Tight Blood Pressure Control Research Articles

Tight Blood Pressure Control in Diabetes: Evidence-Based Review of Treatment Targets in Patients with Diabetes

Blood pressure (BP) targets in diabetic patients stills represent the object of a major debate, fueled by the recent publication of post hoc observational analyses of the INVEST and the ONTARGET trials, suggesting an increased risk of cardiovascular events with tighter control, the J-curve effect, and by the results of the ACCORD trial, showing no improvements in the composite primary outcome of nonfatal myocardial infarction, stroke, or cardiovascular death in the intensive BP-lowering arm (<120/80mmHg). In the present review, we focus on existing evidence about different BP targets in diabetic subjects and we present the results of our recent meta-analysis, showing that tight BP control may significantly reduce the risk of stroke in these patients without increasing the risk of myocardial infarction. Therapeutic inertia (leaving diabetic patients with BP values of 140/90mmHg or higher) should be avoided at all costs, as this would lead to an unacceptable toll in terms of human lives, suffering, and socioeconomic costs.

Markers of Arrhythmogenic Risk in Hypertensive Subjects

Hypertension is increasingly considered a strong and independent risk factor for supraventricular and ventricular arrhythmias. The presence and complexity of both supraventricular and ventricular arrhythmias influence morbidity, mortality, as well as the quality of life of patients. Diastolic dysfunction of the left ventricle, left atrial size and function, and left ventricular hypertrophy have been suggested as the foremost underlying risk factors for supraventricular and ventricular arrhythmias in hypertensive patients. In particular, the presence of hypertension is a risk for sudden death and this risk is higher in those with left ventricular hypertrophy. Moreover, arrhythmias in the hypertrophic heart are often facilitated and aggravated by electrolyte disturbances, sympatho-vagal unbalance, transient blood pressure peaks, and occurrence of myocardial ischaemia. Several noninvasive biohumoral, electrocardiographic and imaging parameters have been widely investigated to identify hypertensive patients at higher risk for the development of arrhythmias. These parameters include neurohormones, signal averaged analysis of P wave, QT interval dispersion, heart rate variability, ventricular late potentials and T wave morphology analysis, as well as echocardiographic and magnetic resonance indexes of atrial and ventricular shape and function. The aim of this review is to evaluate the relationship of high blood pressure with ventricular and supraventricular arrhythmias, to discuss the available biomarkers for arrhythmic risk assessment in hypertensive patients and the effects of a tailored tight blood pressure control on the occurrence of arrhythmias.

Advances in stroke care and research in 2010

1. There have been many advances in stroke research and care over the past year. The aim of the present review is to highlight the significant advances that are likely to have considerable impact on the direction of future investigations and models of clinical practice. 2. In terms of the acute treatment of stroke, there is now Level I evidence for the use of thrombolysis in the treatment of ischaemic stroke. The results of clinical trials suggest potential new treatments for stroke of inherited origin, whereas other potential treatments have been suggested following the identification of a novel mechanism of emboli clearance by extravasation. Clinical guidelines have also been updated, with tight blood pressure control advocated in cases of acute intracerebral haemorrhage. 3. In terms of stroke prevention, new information has been added to the long-standing debate regarding the value of carotid stenosis management: the predictive value of asymptomatic carotid emboli may enable the identification of individuals at high risk of stroke. Furthermore, the identification of novel risk factors for stroke opens up new avenues for stroke prevention. 4. Robot-assisted therapy has heralded a new era in stroke rehabilitation and the 'Get With The Guidelines' programme has set a milestone in the quality control of stroke care. 5. Undoubtedly these advances will have a marked impact on future research and clinical practice.

Does achieving an intensive versus usual blood pressure level prevent stroke?

