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Query: UMLS:C0011849 (diabetes)
 277,896 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Arterial hypertension and diabetes are potent independent risk factors for cardiovascular, cerebral, renal and peripheral (atherosclerotic) vascular disease. The prevalence of hypertension in diabetic individuals is approximately twice that in the non-diabetic population. Diabetic individuals with hypertension have a greater risk of macrovascular and microvascular disease than normotensive diabetic individuals. Hypertension is a major contributor to morbidity and mortality in diabetes, and should be recognized and treated early. Type 2 diabetes and hypertension share certain risk factors such as overweight, visceral obesity, and possibly insulin resistance. Life-style modifications (weight reduction, exercise, limitation of daily alcohol intake, stop smoking) are the foundation of hypertension and diabetes management as the definitive treatment or adjunctive to pharmacological therapy. Additional pharmacological therapy should be initiated when life-style modifications are unsuccessful or hypertension is too severe at the time of diagnosis. All classes of antihypertensive drugs are effective in controlling blood pressure in diabetic patients. For single-agent therapy, ACE-inhibitors, angiotensin receptor blocker, beta-blockers, and diuretics can be recommended. Because of concerns about the lower effectiveness of calcium channel blockers in decreasing coronary events and heart failure and in reducing progression of renal disease in diabetes, it is recommended to use these agents as second-line drugs for patients who cannot tolerate the other preferred classes or who require additional agents to achieve the target blood pressure. The choice depends on the patients specific treatment indications since each of these drugs have potential advantages and disadvantages. In patients with microalbuminuria or clinical nephropathy, both ACE-inhibitors and angiotensin receptor blockers are considered first line therapy for the prevention of and progression of nephropathy. Since treatment is usually life-long, cost effectiveness should be included in treatment evaluation.
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PMID:[Treatment of hypertension in type 2 diabetes mellitus--2002 update]. 1223 35

Atherosclerotic renovascular disease (ARVD) is common in the general population, and its prevalence increases with age. Parallel studies show it is also common in patients with diabetes. The widespread use of angiotensin converting enzyme inhibitors and angiotensin receptor antagonists for heart and kidney disease might therefore expose arteriopathic diabetic patients to potential harm if they had critical renal artery stenosis. This review looks at the natural history of ARVD in the diabetic and non-diabetic populations: while it is common, it only rarely leads to renal failure. Hence intervention to revascularize ischaemic kidney son the basis of radiological appearances alone may subject some patients to unnecessary therapy. Although untested by randomized trial, a policy of watchful waiting may be the simplest strategy for most diabetic patients with suspected ARVD, reserving angiography and angioplasty (usually backed up by a stent) for those with an abrupt decline in renal function and no other cause for renal deterioration. Future clinical trials may better define subgroups of patients who will truly benefit from renal revascularization.
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PMID:The impact of atherosclerotic renovascular disease on diabetic renal failure. 1242 24

Diabetes mellitus increases the risk for hypertension and associated cardiovascular diseases, including coronary, cerebrovascular, renal and peripheral vascular disease. The risk for developing cardiovascular disease is increased when both diabetes and hypertension co-exist; in fact, over 11 million Americans have both diabetes and hypertension. These numbers will continue to climb, internationally, since the leading associated risk for diabetes development, obesity, has reached epidemic proportions, globally. Moreover, the frequent association of diabetes with dyslipidemia, as well as coagulation, endothelial, and metabolic abnormalities also aggravates the underlying vascular disease process in patients who possess these comorbid conditions. The renin-angiotensin-aldosterone system (RAS) and arginine vasopressin (AVP) are overactivated in both hypertension and diabetes. Drugs that inhibit this system, such as ACE inhibitors and more recently angiotensin receptor antagonists (ARBs), have proven beneficial effects on the micro- and macrovascular complications of diabetes, especially the kidney. The BRILLIANT study showed that lisinopril reduces microalbuminuria better than CCB therapy. Numerous other long-term studies confirm this association with ACE inhibitors including the HOPE trial. Furthermore, the European Controlled trial of Lisinopril in Insulin-dependent Diabetes (EUCLID) study, showed that lisinopril slowed the progression of renal disease, even in individuals with mild albuminuria. In fact, there are now five appropriately powered randomized placebo-controlled trials to show that both ACE inhibitors and ARBs slow progression of diabetic nephropathy in people with type 2 diabetes. These effects were shown to be better than conventional blood pressure lowering therapy, including dihydropyridine CCBs. In patients with microalbuminuria, ACE inhibitors and ARBs reduce the progression of microalbuminuria to proteinuria and provide a risk reduction of between 38 and 60% for progression to proteinuria. This is important since microalbuminuria is known to be associated with increased vascular permeability and decreased responsiveness to vasodilatory stimuli. Recently, increased AVP levels have been lined to microalbuminuria and hyperfiltration in diabetes. The microvascular and macrovascular benefits of ACE inhibition, ARBs and possible role of AVP antagonists in diabetic patients will be discussed, as will be recommendations for its clinical use.
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PMID:Treatment of the diabetic patient: focus on cardiovascular and renal risk reduction. 1243 44

