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NEED FOR MORE AGGRESSIVE BLOODPRESSURE CONTROL IN DIABETESEffective control of blood pressure has been associatedwith a reduction in both the microvascular andmacrovascular complications of diabetes. Most recent-ly, the Joint National Committee on the Prevention,Detection, Evaluation, and Treatment of High BloodPressure (JNC 7) has recommended a target bloodpressure of less than 130/80 mm Hg in hypertensivepatients with diabetes. However, reaching this level ofblood pressure control has been difficult to achieve.

In an effort to better understand how often weare achieving these current national recommenda-tions, investigators from Boston, MA, evaluated themedical records of 800 male hypertensive veteranswith and without diabetes between 1990 and 1995from five Veteran Affairs medical centers in NewEngland. Followed for 2 years, they compared the274 men (34%) who had coexisting diabetes with acontrol group of 526 nondiabetic men to examinethe proportion of patients whose blood pressurewas <140/90 mm Hg. They also compared theintensity of antihypertensive treatment in these twogroups of patients in an effort to better understandwhether adjustment of diabetes medications affectsdecisions to increase antihypertensive therapy.

Those with diabetes were more likely to be non-white, have coronary artery disease, and be obese thantheir nondiabetic counterparts. They were, however,no more likely to be older (mean age 65 years), be onmore antihypertensive medications, or have a longerduration of hypertension (average duration 13 years).

Overall, systolic blood pressure control was worsein those with diabetes. The mean systolic blood pres-sure in the diabetic group was 148.4 mm Hg com-pared with 143.8 mm Hg in those without diabetes.No differences were noted in mean diastolic blood

pressure, which was 83.0 mm Hg in both groups.While 34% of those without diabetes had their bloodpressure controlled to <140/90 mm Hg, only 27% ofthose with diabetes achieved this level of control.

Less intensive antihypertensive therapy was themajor reason for the lack of blood pressure controlin those with diabetes. Diabetic patients were lesslikely to have been prescribed a new antihyperten-sive medication at each visit or an increased dosageof their existing medication. In addition, they wereas likely to be on the same number of antihyper-tensive agents as those without diabetes. In thosewith diabetes, 31% were taking two antihyperten-sive agents and 30% were taking three or moreantihypertensive agents, whereas in those withoutdiabetes, these values were 32% and 25%, respec-tively. In addition, antihypertensive medicationswere no more likely to be added at visits where achange in diabetic medications had occurred.

Diabetic patients with hypertension achieve lowerrates of blood pressure control and receive less inten-sive treatment than their nondiabetic counterparts.This occurs despite the lower levels of blood pressurecurrently recommended in these patients. This failureto control diabetic hypertension appears to be due tothe failure to intensify antihypertensive therapyrather than any pathophysiologic differencesbetween the populations studied. We need to bemore aggressive in managing blood pressure in dia-betics.—Berlowitz DR, Ash AS, Hickey EC, et al.Hypertension management in patients with diabetes:the need for more aggressive therapy. Diabetes Care.2003;26:355–359.

CommentThe prevalence of diabetes continues to increase at arapid rate, affecting 17 million people or 8% ofAmericans in 2001. It is estimated that diabetes willaffect 29 million Americans by 2050. Type 2 diabetesplaces a person at double the risk of cardiovascularmorbidity and mortality compared with those with-out diabetes. Diabetes is the most common cause ofend-stage renal disease in the United States, and thepresence of hypertension in patients with diabetes

A n a l y s i s o f R e c e n t P a p e r s i n H y p e r t e n s i o nJ a n B a s i l e , M D , S e c t i o n E d i t o r

Jan Basile, MD

From the Ralph H. Johnson VA Medical Center,Medical University of South Carolina, Charleston, SCAddress for correspondence:Jan N. Basile, MD, Ralph H. Johnson VA MedicalCenter, 1090 Bee Street, Charleston, SC 29403

www.lejacq.com ID: 3118

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accelerates the risk of diabetic nephropathy. As manyas 60% of patients with diabetes have hypertension.Clinical trials have convincingly demonstrated thebenefit of intensive treatment of hypertension in thispopulation. This has challenged practitioners to con-trol blood pressure more effectively in these patients.

In this study, in which a majority of veterans hadtype 2 diabetes, diabetics were no more likely tohave their blood pressure controlled than nondia-betics. Diabetics were less likely to have their bloodpressure aggressively treated. Practitioners failed toup-titrate the dose of medication as well as to usemore antihypertensive medication in these patients.Focused attention to glucose control was not a rea-son for the lack of effective blood pressure control.

The study was carried out between 1990 and 1995,when expert panels were just beginning to suggest thatblood pressure less than 140/90 mm Hg in the diabet-ic might be appropriate. It was not until 1997 that theJNC VI guidelines recommended a target blood pres-sure of less than 130/85 mm Hg in those with dia-betes. Most recently, the target is 130/80 mm Hg. It istherefore possible that clinicians in this study did nothave the knowledge to recommend more aggressivetherapy, but even today clinicians are no more likely toeffectively control blood pressure in those with dia-betes. Two recent large databases found the averageblood pressure was 143/78 mm Hg and 141/79 mmHg, respectively in type 2 diabetics with hypertension.The mean number of antihypertensive medicationsrequired to achieve a blood pressure less than 130/85mm Hg was 3.1, whereas those with a blood pressuregreater than 130/85 were receiving 3.3 medications.

