Standards of Medical Care in Diabetes - 2012
The 2012 Standards of Medical Care in Diabetes from the American Diabetes Association (ADA) contain recommendations on preventing and managing diabetes complications, including cardiovascular complications.
The ADA recommendations for hypertension and blood pressure control are summarized below.
Screening and Diagnosis
- Patients with diabetes should have their blood pressure measured at every diabetes visit.
- If systolic blood pressure (SBP) is ≥ 130 mmHg, or if diastolic blood pressure (DBP) is ≥ 80 mmHg, then the patient should return on a different day to have his/her blood pressure confirmed.
- With a repeat SBP ≥130 mmHg or DBP ≥ 80 mmHg, a diagnosis of hypertension can be made.
- SBP: < 130 mmHg
- DBP: < 80 mmHg
- In women with diabetes who are pregnant: 110-129/65-79 mmHg
- Individual SBP goals may be more appropriate, based on patient characteristics and response to treatment.
- Lifestyle Therapy
- Appropriate for patients with SBP 130-139 mmHg or DBP 80-89 mmHg. This can be suggested for 3 months, and if targets aren’t met, pharmacological agents can be used.
- This includes:
- Weight loss (if appropriate)
- Dietary Approaches to Stop Hypertension (DASH) dietary pattern
- Moderation of alcohol intake
- Increased physical activity
- Pharmacological Therapy
- Appropriate for patients with severe hypertension (SBP ≥ 140 mmHg or DBP ≥ 90 mmHg)
- Should be used in conjunction with lifestyle therapy
- Should include either an ACE inhibitor or an ARB
- If one of these or a diuretic is used, kidney function and serum potassium levels should be monitored.
- These are contraindicated during pregnancy.
- Generally, 2 or more agents are needed to achieve blood pressure goals
- Should be administered at bedtime
The ADA guidelines for blood pressure control in patients with diabetes are based on JNC 7, which was published in 2004. Fortunately, JNC 8 should be coming out in the fall of 2012.
The blood pressure goals in JNC 8 may be different than JNC 7, in that the goal blood pressure may be less than 140/90 in patients with diabetes. This is based on the ACCORD trial and the ADVANCE trial, which are the only prospective trials to date that have actually achieved systolic blood pressure levels less than 130 mmHg. In ACCORD, despite a sustained difference in blood pressure between the two treatment groups (133 mmHg versus 119 mmHg) for more than 4 years, there was no additional benefit on the primary endpoint, CV events. Of note, there was a benefit in stroke events. All physicians who manage hypertension should review the much anticipated JNC 8.