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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Prevention and Management of Hypertension in the Diabetic Patient


GOAL
To provide primary care physicians, primary care nurse practitioners, and primary care physician assistants with up-to-date information on the prevention and management of hypertension in the diabetic patient.

TARGET AUDIENCE
This activity is designed for primary care physicians, primary care nurse practitioners, and primary care physician assistants. No prerequisites required.

LEARNING OBJECTIVES
At the conclusion of this activity, the participant should be able to:

  • Identify risk factors and risk factor reduction strategies to reduce diabetic hypertensive morbidity and mortality.
  • Describe the progression of the treatment standards for diabetes and hypertension, identifying the gaps and additional needs in current therapeutic guidelines to include updated, evidence-based recommendations for the management of diabetic hypertension.
  • Evaluate the role of the renin-angiotensin-aldosterone system (RAAS) in the continuum of diabetic hypertension and the effects on the vessels, heart, and kidneys.
  • Review the potential benefits of RAAS-targeted therapies, including emerging data from recent trials.
  • Discuss the safety, tolerability, and efficacy of traditional, as well as novel pharmacotherapies, in the treatment of diabetic hypertension.
  • Interpret findings of current clinical trials and the complementary actions of different hypertension-modifying drugs to optimize patient outcomes.

The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity.

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The estimated time to complete this educational activity: 2 hours.

After reading this monograph, participants may receive credit by completing the CME test, evaluation, and receiving a score of 70% or higher.

Release date: October 15, 2007. Expiration date: October 15, 2009.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of The Johns Hopkins University School of Medicine name implies review of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an educational grant from King Pharmaceuticals.

Full Disclosure Policy Affecting CME Activities
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of the Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a provider has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation.  The presenting faculty reported the following:

PROGRAM DIRECTORS

Roger S. Blumenthal, MD, FACC, FAHA
Professor of Medicine
Director, Preventive Cardiology
Johns Hopkins University School of Medicine
Baltimore, Maryland
Dr Blumenthal reports having no financial or advisory relationships with corporate organizations related to this activity.

PARTICIPATING FACULTY

George L. Bakris, MD
Professor of Medicine
Director, Hypertension Unit
Section of Endocrinology, Diabetes, and Metabolism
Department of Medicine
Division of Biological Sciences
The University of Chicago, Pritzker School of Medicine
Chicago, Illinois
Dr Bakris reports receiving grants/research support from Forest, Gileada, GlaxoSmithKline, National Institutes of Health, and Sanofi-Aventis; and serving as a consultant or on the speakers' bureau for Abbott Laboratories, Boehringer-Ingelheim, Bristol-Myers Squibb/Sanofi-Aventis, Forest, Gileada, GlaxoSmithKline, Merck and Company, Novartis, Sankyo, and Walgreen's.

William J. Elliott, MD, PhD
Professor of Preventive Medicine and Internal Medicine and Pharmacology
Rush Medical College of Rush University
Rush University Medical Center
Chicago, Illinois
Dr Elliott reports receiving grants/research support from Pfizer Inc; serving as a consultant for Abbott Laboratories, Accu-Break Pharmaceuticals, AstraZeneca, King Pharmaceuticals, Kos Pharmaceuticals, KV Pharmaceutical, Novartis, and Pfizer Inc; and serving on the speakers' bureau for Abbott Laboratories, AstraZeneca, Bristol-Myers Squibb Company, Kos Pharmaceuticals, Novartis, Pfizer Inc, and Sanofi-Aventis.

William B. White, MD
Professor of Medicine
Chief, Hypertension and Clinical Pharmacology
The Pat and Jim Calhoun Cardiology Center
University of Connecticut Health Center
Farmington, Connecticut
Dr White reports having no financial or advisory relationships with corporate organizations related to this activity.

Notice: The audience is advised that articles in this CME activity may contain reference(s) to unlabeled or unapproved uses of drugs or devices.

Dr Bakris–proteinuria reduction and renal outcomes.
Dr Elliott–prevention of stroke, myocardial infarction, cardiovascular death, and diabetes mellitus.

All other faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Johns Hopkins Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Johns Hopkins Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Prevention and Management of Hypertension in the Diabetic Patient
Roger S. Blumenthal, MD, FACC, FAHA*

It is generally now well understood and accepted that the prevalence of 2 of the most serious risk factors for cardiovascular disease–overweight/obesity and type 2 diabetes–are rising at alarming rates. In fact, overweight/obesity is now the norm in American society, prevalent in the majority of adults.1 However, what about hypertension, another of the strongest cardiovascular risk factors?

