Tight Blood Pressure Control Research Articles

Usual versus tight control of systolic blood pressure in non-diabetic patients with hypertension (Cardio-Sis): an open-label randomised trial

Usual versus tight control of systolic blood pressure in non-diabetic patients with hypertension (Cardio-Sis): an open-label randomised trial

Circulation: Clinical Summaries

<i>Circulation:</i> Clinical Summaries

Pathophysiology and management of diabetic retinopathy

Diabetic retinopathy remains a major cause of worldwide preventable blindness. In this review, we evaluate the recent advances in understanding the molecular mechanisms of diabetic retinopathy, highlight the current management of diabetic retinopathy and new therapeutic approaches, and discuss the range of potential future therapeutic strategies in order to combat the disease. The microvasculature of the retina responds to hyperglycemia through a number of biochemical changes, including the activation of PKC, increased advanced glycation end-products formation, polyol pathway and oxidative stress, and activation of the renin–angiotensin system. There is an accumulating body of evidence that inflammation and neurodegeneration play a prominent role in the pathogenesis of diabetic retinopathy. Strict metabolic control, tight blood pressure control, laser photocoagulation and vitrectomy remain the standard care for diabetic retinopathy. Emerging therapies include intravitreal triamcinolone or anti-VEGF agents, ruboxistaurin, renin–angiotensin system blockers, fenofibrate, islet cell transplantation, PPAR-γ agonists and intravitreal hyaluronidase. However, more randomized, controlled clinical trials are required to clarify their role alone or in combination.

Pregnancy-induced sight-threatening diabetic retinopathy in women with type 1 diabetes

Diabet. Med. 27, 431–435 (2010) Abstract Aims To determine the progression of diabetic retinopathy in pregnant women with diabetes offered tight glycaemic and blood pressure control. Methods A prospective study of 102 (87%) out of 117 consecutive pregnant women with Type 1 diabetes for median 16 years (range 1–36) and HbA1c 6.7% (4.9–10.8) in early pregnancy. Fundus photography was performed at 8 and 27 weeks. Retinopathy was classified in five stages. Diabetic macular oedema was classified as present in a mild form or as clinically significant macular oedema (CSMO). Progression was defined as at least one stage of deterioration of retinopathy and/or development of macular oedema in at least one eye. Sight-threatening progression was defined as loss of visual acuity ≥ 0.2 on Snellen’s chart or laser treatment performed during pregnancy due to proliferative retinopathy or CSMO. Results Diabetic retinopathy was present at inclusion in at least one eye in 64 (63%) women and proliferative retinopathy and macular oedema were present in nine and 16 women, respectively. Progression of retinopathy occurred in 28 (27%) women. Sight-threatening progression occurred in six women; in three, visual acuity deteriorated and four required laser treatment. Sight-threatening progression was associated with presence of macular oedema (P = 0.007), impaired visual acuity (P = 0.03) and higher blood pressure (P = 0.016) in early pregnancy, but not with HbA1c, decline in HbA1c, or prevalence of severe hypoglycaemia. Conclusions Loss of visual acuity and the need for laser treatment during diabetic pregnancy remain clinical problems associated with presence of macular oedema, visual impairment and higher blood pressure in early pregnancy.

New treatment target for systolic blood pressure?

The degree to which systolic blood pressure should be lowered in individuals with mild hypertension is unclear. The Cardio-Sis trial has investigated whether tight systolic blood pressure control is more beneficial than usual control in individuals with hypertension but without diabetes.

Tight BP control reduced left ventricular hypertrophy in nondiabetic patients with hypertension

Source Citation Verdecchia P, Staessen JA, Angeli F, et al. Usual versus tight control of systolic blood pressure in non-diabetic patients with hypertension (Cardio-Sis): an open-label randomised t...

Changing paradigms in the treatment of diabetic retinopathy

To review current treatment approaches in diabetic retinopathy. Diabetic retinopathy remains one of the leading causes of blindness worldwide. Strict metabolic control, tight blood pressure control, laser photocoagulation, and vitrectomy remain the standard care for diabetic retinopathy. Focal/grid photocoagulation is a better treatment than intravitreal triamcinolone acetonide in eyes with diabetic macular edema. The current evidence suggests that intravitreal triamcinolone acetonide or antivascular endothelial growth factor agents are effective adjunctive treatment to laser photocoagulation or vitrectomy. However, triamcinolone is associated with risks of elevated intraocular pressure and cataract. Vitrectomy with removal of the posterior hyaloid without internal limiting membrane peeling seems to be effective in eyes with persistent diffuse diabetic macular edema, particularly in eyes with associated vitreomacular traction. Emerging therapies include islet cell transplantation, fenofibrate, ruboxistaurin, and intravitreal hyaluronidase. A variety of promising new medical and surgical therapies are emerging, but more randomized controlled clinical trials are required to clarify their role alone or in combination.

