The Treatment of Hypertension in Adult Patients With Diabetes

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Abstract
Epidemiological studies and therapeutic trials have often used different criteria to define hypertension in diabetic patients. Studies in the general population indicate an increased risk of cardiovascular disease with an increase in the level of blood pressure. Thus, an increase in diastolic or systolic blood pressure of 5 mmHg is associated with a concomitant increase in cardiovascular disease of 20–30% (14). Studies in diabetic populations have shown a markedly higher frequency of the progression of diabetic retinopathy when diastolic blood pressure is in excess of 70 mmHg (15). Most epidemiological studies have used a categorical definition of hypertension, using levels of 160 mmHg for systolic and 90 mmHg for diastolic blood pressure. Based on the current evidence from clinical trials showing clinically significant benefits of treating diabetic individuals to lower levels of blood pressure, these values are considered too high to serve as a threshold for the definition of hypertension in diabetic patients. In 1997, the Joint National Committee (JNC) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure published revised recommendations (JNC VI) on the management of hypertension in the general population and on diabetic patients that recommended a lower target for patients with diabetes (130/85 mmHg) than for the general population (140/90 mmHg). The standard definition of hypertension is a blood pressure ≥140/90 mmHg (16). Evidence obtained from clinical trials in diabetic patients suggests a continuum of risk and clinically significant benefit in outcomes with reductions of blood pressure below 140 mmHg systolic and 80 mmHg diastolic blood pressure, as will be discussed in this review. For elderly populations with systolic hypertension, benefits have been shown when blood pressure is reduced below systolic levels of 140 mmHg (2,3). Epidemiological studies indicate that there is a benefit to reducing systolic blood pressure still further to 130 mmHg or below (17,18). Therefore, the goal for blood pressure should be ≤130 mmHg for systolic and ≤80 mmHg for diastolic blood pressure.