The Third National Health and Nutrition Evaluation Survey (1988-1994) has recently shown us that 71% of individuals with diabetes have hypertension, 29% of diabetic individuals with hypertension were unaware of the diagnosis, and 43% of diabetic individuals with hypertension were untreated.2,3 This high prevalence of hypertension and seeming lack of awareness has important consequences. A meta-analysis of 61 prospective, observational studies of blood pressure and mortality involving 1 million adults published in The Lancet revealed the continuous relationship between hypertension and cardiovascular risk throughout the normal range of blood pressure. The study showed that small differences in blood pressure (ie, 2 mm Hg) may produce a difference in risk of cardiovascular events by up to 10%. Specifically, within each decade of life, risk of vascular death is reduced with lower blood pressure, down to approximately 115/75 mm Hg. Below that blood pressure, there are very few data on risk of cardiovascular disease. For those ages 40 to 69 years, each 20- mm Hg difference in systolic blood pressure (or 10-mm Hg difference in diastolic blood pressure) is associated with a more than 2-fold difference in stroke death rate, ischemic heart disease death rate, and death from other vascular causes. This benefit of blood pressure lowering extends to the "old-old," although the effect on hazard ratios declines after age 80 years; each 20/10-mm Hg decrease in blood pressure is associated with approximately 33% less vascular mortality in this age group.4

Why then are we and our patients not feeling compelled to act aggressively to prevent or detect and treat earlier hypertension in patients with type 2 diabetes–patients with an already established high risk of cardiovascular disease? The American Diabetes Association has taken an important first step with their "Make the Link!" campaign to raise awareness among patients about the link between diabetes and heart disease, but hypertension appears to the average person to be a benign condition. There are no symptoms, thus it is easily ignored. Yet, we sometimes ignore hypertension at our and our patients' peril.

This issue of Johns Hopkins Advanced Studies in Medicine was created to help primary care practitioners understand the pathophysiology of hypertension, particularly in the setting of type 2 diabetes, to address the established risk factors for cardiovascular disease with a tailored approach, and to understand the mechanisms behind antihypertensive therapy and why certain agents are recommended as first-line treatments, namely those that address the renin-angiotensin-aldosterone system (RAAS).

William B. White, MD, opens the monograph with an overview of hypertension pathophysiology, explaining the various mechanisms that influence and are influenced by the RAAS, and he briefly reviews the current consensus from the major guidelines on managing hypertension in patients with type 2 diabetes.

George L. Bakris, MD, continues the discussion of the guidelines by reviewing some of the key evidence to support those guidelines, in addition to newer clinical studies since the guidelines were published. He also discusses some of the safety and dosing considerations with recommended pharmacotherapies, particularly in specific patient subpopulations (eg, the elderly, women, and those with comorbid renal disease). He also includes a discussion of nonpharmacologic strategiesÑlifestyle modifications, which, as he notes, address every cardiovascular risk factor, not just hypertensionÑthat are so important and necessary for any antihypertensive drug to have its full effect.

Finally, William J. Elliott, MD, PhD, provides a case study on prehypertension. As he points out, the concept of "prehypertension" is relatively new, defined only since the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure in 2004.5 There is still much discussion on whether and how to treat this condition, and Dr Elliott discusses some specific strategies and factors to consider.

In all of these articles, 2 important themes emerge–the pivotal role of lifestyle modifications and the use of tailored treatment plans. These are important points because patients with diabetes and hypertension are a high-risk population for cardiovascular events. As Dr White notes, "Diabetes and hypertension are 2 of the most well-known and potent risk factors for cardiovascular disease development, and they rarely exist in isolation."

REFERENCES

1. National Center for Health Statistics. Prevalence of overweight and obesity among adults: United States, 2003-2004. Available at: www.cdc.gov/nchs/products/pubs/pubd/hestats/overweight/overwght_adult_03.htm. Accessed September 15, 2007.
2. Geiss LS, Rolka DB, Engelgau MM. Elevated blood pressure among US adults with diabetes, 1988-1994. Am J Prev Med. 2002;22:42-48.
3. American Diabetes Association/American College of Cardiology. Hypertension in diabetes. Diabetes and cardiovascular review. Available at: www.ada.org. Accessed September 1, 2007.
4. Lewington S, Clarke R, Qizilbash N, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360:1903-1913.
5. US Department of Health and Human Services. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Complete Report. NIH publication 04-5230; August 2004.

The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of his article and all its contents.

*Professor of Medicine, Director, Preventive Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Address correspondence to: Roger S. Blumenthal, MD, FACC, FAHA, Professor of Medicine, Director, Preventive Cardiology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Blalock 524C, Baltimore, MD 21287. E-mail: rblument@jhmi.edu.



Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.