The purpose of this study was to compare the impact of achieving tight versus usual systolic blood pressure (SBP) control on stroke prevention through meta-analysis of randomized controlled trials. We searched PubMed and bibliographies of recent review articles. Relative risk with 95% confidence interval was used as a measure of the association between an active treatment group with achieved SBP <130 mmHg versus a comparator group with achieved SBP 130 to 139 mmHg, and risk of stroke after pooling data across trials. The search identified 11 studies with 42,572 participants and 794 stroke events. The final SBPs, weighted for trial size, were a mean of 126.5 mmHg in the intensive treatment arms and 132.6 mmHg in the conventional arms (mean SBP reduction, 6.1 mmHg). Achieving a tight SBP level was associated with a lower stroke risk (relative risk, 0.80; 95% confidence interval, 0.70-0.92; p < 0.01) and a lower risk of major vascular events (0.91; 0.86-0.96; p < 0.001). In subgroup analyses, subjects with risk factors but no established cardiovascular disease showed substantial reduction of future stroke risk with tight control (0.49; 0.34-0.69), but those with established cardiovascular disease at entry did not experience stroke risk reduction with tight control (0.92; 0.83-1.03). Achieving an SBP <130 mmHg compared to 130 to 139 mmHg appears to provide additional stroke protection only among people with risk factors but no established cardiovascular disease.

Podocytopathy in Diabetes: A Metabolic and Endocrine Disorder

Diabetic nephropathy (DN) represents a major public health cost. Tight glycemic and blood pressure control can dramatically slow, but not stop, the progression of the disease, and a large number of patients progress toward end-stage renal disease despite currently available interventions. An early and key event in the development of DN is loss of podocyte function (or glomerular visceral epithelial cells) from the kidney glomerulus, where they contribute to the integrity of the glomerular filtration barrier. Recent evidence suggests that podocytes can be the direct target of circulating hormones, lipids, and adipokines that are affected in diabetes. We review the clinical and experimental evidence implicating novel endocrine and metabolic pathways in the pathogenesis of podocyte dysfunction and the development of DN.

Managing kidney disease with blood-pressure control

The progression of chronic kidney disease (CKD) is largely independent of the underlying kidney disorder once renal function has fallen below a critical level. Hypertension is an independent risk factor for disease progression in both adult and pediatric patients with kidney disorders. Increasing evidence from clinical trials indicates that the rate of CKD progression can be lowered by pharmacological interventions. Nephroprotective strategies currently focus on the blockade of the renin-angiotensin system. Angiotensin-converting-enzyme inhibitors and angiotensin-receptor blockers provide efficient control not only of blood pressure, but also of proteinuria, an effect associated with improved long-term nephroprotection compared with other antihypertensive drug classes. In addition, evidence for an additional nephroprotective advantage of tight blood-pressure control towards the low-normal range in young patients and patients with proteinuria is emerging. In this Review, we describe the role of hypertension in CKD and discuss the therapeutic principle of the prevention of CKD progression with antihypertensive agents.

