You'll hear continued debate about how to manage hypertension in patients with diabetes.
The recent Am College of Cardiology and Am Heart Assn guidelines recommend a BP goal of less than 130/80 mmHg in patients across the board.
Years ago, many of us were also taught this goal for patients with diabetes.
But the Am Diabetes Assn has backed off over the past few years.
They now recommend a goal of less than 140/90 for most diabetes patients...or less than 130/80 for diabetes PLUS other CV risk factors.
These BP goals have been a moving target because the benefits of stricter BP control are less clear-cut in patients with diabetes.
For example, a systolic BP goal of less than 120 in diabetes might reduce stroke risk...but not other CV events or death.
Plus reaching a lower goal usually means adding one more BP med...and increases the risk of hypotension, electrolyte problems, etc.
Individualize BP goals for diabetes patients with hypertension.
First, continue to aim for a goal of less than 140/90. There's good evidence this goal improves CV and renal outcomes in diabetes patients.
Then discuss the pros and cons of a lower goal with your patient.
Weigh CV risks, especially a prior CV event, kidney disease, etc...with med side effects, fall risk, life expectancy, etc.
Consider a goal of less than 130/80 for those at highest CV risk.
For example, suggest a goal of less than 130/80, if tolerated, in a 70-year-old with a prior heart attack who's motivated and adherent.
Continue to recommend an ACEI or ARB first for diabetes patients with hypertension AND albuminuria...to slow kidney damage.
But for patients withOUT albuminuria, feel comfortable with an ACEI, ARB, thiazide diuretic, or dihydropyridine calcium channel blocker first.
For example, black patients may get better BP lowering with a thiazide or calcium channel blocker first, compared to an ACEI or ARB.
Emphasize proper home BP monitoring...resting before checking BP, using proper cuff size, etc. Remind patients to track and share results.
- JAMA 2018;319(13):1319-20
- Hypertension Published online Nov 13, 2017; doi:10.1161/HYP.0000000000000066
- Diabetes Care 2017;40(9):1273-84