427
2005
1 2 3
1
2
3
( 140 mmHg / 90 mmHg )
130 mmHg 80 mmHg
11 5 / 7 5
mmHg 130/80 mmHg
(Angiotensin-converting enzyme in- hibitors ACEI) Angiotension receptor blockers ARB
-blockers ( Diuretics ) Calcium channel blockers CCB 160/100 mmHg
( Diabetes mellitus, DM ) ( Hypertension, HTN )
( Cardiovascular disease, CVD )
( 140 mmHg /
90 mmHg )
20~60%
11
30% 1
2-3
2 20-60%
1
2 1.5
14 0
19% 38%
4 0
3 0 . 6 %
4
140/90 mmHg 5 mmHg 20-30%
5130 mmHg 80
mmHg
6-9
115/75 mmHg
6,10,11
2000
130/80 mmHg
12JNC 130/80 mmHg
1 g
125/75 mmHg
4600 mg 2300 mg 5 / 2 - 3 m m H g
6
1
1 mmHg
13
( A n g i o t e n s i n - c o n v e r t i n g e n z y m e i n h i b i t o r s A C E I )
Angiotension receptor blockers ARB -blockers ( Diuretics )
Calcium channel blockers CCB
dihydropyridine calcium channel blockers ( D- CCB )
14,15DCCB
162 2 , 5 7 6
Verapamil SR-Trandolapril (IN-
VEST) verapamil (non- D-
CCB )
17
18-19
20
ALLHAT ( antihypertensive and lipid-lowering treatment to prevent heart attack trial )
chlorthalidone am- lodipine lisinopril
thiazide
21
SHEP ( systolic hy- pertension in the elderly program )
60 thi-
azide
34% (p< 0.05)
22
23 24
130/85 mmHg
X
25
160/100 mmHg
6
( )
110-129 mmHg 65-79 mmHg
methyldopa labatolol diltiazem clonidine prazosin
26
ADA
26
A-Level evidence
B-Level evidence
C-Level evidence
Expert consensus
130/80 mmHg (C )
1. 130 mmHg
(C )
2. 80 mmHg
(B )
1. 140 mmHg
90 mmHg (A ) 2.
( ) (B )
3. 130-139/80-89 mmHg
(E ) 4.
(
) (A ) 5.
thiazide (E
) 6.
(E ) 7.
(1) 1
(A ) ( 2 ) 2
(A )
(3) 2
(A ) ( 4 )
1 1 0 - 1 2 9
mmHg 65-79 mmHg
(E ) ( 5 )
(E ) ( 6 )
(E ) ( 7 )
(E )
1.Hypertension in Diabetic Study (HDS). Prevalence of hyper- tension in newly presenting type 2 diabetic patients and the as- sociation with risk factors for cardiovascular and diabetic com- plications. J Hyperten 1993; 11: 309-17.
2.Nishimura R, LaPorte RE, Dorman JS, Tajima N, Becker D, Orchard TJ. Mortality trends in type 1 diabetes: the Allegheny County (Pennsylvania) Registry 1965-1999. Diabetes Care 2001; 24: 823-7.
3.Mathiesen ER, Ronn B, Jensen T, Storm B, Deckert T.
Relationship between blood pressure and urinary albumin ex- cretion in development of microalbuminuria. Diabetes 1990; 39:
245-9.
4.Tai TY, Chuang LM, Chen CJ, Lin BJ. Link between hyperten- sion and diabetes mellitus epidemiological study of Chinese adults in Taiwan. Diabetes Care 1991; 14: 1013-20.
5.MacMahon S, Peto R, Cutler J, et al. Blood pressure, stroke, and coronary heart disease. Part 1. Prolonged difference in blood pressure: prospective observational studies corrected for the re- gression dilution bias. Lancet 1990; 335: 765-74.
6.Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report
of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003; 289 : 2560-72.
7.UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complica- tions in type 2 diabetes: UKPDS 38. BMJ 1998; 317: 703-13.
8.Hansson L, Zanchetti A, Carruthers SG, et al. Effects of inten- sive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial: the HOT Study Group.
Lancet 1998; 351: 1755-62.
9.Adler AI, Stratton IM, Neil HA, et al. Association of systolic blood pressure with macrovascular and microvascular compli- cations of type 2 diabetes (UKPDS 36): prospective observa- tional study. BMJ 2000; 321: 412-9.
10.Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Age- specific relevance of usual blood pressure to vascular mortali- ty: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002; 360: 1903-13.
11.Stamler J, Vaccaro O, Neaton JD, Wentworth D. Diabetes, oth- er risk factors, and 12-yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial. Diabetes Care 1993; 16: 434-44.
12.Bakris GL, Williams M, Dworkin L, et al. Special Report:
Preserving renal function in adults with hypertension and dia- betes: a consensus approach. Am J Kidney Dis 2000; 36: 646- 61.