As a joint effort of the Hypertension Initiative ofSouth Carolina and the American Society ofHypertension (ASH) Carolinas-Georgia Chapter,primary care providers in South Carolina wererecently invited to participate in a data feedbackprogram. Blood pressure levels les than <140/90mm Hg were achieved in 44.3% of hypertensiveswith diabetes and 49.6% in those without diabetes.A blood pressure of less than 130/85 mm Hg wasattained in 25.6% of diabetics and 34.3% of non-diabetics. To achieve a blood pressure less than130/85 mm Hg, 72.4% were prescribed at least twoor more antihypertensive medications. Of note, thenumber of antihypertensive medications used wassimilar in diabetic and nondiabetic patients with amean of 2.7 and 2.8 agents, respectively.

While we continue to improve the overall controlof blood pressure in those with hypertension, blood

pressure control remains worse in those with dia-betes mainly as a failure to intensify therapy. Moreinformation is required to understand why thisoccurs. Barriers to implement treatment guidelinesand achieve control goals in clinical practice remain.Physicians are often unaware of treatment patternsand control rates in their own patients. A data feed-back system may be one tool to enable practitionersto improve on these rates of blood pressure control.

POST MENOPAUSAL HORMONE REPLACE-MENT THERAPY PREVENTS DIABETESPrevious studies have noted an inconsistent effect ofpostmenopausal hormone replacement therapy(HRT) on glucose metabolism and the risk of devel-oping new onset diabetes. To evaluate the effect ofhormone therapy on fasting glucose and incidentdiabetes among women who are on HRT, a post-hoc, re-examination of the randomized, double-blindplacebo-controlled Heart and Estrogen/progestinReplacement Study (HERS) conducted between1993 and 1994 was performed to examine whetherpostmenopausal hormone use can prevent diabetes.

HERS investigators evaluated the 2029 post-menopausal women without diabetes on entry fromthe 2763 women with underlying coronary artery dis-ease for their risk of developing diabetes (fasting glu-cose at or above 126 mg/dL) or beginning diabetesmedication while on HRT. Over a mean 4.1 years, therisk of developing new onset diabetes was 6.2% inthe women assigned to HRT (0.625 mg conjugatedestrogen and 2.5 mg medroxyprogesterone acetatedaily) and 9.5% in the placebo group (35% reduc-tion). One case of diabetes could be prevented forevery 30 women who took HRT. Of note, fasting glu-cose levels increased among women assigned to place-bo but did not change among women receiving HRT.In a multivariable analysis adjusting for smoking,alcohol use, physical activity, body mass index, waistcircumference, medication use including diuretics, βblockers, angiotensin converting enzyme inhibitors,statins, and patient demographics, HRT continued tobe associated with a decrease in the risk of diabetes.The authors believe this provides important insightsinto the metabolic effects of HRT but is insufficientevidence to recommend the use of hormones for thesecondary prevention of heart disease.—Kanaya M,Herrington D, Vittinghoff E, et al. Glycemic effects ofpostmenopausal hormone therapy: The Heart andEstrogen/progestin Replacement Study. Ann InternMed. 2003;138(1):1–9.

CommentRecent trials support the use of diet and exercise,insulin-sensitizing agents (metformin and troglita-zone), acarbose, and antihypertensive (angiotensinconverting enzyme inhibitor and angiotensin receptorblocker) agents as a means of preventing new-onsetdiabetes. This study, involving a predominantly whitepopulation, suggests HRT also prevents new-onsetdiabetes in postmenopausal women with coronaryartery disease. The results should be viewed with cau-tion as they were derived from a post hoc analysis ofthe original HERS study.

Previous studies have suggested that the effect of estro-gen plus progestin on glucose metabolism is similar toestrogen-alone. Oral estrogen may suppress hepatic glu-cose production. In the present study, three fasting glu-cose measurements were measured over the 4 years of thestudy. The fasting glucose values remained unchanged inthose assigned HRT while an increase was noted inplacebo-treated subjects. As both fasting insulin levelsand postprandial glucose levels were not measured, therole of HRT on insulin resistance was not evaluated.

Recent studies have demonstrated an increasedrisk of coronary events, stroke, breast cancer, and

venous thromboembolism in postmenopausal wo-men taking hormone replacement therapy. A recentDanish study in nurses reported that diabeticwomen who used HRT had higher risks of ischemicheart disease, myocardial infarction, and all-causemortality compared with diabetic women who didnot use HRT (BMJ. 2003;326:426–428).

HRT is no longer used for the prevention ofheart disease. The Food and Drug Administrationhas revised the labeling for HRT stating thesedrugs should only be used when the benefits of useclearly outweigh their associated risks. Theyshould be used mainly to alleviate vasomotorsymptoms at the lowest effective dosage and forthe shortest possible period of time.

This study is helpful in understanding the meta-bolic mechanisms by which HRT may prevent dia-betes. Given the narrow time frame between thepossible prevention of diabetes associated withHRT and the worse outcome in those diabetics onHRT, there appears to be a very small window ofopportunity for the use of HRT in women forreducing vascular risk. The use of HRT cannot berecommended to prevent diabetes.

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