Using data to inform care needs planning for people with diabetes

Practice NursingVol. 22, No. 5 Diabetes Evidence-Based Management 31Using data to inform care needs planning for people with diabetesNaomi Holman, Anne PhillipsNaomi HolmanSearch for more papers by this author, Anne PhillipsSearch for more papers by this authorNaomi Holman; Anne PhillipsPublished Online:29 Sep 2013https://doi.org/10.12968/pnur.2011.22.5.258AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View articleReferencesCraig R, Hirani V, eds. (2009) Health Survey for England 2008. Volume 2. Methods and Documentation. The Information Centre, London Google ScholarFolsom AR, Szklo M, Stevens Jet al. (1997) A prospective study of coronary heart disease in relation to fasting insulin, glucose, and diabetes. The Atherosclerosis Risk in Communities (ARIC) Study. Diabetes Care 20(6): 935–42 Crossref, Google ScholarFolsom AR, Rasmussen ML, Chambless LEet al. (1999) Prospective associations of fasting insulin, body fat distribution, and diabetes with risk of ischemic stroke. Diabetes Care 22(7): 1077–83 Crossref, Google ScholarForouhi NG, Merrick D, Goyder E,et al. (2005) Diabetes prevalence in England, 2001. Estimates from an epidemiological model. Diabet Med 23(2): 189–97 Crossref, Google ScholarHolman N (2008) Diabetes attributable deaths: estimating the excess deaths among people with diabetes. Poster Presentation at the Diabetes UK Annual Professional Conference 2009, Glasgow Google ScholarHolman RR, Paul SK, Bethel MA, Neil HAW, Matthews DR (2008a) Long-term follow up after tight control of blood pressure in type 2 diabetes. N Engl J Med 359(15): 1565–76 Crossref, Google ScholarHolman RR, Paul SK, Bethel MA, Matthews DR, Neil HAW (2008b) 10 year follow-up of intevsive glucose control in type 2 diabetes. New Engl J Med 359(15): 1577–89 Crossref, Google ScholarHolman N, Forouhi NG, Goyder E, Wild S (2011) The APHO Diabetes Prevalence Model. Estimates of total diabetes prevalence 2010-2030. Diabet Med 28(5): 575–82 Crossref, Google ScholarJones S, Young R, Jeffcoate W, Holman N (2011) Variation in the incidence of lower limb amputations in adults with diabetes. Poster presentation at the Diabetes UK Annual Professional Conference 2011, London Google ScholarLusignan S, Khunti K, Belsey Jet al. (2010) A method of identifying and correcting miscoding, misclassification and misdiagnosis in diabetes: a pilot and validation study of routinely collected data. Diabet Med 27(2): 203–9 Crossref, Google ScholarInformation Centre for Health and Social Care (2010) Key findings about the quality of care for people with diabetes in England and Wales: Report for the audit period 2008/09 http://tiny.cc/t2mf4 (accessed 6 April 2011) Google ScholarMindell J, Zaninotto P (2006) Cardiovascular disease and diabetes. In: K, Mindell J, eds. Health Survey for England 2004: The health of ethnic minority groups. The Information Centre for Health and Social Care, Leeds Google ScholarNational Collaborating Centre for Chronic Conditions (2008) Type 2 Diabetes. National Clinical Guideline for Nanagement in Primary and Secondary Care (Update). [NICE clinical guideline 66.] Royal College of Physicians, London Google ScholarRetnakaran Ret al. (2006) Risk factors for renal dysfunction in type 2 diabetes: UK Prospective diabetes study 74. Diabetes 55(6): 1832–9 Crossref, Google ScholarRiste L, Khan F, Cruickshank K, (2001) High prevalence of type 2 diabetes in all ethnic groups, including Europeans, in a British Inner City: Relative poverty, history, inactivity or 21st centrury Europe? Diabetes Care 24(8): 1377–83 Crossref, Google ScholarSproston K, Mindell J, eds. (2006) Health Survey for England 2004: The health of ethnic minority groups Leeds: The Information Centre for Health and Social Care, Leeds Google ScholarThomson MJ, Biddulph JP, Cull CA, Holman RR (2005) Reporting of diabetes on death certificates using data from the UK Prospective Diabetes Study Diabetic Medicine 22: 1031–6 Crossref, Google ScholarUK Prospective Diabetes Study Group (1998) Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 352(9131): 837–53 Crossref, Google Scholar FiguresReferencesRelatedDetailsCited byThe importance of screening for Charcot neuroarthropathy29 September 2013 | Practice Nursing, Vol. 23, No. 8Identifying neuropathic presentations of diabetes29 September 2013 | Practice Nursing, Vol. 22, No. 12 1 May 2011Volume 22Issue 5ISSN (print): 0964-9271ISSN (online): 2052-2940 Metrics History Received 28 February 2011 Accepted 6 April 2011 Published online 29 September 2013 Published in print 1 May 2011 Information© MA Healthcare LimitedKeywordsdiabetesprevalenceneedsoutcomesPDF download

Heavy drinking is associated with poor blood pressure control in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study.

