randomized to ramipril, telmisartan, or both and observed for 4.6 years. We pooled the treatment arms to examine the relationships between BP and the primary composite outcome (CV death, nonfatal myocardial infarction or stroke, or hospitalized heart failure) and its components.

RESULTS

The primary outcome occurred in 1,938 (20.2%) diabetic patients and in 2,276 (14.2%) nondiabetic patients. Compared with nondiabetic patients, diabetic patients had a significantly higher risk for the primary endpoint (hazard ratio [HR]: 1.48; 95% confidence interval [CI]: 1.38 to 1.57) and CV death (HR: 1.56; 95% CI: 1.42 to 1.71); myocardial infarction (HR: 1.30 (95% CI: 1.17 to 1.46); stroke (HR: 1.39; 95% CI: 1.23 to 1.56); and congestive heart failure hospitalization (HR: 2.06; 95% CI: 1.82 to 2.32). The CV risk was significantly higher in diabetic than in nondiabetic patients regardless of the systolic BP changes during treatment. In both diabetic and nondiabetic patients, progressively greater systolic BP reductions were accompanied by reduced risk for the primary outcome only if baseline systolic BP levels ranged from 143 to 155 mm Hg; except for stroke, there was no benefit in fatal or nonfatal CV outcomes by reducing systolic BP below 130 mm Hg.

CONCLUSIONS

The relationship between BP and overall CV risk had a similar pattern in diabetic and nondiabetic patients over a wide range of baseline and in-treatment BP values although, for the same systolic BP, a higher risk is observed in diabetic patients.