American Diabetes Association Issues Updated Diabetes and Hypertension Position Statement
August 22, 2017
Hypertension, or high blood pressure, is a common condition particularly among people with diabetes. If uncontrolled, hypertension can lead to damage of the heart and blood vessels. On behalf of the American Diabetes Association (Association), a team of nine leading diabetes experts has reviewed and updated guidelines on the assessment and treatment of hypertension in people with diabetes. The detailed recommendations, which include a newly added pictorial algorithm for the treatment of confirmed hypertension in people with diabetes, are featured in the article, “Diabetes and Hypertension: A Position Statement by the American Diabetes Association,” to be published in the September 2017 issue of Diabetes Care, and online on August 22, 2017.
The prevalence of hypertension varies based upon a patient’s health, age, gender, family history of heart disease and genetics. Hypertension is a strong, yet modifiable risk factor for atherosclerotic cardiovascular disease (ASCVD), heart failure and microvascular complications. ASCVD refers to a buildup of fatty deposits in the arteries, which can result in issues such as myocardial infarction, stroke, peripheral arterial disease and more. ASCVD is the leading cause of morbidity and death among people with diabetes, as well as the largest contributor to the economic cost of diabetes. It is well established that treating hypertension impacts and reduces ASCVD events, heart failure and microvascular complications in people with diabetes.
The Association recommends that people with diabetes have blood pressure measurements taken at every routine clinical visit and, for people with diagnosed hypertension, taken at home as well. Blood pressure should also be measured while standing at the initial clinical evaluation to assess for orthostatic hypertension, a condition that may signal underlying nerve damage and influence blood pressure targets and treatment strategies. Patients with an elevated blood pressure (office-based measurements of 140/90 mmHg and above) should have their blood pressure conﬁrmed with multiple readings, including measurements on a separate day, to diagnose hypertension.
While the Association recommends a blood pressure target of less than 140/90 mmHg for most people with diabetes and hypertension, a lower blood pressure goal might be beneficial for some patients who have a high risk of cardiovascular disease. The position statement summarizes outcomes of clinical trials that have researched intensive hypertension treatment strategies, including the Action to Control Cardiovascular Risk in Diabetes blood pressure (ACCORD BP) trial; the Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation–Blood Pressure (ADVANCEBP) trial; the Hypertension Optimal Treatment (HOT) trial; and the Systolic Blood Pressure Intervention Trial (SPRINT).
Lifestyle management plans for lowering blood pressure are also highlighted in the guidelines and include suggestions on weight loss, nutrition and increased physical activity. The statement also details, step-by-step, the recommended approach for the use of medication in the treatment of hypertension in people with diabetes, which depends on initial blood pressure, kidney health, response to treatment and adverse effects.
The Association provides detailed information regarding pregnancy, diabetes and hypertension. The statement emphasizes that women with preexisting hypertension or mild gestational hypertension (blood pressures less than 160/105 mmHg), and no evidence of end-organ damage, should not be treated with antihypertensive medications, as there is no benefit that clearly outweighs the potential risks. Blood pressure targets and potential medication guidelines are also included for pregnant patients with diabetes who do require treatment for hypertension.
Antihypertensive treatment for people with diabetes in the absence of hypertension is addressed, with the position statement indicating there is little evidence that blood pressure medication improves health outcomes in this group of patients. Additionally, the statement offers recommendations for adults who are 65 years of age and older who have diabetes and hypertension.
“In the past two decades, we have seen a decrease in ASCVD morbidity and mortality in people with diabetes, and evidence indicates that advances in blood pressure control are likely the key to such improvements,” said the Association’s Chief Scientific, Medical & Mission Officer William T. Cefalu, MD. “As medical and pharmacological developments occur, it is imperative that medical providers, diabetes educators and patients stay abreast of the most current care recommendations that can lead to improved cardiovascular health for people with diabetes and will ultimately result in better overall health and fewer diabetes-related complications.”
The position statement was compiled by a team of nine diabetes experts from the fields of endocrinology, nephrology, cardiology and internal medicine from the U.S., Europe and Australia. The in-depth guidelines are based upon an intense review of research, and references 137 of the most critical hypertension studies from around the world
The position statement will be published online at http://care.diabetesjournals.org/lookup/doi/10.2337/DCi17-0026 on August 22, 2017.
About the American Diabetes Association
More than 30 million Americans have diabetes, and every 21 seconds another person is diagnosed with diabetes. The American Diabetes Association (Association) is the global authority on diabetes and since 1940 has been committed to its mission to prevent and cure diabetes and to improve the lives of all people affected by diabetes. To tackle this global public health crisis, the Association drives discovery in research to treat, manage and prevent all types of diabetes, as well as to search for cures; raises voice to the urgency of the diabetes epidemic; and provides support and advocacy for people living with diabetes, those at risk of developing diabetes and the health care professionals who serve them. For more information, please call the American Diabetes Association at 1-800-DIABETESS (1-800-342-2383) or visit diabetes.org. Information from both of these sources is available in English and Spanish. Find us on Facebook (American Diabetes Association), Twitter (@AmDiabetesAssn) and Instagram (@AmDiabetesAssn)