Alcohol intake has been shown to have a J-shaped association with blood pressure (BP). However, this association has not been examined in mixed race populations or in people with diabetes where tighter blood pressure control is recommended. Participants in the REGARDS study who were 45 years or older (n = 30,239) were included. Medical history (including self-reported alcohol intake) was collected by telephone while blood collection and clinical measurements were done during an in-home visit. We defined diabetes as use of medications and/or fasting glucose ≥ 126 mg/dL and hypertension as use of blood pressure lowering medications and/or BP ≥ 140/90 mmHg or BP ≥ 130/80 mmHg in people with diabetes. After adjustment for confounders, heavy drinking was associated with an increased odds of hypertension (OR = 1.59; 95% CI = 1.37, 1.87). Diabetes and gender significantly modified (interaction P < 0.05 for both) the association between alcohol use and hypertension, although heavy drinking remained associated with increased odds of hypertension in sub-group analyses. We did not observe the previously described J-shaped relationship in any sub-group except white females. These data suggest heavy alcohol consumption is associated with poor BP control and that heavy drinkers may want to consider limiting alcohol intake in order to manage hypertension.

Benefits of Tight Blood Pressure Control in Diabetic Patients With Hypertension

In 2008, when the UK Prospective Diabetes Study (UKPDS) group presented their 30-year findings concerning the possible sustained effects of improved glycemic control after 10 years of extended follow-up in type 2 diabetic patients, a so-called “legacy effect” was reported to address the long-term emergent and/or sustained benefits of early improved glycemic control. Opposite results were obtained by the Hypertension in Diabetes Study (HDS) carried out in the frame of UKPDS, with no evidence of any legacy effect on cardiovascular (CV) outcomes for an initial 4-year period of tight blood pressure (BP) control. Thus, it was concluded that BP control has to be continued over time, since, although it had a short time-to-effect relationship in preventing stroke, BP control was associated with a short persistence of its clinical benefits once the intervention was discontinued. These findings are unique because, whereas most interventional trials in hypertension that included diabetic patients have shown a reduction in CV outcomes shortly after starting treatment, only the UKPDS-HDS specifically explored the possible persistence of clinical benefits after discontinuing intensive BP-lowering intervention. This article aims to provide a critical interpretation of the UKPDS findings of lack of BP legacy, in the context of the currently available evidence on the benefits of antihypertensive treatment. The importance of effective BP control in type 2 diabetic patients to prevent CV outcomes and other diabetes-related complications is underlined, with emphasis on early, tight, and continuous BP control to optimize patients’ protection.

Diabetes, Hypertension, and Outcome Studies: Overview 2010

The treatment of hypertension in type 2 diabetes is of great importance in avoiding costly complications and human suffering. The evidence base for recommending a treatment target for blood pressure control has expanded as the result of the publication of new studies in 2010, which will be summarized and commented on in this overview. Hypertension is a leading risk factor for mortality in both developing and developed countries (1) and a well established risk factor for cardiovascular disease (CVD) in patients with diabetes (2). An observational analysis from the UK Prospective Diabetes Study (UKPDS) has demonstrated a linear relationship between mean in-study systolic blood pressure (SBP) and the risk of macro- and microvascular complications (3). Tighter blood pressure control in hypertensive patients with type 2 diabetes by use of several antihypertensive drug classes versus placebo has been reported to reduce the risk of both micro- and macrovascular disease in the UKPDS (4,5) as well as several other intervention studies (6–9). Guidelines have so far advocated a treatment target blood pressure of <130/80 mmHg for patients with type 2 diabetes (10–12). However, the 2009 European guidelines from the European Society of Hypertension (ESH) recommend that patients with diabetes lower their SBP well below 140 mmHg—without mentioning a specific lowest target (13)—against a background of the lower blood pressure goals (<130/80 mmHg) recommended for patients with diabetes, which have never really been achieved in any single large trial and are even more rarely attained in medical practice. This ESH recommendation was also based on the results in some trials (14,15) and post hoc analyses of high-risk hypertensive patients (16,17), as in the Ramipril Global Endpoint Trial (ONTARGET) post hoc study (18,19) of high-risk patients (49% with a previous coronary …