Effect of tight control of HbA1c and blood pressure on cardiovascular diseases in type 2 diabetes: An observational study from the Swedish National Diabetes Register (NDR)

Aim To estimate hazard ratio (HR) of first incident fatal/non-fatal cardiovascular diseases (CVD) in female/male type 2 diabetic patients, with tight versus adverse control of HbA1c and blood pressure (BP) at baseline, age 30–70 years, no baseline CVD, followed for mean 5.7 years. Methods 2593 patients with tight control of HbA1c <7.5% and BP ≤140/90 mmHg (median 6.5%/130/80 mmHg), and 2160 patients with adverse control 7.5–9.0%/141–190/91–110 mmHg (median 8.1%/155/85 mmHg). Results The hazard ratio (HR) for CVD with tight/adverse control was 0.67 (0.55–0.80; p < 0.001), adjusting for age, sex, duration, hypoglycaemic treatment, smoking, BMI, lipid-lowering drugs, antihypertensive drugs, microalbuminuria. Adjusted HR for myocardial infarction, coronary heart disease, stroke and total mortality were 0.72 (0.56–0.92; p = 0.01), 0.69 (0.55–0.86; p < 0.001), 0.62 (0.45–0.84; p < 0.001), 1.00 (0.72–1.39). The partial population-attributable risk percent for myocardial infarction, stroke and CVD was 23%, 33%, 29% if adverse HbA1c/BP control could be avoided, while 43%, 38%, 39% with overweight and smoking also avoided. Baseline lower BMI and absence of microalbuminuria were associated with tight control. Conclusion Median difference of HbA1c/BP 1.6%/25/5 mmHg between tight and adverse control considerably reduced the risk of cardiovascular diseases. The findings call for a multi-factorial approach to improve HbA1c, BP, obesity, smoking, and microalbuminuria.

Usual versus tight control of systolic blood pressure in non-diabetic patients with hypertension (Cardio-Sis): an open-label randomised trial

The level to which systolic blood pressure should be controlled in hypertensive patients without diabetes remains unknown. We tested the hypothesis that tight control compared with usual control of systolic blood pressure would be beneficial in such patients. In this randomised open-label trial undertaken in 44 centres in Italy, 1111 non-diabetic patients with systolic blood pressure 150 mm Hg or greater were randomly assigned to a target systolic blood pressure of less than 140 mm Hg (usual control; n=553) or less than 130 mm Hg (tight control; n=558). After stratification by centre, we used a computerised random function to allocate patients to either group. Observers who were unaware of randomisation read electrocardiograms and adjudicated events. Open-label agents were used to reach the randomised targets. The primary endpoint was the rate of electrocardiographic left ventricular hypertrophy 2 years after randomisation. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00421863. Over a median follow-up of 2.0 years (IQR 1.93-2.03), systolic and diastolic blood pressure were reduced by a mean of 23.5/8.9 mm Hg (SD 10.6/7.0) in the usual-control group and by 27.3/10.4 mm Hg (11.0/7.5) in the tight-control group (between-group difference 3.8 mm Hg systolic [95% CI 2.4-5.2], p<0.0001; and 1.5 mm Hg diastolic [0.6-2.4]; p=0.041). The primary endpoint occurred in 82 of 483 patients (17.0%) in the usual-control group and in 55 of 484 patients (11.4%) of the tight-control group (odds ratio 0.63; 95% CI 0.43-0.91; p=0.013). A composite cardiovascular endpoint occurred in 52 (9.4%) patients in the usual-control group and in 27 (4.8%) in the tight-control group (hazard ratio 0.50, 95% CI 0.31-0.79; p=0.003). Side-effects were rare and did not differ significantly between the two groups. Our findings lend support to a lower blood pressure goal than is recommended at present in non-diabetic patients with hypertension. Boehringer-Ingelheim, Sanofi-Aventis, Pfizer.

Low-dose Spinal Anesthesia with Low-dose Phenylephrine Infusions for Cesarean Delivery: Better but Not Necessarily Best

Low-dose Spinal Anesthesia with Low-dose Phenylephrine Infusions for Cesarean Delivery: Better but Not Necessarily Best

Management of hypertension in patients with diabetes: the place of angiotensin‐II receptor blockers

Hypertension is an important cardiovascular (CV) risk factor in patients with diabetes mellitus. In this setting, tight control of blood pressure (BP) significantly reduces CV morbidity and mortality. In the UK Prospective Diabetes Study, a 10 mmHg reduction in systolic blood pressure (SBP) was superior to a 0.7% decrease in glycosylated haemoglobin A1c (HbA1c) as far as reducing morbidity and mortality was concerned. In the Hypertension Optimal Treatment study, the risk of CV events decreased by 51% among patients with type 2 diabetes randomized to the lower BP level. Based on these findings, contemporary treatment guidelines recommend a target SBP/diastolic blood pressure of <130/80 mmHg for patients with diabetes.

