Assessment
Measuring blood pressure (BP) is one of the most important aspect of the clinical examination of a diabetes patient. The patient should be seated with a backrest, their feet resting on the ground, and their arm resting or supported at heart level. BP measurement should be taken with an appropriate cuff size, after 5 min of rest, taking 2–3 readings while the patient is quiet. The cuff should be next to skin, sleeve not rolled up and checked at each patient visit by a trained health care professional. Measuring BP in supine, sitting and standing positions, also enables the exclusion of possible autonomic neuropathy [
4,
13].
Targets and Implications
Lowering of BP is beneficial in many ways. The UKPDS trial showed that reducing BP from 160/94 to 144/82 reduced diabetes-related mortality (BP was 154/87 in another arm of the study) [
4]. The reduced morbidity from heart failure (56%) and reduced mortality from macrovascular complications (34%), as evidenced in UKPDS [
5], and benefit of BP reduction in diabetes were also seen in SHEP, ALLHAT, ASCOT, and HOT trials [
6,
14‐
16].
A multifactorial approach towards the control of hypertension and hyperglycemia reduces both macro- and microvascular complications as seen in various trials (UKPDS [
5], ADVANCE [
7], STENO-2 [
17]). Treatment of hypertension in diabetes must be individualized, depending on comorbidity, advancing age, and advancing diabetes. Treatment should begin when BP is greater than 140/90 [
4,
18]. Certain subsets of hypertension in diabetes, with proteinuria and diabetic kidney disease, may benefit from further lower targets. Control of BP also significantly reduces microalbuminuria and reduces new or worsening nephropathy [
7] and, thus, impacts microvascular complication. In the elderly (over 80 years old) [
19,
20], a BP target of 150/90 seems appropriate (Table
1).
Table 1
Summary of the various targets given by different societies for the management of hypertension in diabetes
| 130/80 | ACEI/ARB |
| 130/80 | ACEI/ARB |
| 130/80 | ACEI/ARB |
| 130/80 | ACEI/ARB |
| 130/80 | ACEI/ARB |
| 140/80 | ACEI/ARB |
| 140/85 | ACEI/ARB |
| 140/90 | ACEI/ARB |
| 140/90 | ACEI/ARB |
| 140/90 | ACEI/ARB |
| 140/90 | ACEI/ARB |
Treatment of hypertension, whether uncomplicated or complicated, with presence of albuminuria and advancing age must be tailored to real-world requirements. For albuminuria patients, targets may be stricter. Masked hypertension is also quite common in type 2 diabetes mellitus (T2DM). Resistant hypertension may also be present in diabetes [
4,
28]. The achievement of the individualized BP goal should guide the antihypertensive medication titration, as stopping medications after the goal is reached may lead to combined micro- and macrovascular complications [
29].
Tight targets of systolic blood pressure (SBP) less than 120 mmHg in 9361 patients aged at least 50 years old with high risk for CV events but without diabetes and with an SBP of at least 130 mmHg have shown benefits in SPRINT [
30]. On the other hand, in the ACCORD BP trial [
31], 4733 patients with type 2 diabetes, average age 62 years, randomly assigned to intensive therapy, targeting an SBP less than 120 mmHg, or standard therapy, targeting an SBP less than 140 mmHg, significantly reduced only stroke but not mortality or CV outcomes. The fact that treatment of hypertension helps patients with diabetes more than those who do not have diabetes in various trials, tempts us to use SPRINT data in patients with diabetes. One recent (2016) systematic review and meta-analysis [
32] suggests that reducing SBP to less than 140 mmHg may be harmful in patients with diabetes. Relying on the ACCORD-BP trial, the JNC-8 [
20] gave recommendations for less than 140/90, which was also accepted by others like ASH [
27], AHA [
26], and ADA [
4].
The “J-shaped” phenomenon (paradoxical increase in morbidity and mortality associated with an excessive reduction in BP), which created controversy, was relaunched by the fact that the excess mortality is not due to low BP per se, but due to other factors (previous stroke, ischemic heart disease, or heart failure) [
33]. In this study, BP reduction to under 120 mmHg had no adverse outcomes. However, further lowering of BP needs confirmation in patients with diabetes from future trials, and we await to solve this major target controversy in the future in this subset of hypertension in patients with diabetes.
Non-Pharmacological Interventions
Salt restriction, weight loss, avoiding smoking, increasing activity, and decreasing alcohol intake may all play a part in the non-pharmacological management of hypertension in diabetes [
4]. Counseling is important to enable the patient to understand the necessity of prescribed drugs and to reduce non-compliance and clinic non-attendance, which also form potential management problems, affecting mortality [
34]. Since the “pill and bill” burden affects both the individual and the family, it is important to implement family therapy, to encourage better patient care and comfort, and thus better control of the disease and its complications [
35]. It helps in relieving the stress of the disease, the protection of elderly hypertensives [
36], and prevention of hypertension and its complications by educating caregivers in the family, especially the educated youth [
37].
Home monitoring of blood pressure (HMBP) may be advantageous in control, compliance, adherence, and response to drugs. Ambulatory blood pressure monitoring (ABPM) is helpful in difficult cases, where there are differences in office and home readings, masked hypertension, and compliance issues. De-stressing strategies such as identifying stimuli and coping mechanisms are also adjuvants in hypertension treatment [
38].