Prof. Robert Fagard,
In the first part of the session, P. Nilsson discussed the problem of whether or not to start antihypertensive treatment in diabetic patients with high normal office BP, that is a BP of 130-139/85-89 mmHg. Several guidelines have recommended that these patients should be treated with antihypertensive drugs in addition to lifestyle measures. However, it has now been recognized that the evidence for drug treatment is scant, with the result that the 2012 European Guidelines on cardiovascular disease prevention in clinical practice state that drug treatment should always be initiated when the BP is ≥ 140/90 mmHg, but that initiation of treatment in the high-normal BP range is at present not sufficiently supported by outcome evidence from trials. However, treatment is suggested if organ damage is present, especially micro- or macro-albuminuria.
During the ensuing panel discussion with R. Schmieder and P. Verdecchia, it was stressed that ambulatory BP monitoring is extremely important in these patients because of the high prevalence of masked hypertension and the absence of night-time dipping, and that if drug treatment is indicated, a RAS blocker should be preferred.
In the second part of the session, R. Schmieder said that hypertension is a frequent problem in diabetes and is often resistant to antihypertensive treatment. Resistant hypertension is defined as lack of BP control with at least 3 antihypertensive drugs from different drug classes, including a diuretic. It is an indication for ambulatory BP monitoring in order to exclude white-coat resistance, for investigations of secondary causes of hypertension, such as renal artery stenosis, and for careful assessment of compliance with the prescribed therapy. Management includes intensification of lifestyle measures, particularly salt restriction and weight reduction if appropriate, optimization of drug treatment with careful association of spironolactone, and if necessary, drugs from other classes. In case of persistent resistance, renal denervation or carotid baroreceptor stimulation should be considered.
Hypertension and diabetes - deadly challenge
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