13.Staessen J, Fagard R, Lijnen P, Amery A. Body weight, sodium intake and blood pressure. J Hyperten 1989; 7: S19-23.
14.Tatti P, Pahor M, Byington RP, et al. Outcome results of the Fosinopril Versus Amlodipine Cardiovascular Events Random- ized Trial (FACET) in patients with hypertension and NIDDM.
Diabetes Care 1998; 21: 597-603.
15.Estacio RO, Jeffers BW, Hiatt WR, Biggerstaff SL, Gifford N, Schrier RW. The effect of nisoldipine as compared with enalapril on cardiovascular outcomes in patients with non-insulin- dependent diabetes and hypertension. N Engl J Med 1998; 338:
645-52.
16.Berl T, Hunsicker LG, Lewis JB, et al. Cardiovascular outcomes in the Irbesartan Diabetic Nephropathy Trial of patients with type 2 diabetes and overt nephropathy. Ann Intern Med 2003;
138: 542-49.
17.Pepine CJ, Handberg EM, Cooper-DeHoff RM, et al. A calcium antagonist vs a non-calcium antagonist hypertension treatment strategy for patients with coronary artery disease: the International Verapamil-Trandolapril study (INVEST): a ran- domized controlled trial. JAMA 2003; 290: 2805-16.
18.Heart Outcomes Prevention Evaluation Study Investigators.
Effects of ramipril on cardiovascular and microvascular out- comes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Lancet 2000; 355: 253-59.
19.PROGRESS group. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with
previous stroke or transient ischaemic attack. Lancet 2001; 358:
1033-41.
20.Lindholm LH, Ibsen H, Dahlof B, et al. Cardiovascular mor- bidity and mortality in patients with diabetes in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet 2002; 359:
1004-10.
21.ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting en- zyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002; 288: 2981-97.
22.Curb JD, Pressel SL, Cutler JA, et al. Effect of diuretic-based antihypertensive treatment on cardiovascular disease risk in older diabetic patients with isolated systolic hypertension:
Systolic Hypertension in the Elderly Program Cooperative Research Group. JAMA 1996; 276: 1886-92.
23.ALLHAT Collaborative Research Group. Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: the antihypertensive and lipid-lowering treat- ment to prevent heart attack trial (ALLHAT). JAMA 2000; 283:
1967-75.
24.Messerli FH. Implications of discontinuation of doxazosin arm of ALLHAT: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Lancet 2000; 355: 863- 4.
25.Arauz-Pacheco, Parrott MA, Raskin P. The treatment of hyper- tension in adult patients with diabetes. Diabetes Care 2002; 25:
134-47.
26.American Diabetes Association. Standards of medical care in diabetes (Position Statement). Diabetes Care 28 (Suppl. 1) 2005;
28: S4-36.
2005 ADA Standard Recommendations for Treatment of Diabetes with Hypertension
Lyh-Jyh Hao, Chwen-Yi Yang
1, Chang-Sheng Ku
2, Kuo-Liang Chai
3Hypertension (HTN) (BP 140/90 mmHg) is a common comorbidity of diabetes, affecting the majority of people with diabetes, depending on type of diabetes, age, obesity, and ethnicity. HTN is also a major risk factor for CVD and microvascular complications such as retinopathy and nephropathy. Randomized clinical trials have demonstrated the benefit (reduction of CHD events, stroke, and nephropathy) of lowering BP to <130 mmHg sys- tolic and <80 mmHg diastolic in individuals with diabetes. Epidemiologic analyses show that BP >115/75 mmHg is associated with increased cardiovascular event rates and mortality in individuals with diabetes. Therefore, a target BP goal of <130/80 mmHg is reasonable. Nonpharmacological strategies include reducing sodium intake and body weight; increasing consumption of fruits, vegetables, and low-fat dairy products; avoiding excessive al- cohol consumption; and increasing activity levels have been shown to be effective in reducing BP in nondiabe- tic individuals and may also positively affect glycemia and lipid control. Lowering of BP with regimens based on antihypertensive drugs, including ACE inhibitors, angiotensin receptor blockers (ARBs), -blockers, diuretics, and calcium channel blockers, has been shown to be effective in lowering cardiovascular events. Systolic BP 160 mmHg or diastolic BP 100 mmHg, however, mandates that immediate pharmacological therapy be initiat- ed and should be seen as often as needed . In these patients, other cardiovascular risk factors, including obesi- ty, hyperlipidemia, smoking, presence of microalbuminuria, and glycemic control, should be carefully assessed and treated. Many patients will require three or more drugs to reach target goals. ( J Intern Med Taiwan 2005; 16:
107-112 )
Division of Endocrinology and Metabolism, Yung Kang Veterans Hospital
1
Division of Endocrinology and Metabolism, Department of Internal Medicine, Chi-Mei Foundation Hospital, Tainan, Taiwan
2
Division of Cardiology, Yung Kang Veterans Hospital
3