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Powerful link between blood pressure and diabetes

Comment by Nicolle Kränkel, EACPR Exercise, Basic and Translational Research Section

Usual blood pressure and risk of new-onset diabetes
Emdin CA, et al
J Am Coll Cardiol. 2015;66(14):1552-1562. doi:10.1016/j.jacc.2015.07.059

Diabetes and the Heart

Patients with type 2 diabetes mellitus (T2D) are at increased risk to suffer cardiovascular events. In 2012, an estimated 1.5 million deaths were directly caused by diabetes. Accounting for over 90% of all diabetes cases, T2D therefore ranks among the most prevalent causes of death world-wide. Today, several molecular and cellular mechanisms are known which explain the higher cardiovascular risk in T2D patients. Whether hypertension – another well-known cardiovascular risk factor – can affect the risk of T2D is controversial.

A new study covering ca. 4.1 million adults and provided together with a meta-analysis of prospective observational studies now provides strong evidence that hypertension increases T2D risk [1]. For the first part of the paper, the team by Emdin et al. used the U.K. health record “Clinical Practice Research Datalink” to obtain data from 4.1 million U.K. individuals before T2D onset and free of vascular disease at incusion. Usual blood pressure was used and regression dilution bias was accounted for. After adjustment for age, sex and BMI a hazard ratio of 1.58 per each 20mm Hg was calculated. Additional adjustment for smoking and the use of antihypertensive or lipid-lowering drugs had little additional effect. The association was strongest in patients with normal-to-mildly elevated blood pressure and losing strength with increasing age and BMI of the participants, where both variables on their own account for an increased risk of diabetes.

In the systematic review, the group obtained results from 30 studies including over 285.000 patients. This analysis yielded a comparable hazard ratio of 1.77 per 20 mm Hg. Taking together both datasets, Emdin et al. report a 76% of risk increase for each 20mm HG BP increase.

The study therefore provides solid evidence of an association between blood pressure and the onset of diabetes – whether causal or not remains to be determined. Another meta-analysis indicates a role for the renin-angiotensin-system, which might affect both, blood pressure regulation as well as mechanisms predisposing for T2D development [2]. The authors speculate that one effect of RAS-inhibitors – the reduction of inflammatory signalling – might be a common pathway for both, hypertension as well as T2D onset. Endothelial dysfunction – under the effect of chronic inflammation or not – might be a common mechanism for hypertension and diabetes as well – and it is also affected by ACE inhibitors. Further (meta-)analyses could provide additional information on the role of RAS inhibition for both, hypertension and T2D onset, while translational studies need to substantiate causalities.


The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology


1    Emdin CA, Anderson SG, Woodward M, Rahimi K. Usual Blood Pressure and Risk of New-Onset Diabetes: Evidence From 4.1 Million Adults and a Meta-Analysis of Prospective Studies. J Am Coll Cardiol. 2015;66(14):1552-62.
doi: 10.1016/j.jacc.2015.07.059.
2    Elliott WJ, Meyer PM. Incident diabetes in clinical trials of antihypertensive drugs: a network meta-analysis. Lancet 2007;369:201–7.

Notes to editor

Nicolle Kränkel, Charité – Universitätsmedizin Berlin, Berlin Germany