Angiotensin-converting enzyme inhibitors (ACEIs) are an important class of drugs in cardiovascular disease. As their name suggests, they act by blocking angiotensin converting enzyme, thereby limiting the production of angiotensin II, the most active component of the renin-angiotensin- aldosterone system. This system plays an important role in maintenance of blood pressure and electrolyte and fluid balance. Therefore, by blocking this system, the ACEIs have wide ranging effects. Recent trials have reaffirmed their place in the management of hypertension, congestive cardiac failure, in the prevention of renal complications in diabetes and the prevention of strokes in 'at risk' patients. There are still many ongoing trials using the ACEIs. These trials are mainly aimed at comparing their efficacy with 'older' drugs (such as betablockers) and 'newer' drugs such as the angiotensin receptor blockers and calcium antagonists in different indications, such as heart failure and diabetic nephropathy. The impact of these drugs on the prevention of macro- and micro vascular complications in diabetes is also being investigated. The results of all these trials, when available, are expected to reaffirm the important role of this class of drugs in our modern day medical armamentarium. In this review, the ongoing clinical trials involving ACEIs, the rationale behind these trials and what impact they hope to have on our current understanding of the role of this important class of drug in medical practice, will be discussed.
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PMID:Ongoing trials involving angiotensin-converting enzyme inhibitors. 1243 9

To evaluate the current status of the management of hypertensive patients in Japan, we investigated 907 treated hypertensive patients (486 females and 421 males; mean age, 66.7 years) followed by cardiologists. According to the guidelines for the management of hypertensive patients in Japan in 2000 (JSH-2000), only 41.5% of the subjects achieved the target blood pressure, with a mean systolic blood pressure of 140.0+/-14.9 mmHg and a mean diastolic blood pressure of 80.0+/-10.7 mmHg. There were no differences between patients with and without concurrent disease or among age groups (<60, 60-69, 70-79, and 80 years and over) in systolic blood pressure levels achieved. However, the diastolic blood pressure decreased with age, indicating an increase of the pulse pressure. Overall, the prescription rates were: calcium channel blockers (CCBs), 73.0%; angiotensin converting enzyme inhibitors (ACE-inhibitors), 31.3%; angiotensin receptor blockers (ARBs), 18.9%; beta-blockers, 16.2%; and diuretics, 10.1%. Although some selection of antihypertensive drugs was based on evidence from previous trials on hypertensive patients with diabetes mellitus, chronic heart failure and renal insufficiency, overall, CCBs were selected in all age groups and in all comorbid conditions. In conclusion, Japanese cardiologists do not appear to consider age and comorbidity when choosing antihypertensive managements. Based on current evidence, the management of hypertension should be individualized, with the blood pressure target level and antihypertensive medications chosen on the basis of age and comorbidity.
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PMID:The status of hypertension management in Japan in 2000. 1245 24

Numerous hypertension treatment trials have been reported during the past several years. In comparative studies it has been shown that the use of diuretics or diuretics/beta blockers has resulted in a reduction in morbidity/mortality equivalent to the use of other antihypertensive medications. This is true in both young and elderly patients. In one large 8-year study in diabetics, the use of a beta blocker/diuretic combination was shown to be as effective in reducing overall cardiovascular events as an angiotensin-converting enzyme (ACE) inhibitor/diuretic treatment program. Although most data indicate that the degree of blood pressure lowering accounts for most of the benefit, there are some differences in outcome that may be explained by different mechanisms of drug action. For example: 1) diuretics are more effective in preventing heart failure and overall cardiovascular events than alpha blockers; 2) an ACE inhibitor-based program is more effective in the elderly in reducing myocardial infarctions and heart failure than a calcium channel blocker-based program; and 3) a nondihydropyridine is more effective in reducing strokes, but less effective in preventing myocardial infarctions or heart failure, than a program based on diuretic therapy. There is also abundant evidence that the use of ACE inhibitors may prevent the occurrence of diabetes in hypertensive individuals and will reduce cardiovascular events in diabetics. Finally, the angiotensin receptor blockers have been shown to slow the progression of renal disease and prevent the occurrence of end-stage renal disease when compared to treatment regimens that do not include an angiotensin receptor blocker or ACE inhibitor. Updated treatment recommendations should include an ACE inhibitor and possibly an angiotensin receptor blocker along with diuretics and beta blockers as initial therapy. In addition, recommendations for the use of multiple-drug therapy have been reinforced by recent trials. Goal pressures are not readily achieved with monotherapy, especially in high-risk patients.
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PMID:Update on the management of hypertension: do recent clinical trial results indicate a change in national recommendations for therapy? 1246 17