Central retinal vein occlusion: a case report and review of the literature

IntroductionCentral retinal vein occlusion is one of the major causes of severe vision impairment and blindness in adults.Case presentationWe present a case of unilateral ischemic central retinal vein occlusion in a 54-year-old woman with history of uncontrolled hypertension and open angle glaucoma. Laboratory tests including complete hypercoagulability and thrombotic workup were completed.ConclusionOur case illustrates an interesting presentation of unilateral ischemic central retinal vein occlusion, where hypertension and glaucoma were thought to be the main risk factors. Close follow up, tight blood pressure and glaucoma control are crucial to prevent similar scenario in the fellow eye.

Tratamiento de la hipertensión arterial en pacientes con enfermedad renal crónica. Evidencias e implicaciones

The main aim delaying progression of chronic kidney disease (CKD) are tight control of blood pressure to levels below 130/80 mmHg and reductioner 24-h urine protein to <0.5 g or microalbuminuria to <300 mg/g. First-line agents for renoprotection are angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers at the highest tolerated dose. The combination of these types of drugs, the so-called dual blockade, further reduces an elevated urinary albumin or protein excretion but, at least in patients at high cardiovascular risk, does not delay progression of renal failure. An intensified multifactorial intervention is necessary for renal patients because 35 to 50% of cases with grade 3 or 4 CKD are prone to premature complications such as end-stage renal disease and/or cardiovascular events. New strategies to block the renin-angiotensin system could be of help in improving of outcomes in CKD patients.

Update on the metabolic syndrome: Hypertension

The presence of the metabolic syndrome identifies an individual at increased risk for diabetes, cardiovascular disease, and early mortality. However, the increased risk may vary by the absence or presence of hypertension. Current guidelines for the management of high blood pressure in the metabolic syndrome emphasize lifestyle modification as a first-line strategy. Pharmacologic treatment of elevated blood pressure in the metabolic syndrome may be necessary in the presence of other cardiovascular risk factors or to achieve adequate blood pressure control. Currently, there is no consensus as to which antihypertensive therapy should be used to treat hypertension in patients with the metabolic syndrome; it remains unclear whether achieving tight blood pressure control should outweigh the potential for development of glucose intolerance. Future research must focus on this issue given the high prevalence of the syndrome among hypertensive patients and high rates of progression to diabetes among those with the metabolic syndrome.

Improving Microvascular Outcomes in Patients with Diabetes through Management of Hypertension

Diabetes mellitus is an independent risk factor for cardiovascular disease (CVD) and current opinion holds that hyperglycemia directly damages smaller blood vessels, resulting in microvascular complications of nephropathy, retinopathy, and neuropathy. In a patient with diabetes, hypertension compounds and greatly increases the risk of microvascular complications, and thus the risk of end-stage kidney disease, vision loss, and nontraumatic limb amputations. Hypertension and hyperglycemia directly damage the microvasculature, leading to small vessel dysfunction that manifests as the clinical disease states of diabetic retinopathy and nephropathy. Early recognition and treatment of both hyperglycemia and hypertension may prevent vision loss and chronic kidney disease, the devastating outcomes of these microvascular complications. One of the pathogenic mechanisms for microvascular dysfunction is upregulation of the angiotensin II type 1 receptor, the most physiologically common receptor for the vasoconstrictor properties of angiotensin II. In patients with diabetic retinopathy and nephropathy, tight control of blood pressure (BP) (< 130/80 mm Hg) delays the progression of retinopathy and nephropathy in addition to reducing cardiovascular morbidity and mortality. Aggressive treatment with 2 or more antihypertensive agents, selected from different drug classes, is often needed to reach the optimal BP target level. A PubMed search was conducted to identify randomized controlled trials that evaluated hypertension control and microvascular outcomes in patients with diabetes. Several clinical trials have yielded promising data with renin-angiotensin-aldosterone system (RAAS) inhibitors (the direct renin inhibitor aliskiren, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers). Attainment of BP control with RAAS inhibitors reduces the risk for CVD, nephropathy, and retinopathy. In addition, RAAS inhibitors have demonstrated renoprotective effectiveness independent of the BP reduction achieved. This review will examine the results of clinical trials in the context of BP control, diabetes, and the microvascular complications of retinopathy and nephropathy.

Evaluation of antihypertensive therapy in diabetic hypertensive patients: impact of ischemic heart disease.