The Role of Antiplatelets in Hypertension and Diabetes Mellitus

Cardiovascular disease (CVD) remains the main cause of mortality and morbidity in patients with diabetes. Prevention of CVD in diabetes involves a multifactorial approach that aims to treat the cluster of risk factors including hyperglycemia, dyslipidemia, obesity, hypertension, and hypercoagulation associated with this condition. Antiplatelets reduce the prothrombotic environment in diabetes, but complications of this therapeutic approach include a general risk of bleeding, specifically intracranial hemorrhage, the risk of which increases in the presence of hypertension. Current guidelines recommend the use of antiplatelet agents after tight control of blood pressure, which, in clinical practice, is not always possible. In this review, the evidence for antiplatelet use in diabetes with particular emphasis on patients with associated hypertension is examined. Safe levels of blood pressure with antiplatelet therapy, various studies, and general recommendations for diabetes patients, in light of current evidence, are explored.

Are There Pleiotropic Effects of Antihypertensive Medications or Is It All About the Blood Pressure in the Patient With Diabetes and Hypertension?

Many small studies with varied surrogate end points and numerous preclinical data have suggested the likelihood of there being specific benefits that exceed simple blood pressure control with drug classes such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and calcium channel blockers, which may be particularly relevant to the patient with diabetes and hypertension. Large clinical trials, however, have provided only token support for this idea. Likewise, meta-analyses that have incorporated varied clinical trials, albeit with somewhat heterogeneous data, have not been particularly forthcoming in their support of this concept. In the patient with diabetes and hypertension, tight blood pressure control, more so than using a specific drug class, is the most important aspect of therapy.

Fibrates and Statins in the Treatment of Diabetic Retinopathy

Diabetic retinopathy (DR) is one of the leading risk factors and causes of blindness worldwide. Tight glucose and blood pressure control has been shown to significantly decrease the risk of development as well as the progression of retinopathy and represents the cornerstone of medical management of DR. The two most threatening complications of DR are diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR). Photocoagulation is standard treatment for both DME and PDR. However, some patients suffer permanent visual loss despite therapy. Treatment with fibrates first showed reduction in hard exudates, an effect subsequently shown with statins in short term studies, in particular two randomized studies in patients with macular edema. In the FIELD study which pre-specified microvascular outcomes, fenofibrate reduced laser treatment for DME or PDR by 31%:164 (3.4%) patients on fenofibrate vs. 238 (4.9%) on placebo (p<0.001). In the ophthalmology sub-study of FIELD, the composite exploratory endpoint of 2-step progression of ETDRS retinopathy grade, macular edema or laser treatment was significantly reduced by 34%: 53 (11.1%) patients on fenofibrate vs. 75 (16.1%) on placebo (p=0.022). Conversely, there was no reduction in laser treatment or reduced progression of retinopathy in two large scale studies of statins where cardiovascular events were significantly reduced. Neither class of lipid-lowering drugs consistently improved visual acuity. In the ACCORD-EYE study, the combination of fenofibrate and simvastatin reduced by 40% the rate of progression of diabetic retinopathy compared with simvastatin alone. Other studies are needed to establish the place of lipid lowering drugs in the treatment of macular edema and the prevention of vision loss.

