Is new-onset diabetes of clinical significance in treated hypertensive patients?--Con

Utilization of glucose, blood pressure, and lipid lowering medications among people with type II diabetes in the United States, 1999-2010

PURPOSE

Changes in relation to drug treatment to various control targets for diabetes were studied using the National Health and Nutrition Examination Survey, 1999-2010.

METHODS

Data on 3094 participants aged 20 years or older with diagnosed type II diabetes were analyzed. Use of medications for lowering glucose, blood pressure, and lipids in the past month was assessed by questionnaire. Data from two survey cycles were combined together to produce estimates for each 4-year period.

RESULTS

Usage of metformin increased from 34.8% to 53.8% and was the most prevalent medications during this period (P < .001), and half of subjects taking metformin could achieve glycated hemoglobin less than 7.0% in 2007-2010. Dipeptidyl peptidase-4 inhibitors were used by 7.4% of participants in 2007-2010. Usage of angiotensin receptor blockers and beta-blockers increased significantly from 7.4% to 21.4% and from 15.3% to 31.8%, respectively from 1999 to 2010 (P ≤ .001). A total of 64.7% of participants could attain blood pressure control by 2007-2010. Usage of statins doubled in 1999-2010 and 52.2% of subjects took statins by 2007-2010 (P < .001).

CONCLUSIONS

Metformin is the first-line drug for diabetes while dipeptidyl peptidase-4 inhibitors started to be used since 2007. Blood pressure control improved in 1999-2010 partly due to increased drug prescriptions. Although statins were widely used about half of the participants did not take them.

Short- and long-term survival in treated elderly hypertensive patients with or without diabetes: findings from the Second Australian National Blood Pressure study

BACKGROUND

We sought to determine the incidence of newly diagnosed diabetes in treated elderly hypertensive patients and the prognostic impact of diabetes on long-term survival.

METHODS

The Second Australian National Blood Pressure (ANBP2) study randomized 6,083 hypertensive patients aged 65-84 years to angiotensin-converting enzyme inhibitor (ACEI) or thiazide diuretic-based therapy and followed them for a median of 4.1 years. Long-term survival was determined in 5,678 patients over an additional median of 6.9 years after ANBP2 (post-trial).

RESULTS

After ANBP2, the cohort was classified into preexisting (7.2%), newly diagnosed (5.6%), and no diabetes (87.2%) groups. A 44% higher incidence of newly diagnosed diabetes was observed in patients randomized to thiazide diuretic compared with ACEI-based treatment. The other predictors of newly diagnosed diabetes were having a higher body mass index, having a higher random blood glucose, and living in a regional location compared to major cities (a geographical classification based on accessibility) at study entry. After completion of ANBP2, compared with those with no diabetes, the preexisting diabetes group experienced higher cardiovascular (hazards ratio (HR) = 1.65; 95% confidence interval (CI) = 1.03-2.65) and all-cause mortality (HR = 1.40; 95% CI = 1.02-1.92) when adjusted for age, sex, and treatment. A similar pattern was observed after including the post-trial period for cardiovascular (HR = 1.52; 95% CI = 1.20-1.93) and all-cause mortality (HR = 1.50; 95% CI = 1.29-1.73). However, when the newly diagnosed group was compared with the no diabetes group, no significant difference was observed in cardiovascular (HR = 0.33; 95% CI = 0.11-1.05) or all-cause mortality (HR = 0.76; 95% CI = 0.47-1.23) either during the ANBP2 trial or including post-trial follow-up (cardiovascular: HR = 0.82; 95% CI = 0.58-1.17; all-cause mortality: HR = 1.04; 95% CI = 0.85-1.27).

CONCLUSIONS

Long-term presence of diabetes reduces survival. Compared with thiazide diuretics, ACEI-based antihypertensives may delay the development of diabetes in those at risk and thus potentially improve cardiovascular outcome in the elderly.