Macrovascular complications are common in diabetic hypertensive patients. Appropriate antihypertensive therapy and tight blood pressure control are believed to prevent or delay such complication. To evaluate utilization patterns of antihypertensive agents and blood pressure (BP) control among diabetic hypertensive patients with and without ischemic heart disease (IHD). Retrospective cohort study of all diabetic hypertensive patients attending Al-watani medical center from August 2006 until August 2007. Proportions of use of different antihypertensive drug classes were compared for all patients receiving 1, 2, 3, or 4 or more drugs, and separately among patients with and without IHD. Blood pressure control (equal or lower 130/80 mmHg) was compared for patients receiving no therapy, monotherapy, or combination therapy and separately among patients with and without IHD. 255 patients were included in the study; their mean age was 64.4 (SD=11.4) years. Sixty one (23.9%) of the included patients was on target BP. Over 60% of the total patients were receiving angiotensin-converting enzyme inhibitors (ACEI)/ angiotensin receptor blocker (ARB), followed by diuretics (40.8%), calcium channel blockers (25.1%) and beta-blockers (12.5%). The majority (> 55%) of patients were either on mono or no drug therapy. More than 55% of patients with controlled BP were using ACE-I. More than half (50.8%) of the patients with controlled BP were on combination therapy while 42.3% of patients with uncontrolled BP were on combination therapy (p=0.24). More patient in the IHD achieved target BP than those in non-IHD group (p=0.019). Comparison between IHD and non-IHD groups indicated no significant difference in the utilization of any drug class with ACE-I being the most commonly utilized in both groups. Patterns of antihypertensive therapy were generally but not adequately consistent with international guidelines. Areas of improvement include increasing ACE-I drug combinations, decreasing the number of untreated patients, and increasing the proportion of patients with controlled BP in this population.

Benefits of tight blood pressure control to prevent diabetes complications were not sustained

Source Citation Holman RR, Paul SK, Bethel MA, Neil HA, Matthews DR. Long-term follow-up after tight control of blood pressure in type 2 diabetes. N Engl J Med. 2008;359:1565-76. 18784091

Management of diabetic retinopathy: could lipid-lowering be a worthwhile treatment modality?

Diabetic eye disease confers substantial burden on the patient quality of life. Current therapeutic strategies indicate an unmet clinical need for preventive therapy. Tight control of blood pressure and glycaemia are mandatory components of primary prevention strategies, but are insufficient to eliminate risk in all patients. A body of evidence supports a role for lipid-modifying therapy in reducing the diabetic retinopathy endpoints. Although inconclusive for statin therapy, results from the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study show beneficial effects of fenofibrate in reducing the requirement for laser therapy, and particularly in preventing disease progression in patients with pre-existing diabetic retinopathy. However, there is a need for confirmation of these findings in large prospective studies with progression of retinopathy as the primary endpoint, such as the ACCORD-EYE (Action to Control Cardiovascular Risk in Diabetes-EYE) study, and in a clinical trial specifically conducted for diabetic maculopathy. In addition, elucidation of the mechanism(s) of effect of fenofibrate is indicated.

The UK Prospective Diabetes Study (UKPDS): Its legacy for type 2 diabetes management

subjects (> 120% ideal body weight) randomised primarily to metformin, there was a substantial risk reduction for MI (39%, p=0.01) and all-cause mortality (36%, p=0.011). The blood pressure control part of the UKPDS, known as the Hypertension in Diabetes Study (HDS), demonstrated that tight blood pressure control over nine years (mean fall of 160/94 to 144/82 mmHg), with either atenolol or captopril, compared to a less tight blood pressure control group (mean fall of 161/94 to 154/87 mmHg) – a difference of 10/5 mmHg, sustained over the nine years – resulted in significant benefit. There was a reduction in overall risk of microvascular complications by 37% (p=0.0092), diabetes-related deaths by 32% (p=0.0046) but no significant effect was seen in all-cause mortality. After 6 years, 29% of the diabetic subjects required three or more drugs to achieve tight blood pressure control.

Perioperative blood pressure management with clevidipine during coiling of cerebral artery aneurysms

The tight control of blood pressure (BP) is mandatory during cerebral aneurysm coiling to minimize abrupt changes in the transmural pressure across the aneurysm and thereby decrease the risk of rupture. Critical times during these procedures when significant BP changes may occur include anesthetic induction, endotracheal intubation, and emergence. Clevidipine is a recently introduced, rapidly acting dihydropyridine calcium channel antagonist. Its rapid metabolism by tissue and plasma esterases results in an effective half-life of 1 to 3 minutes. We present our preliminary experience with the use of clevidipine to control BP during the anesthetic care of three patients undergoing coiling of cerebral aneurysms in the interventional radiology suite.