Because treating hypertension in the elderly so effectively reduces major cardiovascular events, it is vital to diagnose this very common condition early. Much of the hypertension that occurs with aging results from stiffening of the major capacitance arteries, typically marked by high systolic and low diastolic blood pressures. Pulse pressure, derived by subtracting diastolic from systolic values, is a useful index of stiffness, but new noninvasive techniques for measurement of arterial compliance have shown that blood pressures cannot reliably predict the state of the arteries in older people. The Systolic Hypertension in the Elderly Program (SHEP) and the Systolic Hypertension in Europe (Syst-Eur) trial demonstrated that treating hypertension in the elderly with diuretics or calcium channel blockers reduces strokes and cardiac events; these results are also clearly evident in high-risk groups like diabetics. Further analysis of Syst-Eur has suggested that a calcium channel blocker reduces new-onset dementia, while follow-up data from SHEP indicate that a diuretic provides survival and stroke benefits in obese or overweight elderly hypertensives, but not in the lean. In general, comparisons of antihypertensive agents, including diuretics, beta blockers, angiotensin-converting enzyme inhibitors, and calcium channel blockers have found similar clinical end point effects. But recently, the Losartan Intervention For End Point Reduction in Hypertension (LIFE) study, performed in patients (average age, 67) with left ventricular hypertrophy and predominant systolic hypertension, showed that the angiotensin receptor blocker losartan was significantly more effective than the beta blocker atenolol in reducing such key outcomes as strokes and new-onset diabetes. Even so, careful but effective control of blood pressure in elderly patients, including those over age 80, still remains a critical factor in preventing major cardiovascular events.
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PMID:Outcomes of treating hypertension in the elderly: a short commentary on current issues. 1250 10

In the past few years diabetes has become the leading cause of end-stage renal disease in all Western countries. A correlation between blood pressure and rate of progression in diabetic nephropathy was noted very early, and increased local activity of the renin angiotensin system was identified as a major pathophysiological mechanism for proteinuria and nephrosclerosis in diabetic patients. Angiotensin converting enzyme (ACE) inhibitors have been shown to slow progression of nephropathy in type 1 diabetic patients. The majority of diabetic patients with nephropathy, however, are suffering from type 2 diabetes and until last year there was no convincing evidence of ACE inhibitors being able to slow progression in type 2 diabetic patients with nephropathy. Three new studies now fill this gap, showing that angiotensin receptor blockers (ARB) are nephroprotective in patients with type 2 diabetes, independently of blood pressure. This review provides an in-depth discussion of the results of these studies and provides recommendations for patient management.
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PMID:Angiotensin receptor antagonists in patients with nephropathy due to type 2 diabetes. 1255 90

The renin-angiotensin-aldosterone system (RAAS) plays a fundamental role in the development of atherosclerosis and adverse cardiovascular events. Traditionally, the pathologic effects of the RAAS were assumed to result from vasoconstriction induced by angiotensin II, and salt and water retention due to aldosterone. However, these hormones also have powerful trophic effects, stimulating increased mass in both the arterial wall and left ventricle. In addition, angiotensin II and aldosterone predispose to vascular inflammation, thrombosis, oxidative stress, and sudden cardiac death. Therapy directed at RAAS overactivity is essential for normalizing the prognosis of most patients with atherosclerosis. An angiotensin-converting enzyme (ACE) inhibitor improves the prognosis of patients with atherosclerosis and/or diabetes even in the setting of normal baseline blood pressure. Angiotensin receptor blocking agents also improve cardiovascular structure and prognosis. Although these agents are better tolerated than ACE inhibitors, they do not appear to be as effective in reducing event rates. Aldosterone receptor blocking agents also improve cardiovascular structure, function, and prognosis. Aldosterone receptor blockers appear to provide additive benefit when used in conjunction with either an ACE inhibitor or an angiotensin receptor blocker.
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PMID:The renin-angiotensin-aldosterone system as a target in coronary disease. 1257 98

Diabetes mellitus is the leading cause of end-stage renal disease and also increases the risk of atherosclerotic vascular disease. Hypertension amplifies both problems. Detection of microalbuminuria, a common and early manifestation of diabetic nephropathy and a marker for cardiovascular risk, permits early treatment to reduce progression of nephropathy and vascular disease in diabetes. Although optimal glycemic control is essential to reduce the risk of nephropathy, aggressive blood pressure lowering to a level of 130/80 mg Hg or below in hypertensive diabetic patients is as important as glycemic control. Initial drug therapy for nephropathy should include an angiotensin-converting enzyme inhibitor (or if contra-indicated, an angiotensin receptor blocker), as several large randomized double-blinded multicenter clinical trials have demonstrated an independent renoprotective effect with renin angiotensin system inhibition. The role of advanced glycation end products in the pathogenesis of renal and vascular disease in diabetes is becoming more clearly established. However, the use of therapeutic strategies directed at blocking their effect still awaits further investigation. A multifaceted intervention program that combines optimal glycemic control, lifestyle modification/cardiovascular prevention guidelines such as lipid control and smoking cessation, with appropriate antihypertensive therapy when indicated, will prevent or delay both the occurrence and progression of diabetic nephropathy.
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PMID:Combating diabetic nephropathy with drug therapy. 1264 11


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