Hypertension Treatment in Diabetes: Focus on Heart Failure Prevention

Key points

Diabetes and heart failure

There is a clear and well-established link between diabetes and the incidence of coronary artery disease. Given the high rates of coronary artery disease among patients with diabetes, it is not surprising that patients with diabetes are also at a high risk of developing ischemic cardiomyopathy and heart failure. Although it was previously believed that the link between heart failure and diabetes was predominantly mediated through a higher burden of ischemic heart disease and resulting ischemic

Hypertension and cardiovascular events

Hypertension is also a well-established risk factor for CV disease regardless of the presence of diabetes. In a meta-analysis of studies that included data from more than 1 million patients, reduction in blood pressure resulted in a significant reduction in the risk of vascular death with no lower limit of benefit seen.¹⁶ Furthermore, in a cohort of 1.25 million subjects followed over time, increasing systolic blood pressure was associated with a higher risk of all types of CV disease including

Diabetes, hypertension, and heart failure

Given the overlapping risk factors for diabetes and hypertension, the two diseases frequently coexist. In one meta-analysis, the prevalence of hypertension was found to range from 60% to 75% among patients with diabetes.²⁰ There are also data to suggest that precedent hypertension is associated with a 35% increased risk of diabetes.²¹ The risk of macrovascular complications in patients with hypertension and diabetes is greater than in patients with just one of these conditions.²²

There is also a

Blood pressure lowering and clinical outcomes in diabetes

The United Kingdom Prospective Diabetes Study (UKPDS-38) was one of the earliest studies that attempted to define appropriate blood pressure targets for patients with diabetes. In this study, more than 1000 patients with type 2 diabetes and hypertension were randomized to strict versus lenient blood pressure control and followed over time. Those randomized to a more aggressive blood pressure target achieved an average blood pressure of 144/82 mm Hg compared with the other group who had an

Blood pressure targets

Current guidelines offer clinicians guidance on blood pressure control in patients with diabetes. The American Diabetes Association (ADA) consensus report remains committed to a blood pressure goal of less than 140/90 mm Hg for patients with diabetes.²⁷ Although they acknowledge that some patients with increased risk of CV disease might benefit from a lower blood pressure target, they are compelled by the strongest evidence from the ACCORD trial, which failed to demonstrate this benefit from

Glucose-lowering therapies: new frontier of blood pressure control

Although diabetes is driven by different mechanisms with various underlying causes, all forms of the disease result in elevated serum glucose levels and long-term risk of ischemic and heart failure events. Although there is a clear association between chronic hyperglycemia (as measured by glycated hemoglobin A_1c [HbA_1c]) and ischemic events, the relationship is also seen with regards to heart failure but is not as strong.⁶⁴ No glucose-lowering agents have shown a relationship between degree of

SGLT-2 inhibitors

More recent data have shown CV benefit of novel antihyperglycemics. One class, the SGLT-2 inhibitors, block the renal sodium glucose cotransporter-2, increasing urinary excretion of glucose, and resulting in subsequent osmotic diuresis. The multicenter Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes trial (EMPA-REG OUTCOME) was the first trial to show benefits of the SGLT-2 inhibitors in CV outcomes.⁷⁰ More than 7000 patients with established atherosclerosis were

Current guideline recommendations

Based on the large body of research evaluating blood pressure management in patients with diabetes, the ADA has released guidelines that advise a blood pressure target of 140/90 for patients with diabetes.²⁷ These guidelines recommend that the first line of blood pressure treatment include an ACEI or an ARB to reduce RAAS activation, particularly in patients with evidence of microalbuminuria. Following initiation of an ACEI or and ARB, CCBs or diuretics are recommended. Mineralocorticoids are

Summary

Reducing CV risk in patients with diabetes is of paramount importance given the association between diabetes and CV events, such as MI, stroke, and heart failure. Current guidelines, including those from CV and endocrine societies, are largely similar and support treating most patients to achieve blood pressure target of less than 130 mm Hg. Many patients need multidrug strategies to achieve these goals with thiazide diuretics and RAS inhibitors having the most evidence to support reduction in