Intensive Blood Pressure Control Affects Cerebral Blood Flow in Type 2 Diabetes Mellitus Patients

Type 2 diabetes mellitus is associated with microvascular complications, hypertension, and impaired dynamic cerebral autoregulation. Intensive blood pressure (BP) control in hypertensive type 2 diabetic patients reduces their risk of stroke but may affect cerebral perfusion. Systemic hemodynamic variables and transcranial Doppler-determined cerebral blood flow velocity (CBFV), cerebral CO2 responsiveness, and cognitive function were determined after 3 and 6 months of intensive BP control in 17 type 2 diabetic patients with microvascular complications (T2DM+), in 18 diabetic patients without (T2DM-) microvascular complications, and in 16 nondiabetic hypertensive patients. Cerebrovascular reserve capacity was lower in T2DM+ versus T2DM- and nondiabetic hypertensive patients (4.6±1.1 versus 6.0±1.6 [P<0.05] and 6.6±1.7 [P<0.01], Δ%mean CBFV/mm Hg). After 6 months, the attained BP was comparable among the 3 groups. However, in contrast to nondiabetic hypertensive patients, intensive BP control reduced CBFV in T2DM- (58±9 to 54±12 cm·s(-1)) and T2DM+ (57±13 to 52±11 cm·s(-1)) at 3 months, but CBFV returned to baseline at 6 months only in T2DM-, whereas the reduction in CBFV progressed in T2DM+ (to 48±8 cm·s(-1)). Cognitive function did not change during the 6 months. Static cerebrovascular autoregulation appears to be impaired in type 2 diabetes mellitus, with a transient reduction in CBFV in uncomplicated diabetic patients on tight BP control, but with a progressive reduction in CBFV in diabetic patients with microvascular complications, indicating that maintenance of cerebral perfusion during BP treatment depends on the progression of microvascular disease. We suggest that BP treatment should be individualized, aiming at a balance between BP reduction and maintenance of CBFV.

Remission of diabetic nephropathy in type 2 diabetic Asian population: role of tight glucose and blood pressure control

Asian has higher prevalence of diabetic nephropathy (DN) and end-stage renal disease when compared to Caucasian. No study to date has evaluated whether multifactorial intervention was associated with remission of microalbuminuria in type 2 diabetic Asian population. We evaluated the effect of tightly controlling multiple factors on the remission of DN in type 2 diabetic Chinese with microalbuminuria. A longitudinal cohort study was collected 587 type 2 diabetic patients with microalbuminuria. Cohort members received intensified treatment to meet the following ADA recommended goals: HbA1c <7%, systolic blood pressure (SBP) <130mmHg, diastolic blood pressure <80 mmHg, low-density lipoprotein cholesterol <100mgdL(-1) , triglyceride < 150mgdL(-1) , high-density lipoprotein cholesterol >40mgdL(-1) for men and >50mgdL(-1) for women. Remission of microalbuminuria was defined as shift of albumin-creatinine ratio from mircoalbuminuria to normoalbuminuria. During the 4·5-year period, 210 (35·8%) patients achieved remission to normoalbuminuria. A significant association was found between the achievement of ADA goals, including HbA1c < 7% [hazard ratio (HR)=1·345; 95% confidence interval (CI), 1·010-1·792; P=0·04] and SBP <130mmHg (HR, 1·516; 95% CI, 1·100-2·089; P=0·01) and remission of microalbuminuria. The intensive SBP control (<120mmHg) was significantly associated with remission of microalbuminuria (HR, 2·076; 95% CI, 1·347-3·198; P<0·001). The remission of DN could be achieved under multifactorial intervention. Therapeutic focus on remission by tight glycemic and blood pressure control should be considered in Asian population with diabetes and microalbuminuria.

Relation of Baseline Systolic Blood Pressure and Long-Term Outcomes in Ambulatory Patients With Chronic Mild to Moderate Heart Failure