New-onset diabetes and cardiovascular events in essential hypertensives: a 6-year follow-up study

BACKGROUND

Controversy still exists regarding the impact of new-onset diabetes (NOD) on CV outcomes among patients with hypertension. Our aim was to determine the incidence of NOD in essential hypertensives and to evaluate its association with major cardiovascular (CV) events.

METHODS

We followed-up for a mean period of 6 years 1572 essential hypertensives (mean age 54.3 years, 696 males) for the incidence of NOD, as well as of fatal and non-fatal coronary artery disease and stroke. Based on the development of NOD, the cohort was divided into patients with pre-existing diabetes (10%), patients with NOD (10%) and those who remained free from diabetes.

RESULTS

During the follow-up period, new or recurrent cases of coronary artery disease and stroke events occurred at a rate of 5.6% (n = 88) and 4.65% (n = 73). The independent predictors for NOD were age (OR = 1.026, p = 0.041), waist circumference (OR = 1.044, p < 0.001), family history of diabetes (OR = 2.173, p = 0.003) and systolic BP at follow-up (OR 1.022, p = 0.044). The presence of NOD was independently associated with greater incidence of stroke (HR 2.404, p = 0.046), along with age (HR 1.078, p < 0.001), duration of hypertension (HR 1.039, p = 0.017) and office systolic blood pressure at follow-up (HR 1.022, p = 0.026), whereas development of NOD had no relationship with the incidence of coronary artery disease.

CONCLUSIONS

Our findings indicate the high incidence of NOD and its close association with stroke in essential hypertension. Poorer control of hypertension appears to be a common denominator of both NOD and stroke in this setting.

Antihypertensive medications: benefits of blood pressure lowering and hazards of metabolic effects

Blood pressure reduction is associated with significant reduction in adverse cardiovascular outcomes. Certain blood pressure-lowering drugs have adverse effects on glucose homeostasis, and have been associated with the development of both prediabetes and diabetes during use. There is controversy over the significance of diabetes that develops during treatment with antihypertensives and whether the benefits of blood pressure reduction offset the hazards of dysglycemia that can lead to diabetes. Many treatment guidelines have recently undergone revisions to include consideration for the metabolic effects of antihypertensive drugs, particularly in high-risk populations. This review summarizes the data related to the benefits of blood pressure reduction as well as the adverse metabolic effects and new-onset diabetes associated with some medications.

Impact of new-onset diabetes mellitus on cardiac outcomes in the Valsartan Antihypertensive Long-term Use Evaluation (VALUE) trial population

There has been a lot of interest about new-onset diabetes mellitus in recent hypertension trials, but the implications of diabetes development on cardiac outcomes have not been known. In the Valsartan Antihypertensive Long-Term Use Evaluation trial, 15 245 high-risk patients were followed for an average of 4.2 years. At baseline, 5250 patients were diabetic by the 1999 World Health Organization criteria, and among the 9995 nondiabetic patients, 1298 patients developed diabetes during follow-up. We have investigated the influence of diabetes development on outcomes in the Valsartan Antihypertensive Long-Term Use Evaluation trial. The patients with diabetes at baseline and new-onset diabetes were compared with patients who did not develop diabetes by a Cox regression model with adjustment for prespecified covariates (age, diabetes status, left ventricular hypertrophy, baseline coronary heart disease, and randomized study treatment). Patients with diabetes at baseline had the highest cardiac morbidity defined as myocardial infarction and heart failure with a hazard ratio of 2.20 (95% CI: 1.95 to 2.49). The patients with new-onset diabetes had significantly higher cardiac morbidity, especially more congestive heart failure, than those without diabetes, with a hazard ratio of 1.43 (95% CI: 1.16 to 1.77). This indicates that patients who develop diabetes during antihypertensive treatment have cardiac morbidity intermediate between diabetic subjects and those subjects who never had diabetes and that it is of importance to find these patients at risk of diabetes development and optimize lifestyle and medical treatment.