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Patients with diabetes mellitus experience increased peripheral artery resistance caused by vascular remodeling and increased body fluid volume associated with insulin resistance-induced hyperinsulinemia and hyperglycemia. Both of these mechanisms elevate systemic blood pressure. Thus, fully understanding the pathophysiology of hypertension in diabetes mellitus requires knowing the natural history of type 2 diabetes.
Patients exhibit hyperinsulinemia with insulin resistance due to impaired glucose tolerance and early-stage diabetes.
Hypertension occurs because of increased body fluid volume. After reaching mid-stage diabetes the vascular remodeling has progressed and peripheral vascular resistance also contributes to hypertension. Moreover, vascular remodeling strongly influences diabetic complications. Specifically, afferent arteriolar remodeling during diabetic nephropathy leads to increased glomerular pressure. Thus, treatment with a renin-angiotensin system inhibitor that promotes renal damage regression is critical to lowering the systemic blood pressure and dilating efferent arterioles to reduce glomerular pressure.
Association between changes in systolic blood pressure and incident diabetes in a community-based cohort study in Korea. Hypertens Res. The pathogenic role of the kidney. J Cardiovasc Pharmacol. Sodium restriction shifts circadian rhythm of blood pressure from nondipper to dipper in essential hypertension. Morning hypertension in chronic kidney disease is sustained type, but not surge type. Blood Press Monit.
Am J Hypertens. Joffe D, Yanagisawa RT. Metabolic syndrome and type 2 diabetes: can we stop the weight gain with diabetes? Med Clin North Am. Saltiel AR. Insulin signaling in the control of glucose and lipid homeostasis. Handb Exp Pharmacol.
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The insulin-like growth factor system in vascular smooth muscle: interaction with insulin and growth factors. Insulin as a vascular hormone: implications for the pathophysiology of cardiovascular disease.
Hypertension and Diabetes: Addressing Common Comorbidities
Clin Exp Pharmacol Physiol. Young A. Renal effects. Adv Pharmacol.
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Sweeney G, Klip A. Mol Cell Biochem. Epidemiology of high blood pressure and obesity. Mechanism of the blood pressure-lowering effect of sodium-glucose cotransporter 2 inhibitors in obese patients with type 2 diabetes. Blood pressure should be measured in the supine, sitting, and standing positions. Eye disease—hypertension increases the risk of eye disease in patients with diabetes, including glaucoma and diabetic retinopathy with potential blindness.
Cardiac disease—hypertension in patients with diabetes increases the risk of coronary artery disease, congestive heart failure, and cardiomyopathy. Cerebrovascular disease—hypertension increases the incidence of stroke in patients with diabetes. Survival rates and recovery from stroke are reduced in patients with diabetes compared with patients without diabetes. Peripheral vascular disease—hypertension increases the risk of peripheral vascular disease and subsequent foot ulcers and amputations in patients with diabetes.
Information from references 4 , 7 , and 8.
XII. Treatment of Hypertension in Association With Diabetes Mellitus
To reduce this risk, hypertension must be diagnosed accurately and promptly, and the patient must receive adequate treatment. To confirm the diagnosis of hypertension, blood pressures measured with standard techniques should be elevated on two separate occasions. In the Dietary Approaches to Stop Hypertension trial, lifestyle modifications such as exercise and a diet low in salt and high in potassium have clearly been shown to decrease blood pressure.
Although the benefits of lifestyle modification are clear, few patients are able to achieve blood pressure control with these interventions alone. The JNC VI guidelines recommend that patients with diabetes be started on both antihypertensive medication and lifestyle modifications when hypertension is diagnosed.
Angiotensin II receptor blockers also show promise in the treatment of hypertension in diabetes. In many patients, a combination of two or more of these agents is necessary to reach blood pressure goals. Regardless of the agents selected, a reduction in blood pressure helps to prevent diabetic complications. ACE inhibitors have proved beneficial in patients who have had a myocardial infarction or congestive heart failure, or who have diabetic renal disease early or established.
Recently, a meta-analysis of trials evaluating the use of antihypertensives in high-risk patients, including those with diabetes, showed that ACE inhibitor therapy resulted in a 20 to 30 percent decrease in the risk of stroke, coronary heart disease, and major cardiovascular events. A second meta-analysis compared ACE inhibitors with other antihypertensive agents in patients with diabetes.
hypertension and diabetes - General Practice Notebook
The one exception was the United Kingdom Prospective Diabetes Study UKPDS , which compared captopril with atenolol and found the two agents to be similar in terms of reduction in microvascular and macrovascular complications. ACE inhibitors may provide additional benefits in patients with diabetes. These patients may have impaired fibrinolysis and endothelial dysfunction, which increase their risk of cardiovascular disease. ACE inhibitors have been shown to improve fibrinolysis and endothelial dysfunction.
One area of concern is the use of ACE inhibitors in persons with underlying renal disease, which is common in patients with diabetes. A recent post hoc analysis 19 of the HOPE trial demonstrated that in patients with preexisting vascular disease or diabetes combined with an additional cardiovascular risk factor, mild renal insufficiency i.
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In this study, ramipril reduced cardiovascular risk without increasing adverse effects. However, in patients with bilateral renal artery stenosis, ACE inhibitors can cause renal insufficiency. To help detect the presence of undiagnosed bilateral renal artery stenosis, physicians should monitor the serum creatinine level at baseline and one week after initiation of ACE inhibitor therapy.
Thiazide diuretics have been shown to benefit patients with diabetes and systolic hypertension. The Systolic Hypertension in the Elderly Program trial was initiated to assess the effect of low-dose, diuretic-based antihypertensive treatment on the rates of major cardiovascular events in older patients with isolated systolic hypertension and diabetes. Lower dosages of thiazides e. In general, diuretics are effective in the treatment of hypertension. In addition, many less-expensive generic diuretics are available. Five studies 21 — 25 have evaluated cardiovascular outcomes in patients with hypertension and diabetes who were treated with dihydropyridine CCBs.
Conversely, the Hypertension Optimal Treatment HOT trial, 23 the Systolic Hypertension in Europe trial, 24 and the Isolated Systolic Hypertension in China study 25 concluded that the use of dihydropyridine CCBs, as monotherapy or in combination with another agent, was associated with a reduction in cardiovascular risk.
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