We studied the impact of baseline systolic blood pressure (SBP) on outcomes in patients with mild to moderate chronic systolic and diastolic heart failure (HF) in the Digitalis Investigation Group trial using a propensity-matched design. Of 7,788 patients, 7,785 had baseline SBP data and 3,538 had SBP ≤ 120 mm Hg. Propensity scores for SBP ≤ 120 mm Hg, calculated for each of the 7,785 patients, were used to assemble a matched cohort of 3,738 patients with SBP ≤ 120 and >120 mm Hg who were well-balanced in 32 baseline characteristics. All-cause mortality occurred in 35% and 32% of matched patients with SBPs ≤ 120 and >120 mm Hg respectively, during 5 years of follow-up (hazard ratio [HR] when SBP ≤ 120 was compared to >120 mm Hg 1.10, 95% confidence interval [CI] 0.99 to 1.23, p = 0.088). HRs for cardiovascular and HF mortalities associated with SBP ≤ 120 mm Hg were 1.15 (95% CI 1.01 to 1.30, p = 0.031) and 1.30 (95% CI 1.08 to 1.57, p = 0.006). Cardiovascular hospitalization occurred in 53% and 49% of matched patients with SBPs ≤ 120 and > 120 mm Hg, respectively (HR 1.13, 95% CI 1.03 to 1.24, p = 0.008). HRs for all-cause and HF hospitalizations associated with SBP ≤ 120 mm Hg were 1.10 (95% CI 1.02 to 1.194, p = 0.017) and 1.21 (95% CI 1.07 to 1.36, p = 0.002). In conclusion, in patients with mild to moderate long-term systolic and diastolic HF, baseline SBP ≤ 120 mm Hg was associated with increased cardiovascular and HF mortalities and all-cause, cardiovascular, and HF hospitalizations that was independent of other baseline characteristics.

New challenges in blood pressure goals and assessment

Provocative new studies have shown that tight blood pressure (BP) control (goal systolic BP <120 mmHg) in high-risk patients with diabetes mellitus confers no significant cardiovascular benefit other than stroke reduction, and that BP variability is important for the diagnosis and management of hypertension. the impact of these findings on future hypertension guidelines remains to be assessed.

Does renin-angiotensin system blockade have a role in preventing diabetic retinopathy? A clinical review

Diabetes management has increasingly focused on the prevention of macrovascular disease, in particular for type 2 diabetes. Diabetic retinopathy, one of the main microvascular complications of diabetes, is also an important public health problem. Much of the care invested in retinopathy relates to treatment rather than prevention of disease. Tight glycaemic and blood pressure control helps to reduce the risk of retinopathy, but this is not easy to achieve in practice and additional treatments are needed for both primary and secondary prevention of retinopathy. A renin-angiotensin system (RAS) has been identified in the eye and found to be upregulated in retinopathy. This has led to specific interest in the role of RAS blockade in retinopathy prevention. The recent DIRECT programme assessed use of the angiotensin receptor blocker (ARB) candesartan in type 1 and type 2 diabetes. Although the primary trial end-points were not met, there was a clear trend to less severe retinopathy with RAS blockade. A smaller trial, RASS, reported reduced retinopathy progression in type 1 diabetes from RAS blockade with both the ARB losartan and the angiotensin converting enzyme (ACE) inhibitor enalapril. The clinical implications of these new data are discussed.

The contribution of hypertension to diabetic nephropathy and retinopathy: the role of inflammation and oxidative stress

Diabetes and hypertension frequently coexist and constitute the most notorious combination for the pathogenesis of diabetic nephropathy and retinopathy. Large clinical trials have clearly demonstrated that tight control of glycemia and/or blood pressure significantly reduces the incidence and progression of diabetic retinopathy (DR) and nephropathy. However, the mechanism by which hypertension interacts with diabetes to induce and/or exacerbate nephropathy and retinopathy is very unclear. Substantial evidence implicates the involvement of chronic inflammation and oxidative stress in the pathogenesis of DR and nephropathy. In addition, hypertension causes oxidative stress and inflammation in the kidney and retina. In the present review, we summarized data obtained from our research along with those from other groups to better understand the role of hypertension in the pathogenesis of diabetic nephropathy and retinopathy. It is suggested that oxidative stress and inflammation may be common denominators of kidney and retinal damage in the concomitant presence of diabetes and hypertension.

Editorials Editorial on management of diabetes mellitus with coronary artery disease

Editorials Editorial on management of diabetes mellitus with coronary artery disease