2nd Annual Heart iN Diabetes Medical Conference:

Hypertension in Diabetes: How Low to Go in Patients with Diabetes?

With George L. Bakris, MD

Prompted by the revised American College of Cardiology/American Heart Association guidelines for the detection, prevention, management and treatment of high blood pressure that promoted a lower threshold for hypertension of 130/80 mm Hg rather than the more measured cut off of 140/90 mm Hg, two opposing guidelines committee chair—George Bakris MD,1 who and Paul K. Whelton, MB, MD,2 faced off in a debate-style session at the 2nd annual Heart in Diabetes medical conference in Philadelphia, Pennsylvania.

“There’s been a lot of hype about blood pressure (BP) control in patients with diabetes, fueled by differences in the guidelines issued by the American Diabetes Association3  and that of the American College of Cardiology/American Heart Association,4” said George L. Bakris, MD, professor of medicine and director of the Comprehensive Hypertension Center at the University of Chicago School of Medicine in Illinois who argued for the “higher” level in most cases.

 

"First, consider that the committee members formulating the ADA guidelines were 78% practicing clinicians as compared to about 32% of those sitting on the ACC/AHA guideline task force. Then add to that the failed assumption that everyone will do better with a lower blood pressure when their risk is high, which only plays well if the patient is willing.," said Dr. Bakris in establishing his position.

“The differences between the two professional guidelines are really slight with congruency in many areas, and 96% agreement across most issues,” he said,5 citing a paper just accepted for publication in Diabetes Care. Both guidelines establish that the goal for blood pressure ranges be based on a 10-year 10% risk for cardiovascular disease.1,2

Dr. Bakris argued that the focus has been on numbers but when considering treatment for hypertension, it is essential that we put the blood pressure ranges into the context of individual patient risk.1 The ADA guidelines stress personalizing care with shared decision-making is the best approach to achieve optimum blood pressure goals.3

That means that you need to be an epidemiologist and a clinician when applying the guidelines to an individual, he said, “people are variable, therefore the guidelines need to be flexible.”

Top Concern is Accuracy of Blood Pressure Measurements

Even before the BP ranges can be considered, it is of the utmost necessity for proper blood pressure measurements to be taken correctly, said Bakris, because it is crucial that patients’ blood pressure be assessed in accordance with the guidelines.  

This matters because the guidelines are predicated on proper BP measurements, including correct cuff size, averaging of two measures, and positioning patients properly.  While this may seem overly simplistic, accuracy requires adherence to the complete protocol, not just slapping on a cuff the moment patients walk into the examination room.  Can you confidently affirm that the following steps are taken with every patient?

  • Seated with feet on the ground.
  • Arm is supported.
  • Cuff is appropriately sized for the patient
  • Patient is not talking or on the phone, just quiet and relaxed.

Ideally, the patient should put the button on the first BP measure. Then the technician or nurse should take two more measures and the average of these two numbers should be recorded. This may sound cumbersome and impractical but many offices have adapted their procedures to do this, including my own.

Blood pressure goals should be individualized, tolerable, and attainable.Is this patient's blood pressure going to be accurate?

Without the certainty that this methodology is met, everything you do regarding the patient’s BP—diagnosing and treating,—is likely to be wrong. So, this point cannot be driven home hard enough; an accurate blood pressure must be ascertained in order to appropriately move forward in assessing for hypertension risk.

Blood Pressure Targets in Low-Risk Diabetes Patients: Challenging Subgroup

The second key factor is to assess the initial blood pressure goal in patients relatively low risk such as a young person with no frank cardiovascular disease (CVD) or CVD symptoms. The BP range for these patients is under 140/90 mm Hg.

These patients do not need to be pushed closer to 130/80 mm Hg.

In fact, there are good outcomes data to suggest that patients whose blood pressure was under 130 mm Hg did not do better than those whose blood pressure fell between 130 and 139 mm Hg.2

Patients with diabetes who are deemed at low risk (at 10-15%) for HTN represents the only area of significant disagreement between the two guidelines. However, I advocate for a starting point of less than 140/90 mm Hg and recommend working with the patient to bring the BP a little lower. A BP in this subgroup of 132 mm Hg is really sufficient, as the difference between 132 -130 or 129 mm Hg is negligible.

In effect, guidelines tend to be rigid so there is a need to then apply the goals to fit each patient as there is no one-size-fits-all recommendation. You’ll want to evaluate the patient for risks and determine your patient’s tolerability for achieving a blood pressure below 140 mm Hg for how much closer to the lower range is likely and doable.

However, in patients with diabetes who have a 10-15% risk for hypertension, the BP cut-off should not be less than 130/80 mm Hg. This stems from evidence that people who had diabetes and in whom a 120 mm Hg target blood pressure was achieved, there was no clear difference in the rate of CVD deaths or stroke events, according to results of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) blood pressure trial.6

“Worth considering is the potential for side effects such that patients will stop taking their meds rather than deal with issues of acute renal failure, sleepiness, syncope, or cost (socioeconomics), just to have a BP of 120 mm Hg, and they will also not return for future appointments,1 he said.

In fact, the data are very clear—too aggressive is not good, and the old edict to keep pushing the BP down until they can’t stand up anymore is not appropriate—You don’t want to get the BP numbers below 120 mg Hg because the benefits are outweighed by the risks.1,6,7

Reasons for a Winning Argument in Less Aggressive BP Management

“For people with diabetes, good blood pressure management has with taking a proper blood pressure, ascertaining what do about with each patient, assessing approaches to treatment, and the value of combination therapy for people at high risk,” said Dr. Bakris.

“Attention should be focused on the initial treatment considerations in people who have been diagnosed with type 2 diabetes and are typically at 10/5 mm Hg above goal” Dr. Bakris told EndocrineWeb, “This is consistent with both guidelines and the treatment plan needs to be fully implemented so you can do a more reasoned job of managing hypertension in this largely obese, high-risk diabetes population.”

Overall, the goal is simple. For patients with CVD risk or elevated BP, get them on treatment early, and get them in good control to at least 140 mm Hg, he said, to start.

Next Summary:
Which Glucose-Lowering Drug Class—SGLT2i or GLP1RA—is Better for People with T2D and CVD?
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