Cotrol of Hypertesio amog Type II Diabetics Kawther El-Shafie, Sayed Rizvi Abstract Objectives: Numerous studies have cofirmed the high prevalece of hypertesio amog type 2 diabetics, ad that itesive hypertesive treatmet is more beeficial to diabetics tha o diabetics. The aim of this study is to assess blood pressure cotrol i patiets with type 2 diabetes mellitus ad to study the types of atihypertesives used. Methods: A retrospective study was coducted o hypertesive diabetics followed at a health ceter i Oma withi a year. Patiets age, sex, duratio of diabetes, hypertesio ad the type of atihypertesive used were oted. Patiets were classified accordig to the degree of systolic ad diastolic BP cotrol ito 4 groups. Results: 210 patiets with a mea age of 53.7±9.1 years were icluded with a 2:5 male to female ratio. The mea duratio of diabetes was foud to be 9 years ad 7 years for hypertesio. 10% of the subjects were i the systolic group I, 23% i group II, 23% i group III ad 41% i group IV. While 56% were i diastolic group I, 19% i group II, 16% i group III, ad 7% i group IV. Agiotesi covertig ezyme-ihibitors (ACE) were used i 50% of the subjects followed by a combiatio of agiotesi receptor blockers (ARB) with diuretics i 40%. B blockers were used i 38% of the patiets. Calcium chael blockers were used i 18%, while diuretics were used i 16% of the patiets. Coclusio: Oly 30% of the BP of the hypertesive diabetics met the recommeded BP for diabetes. More effort should be dedicated to cotrol the BP i diabetics. Physicias should be careful i the selectio of hypertesive medicatios, because i some combiatios, they are ot useful. From the Departmet of FAMCO, Sulta Qaboos Uiversity, Muscat, Sultaate of Oma. Received: 07 Nov 2009 Accepted: 15 Dec 2009 Address correspodece ad reprit request to: Dr Kawther El-Shafie, Departmet of FAMCO, Sulta Qaboos Uiversity, Muscat, Sultaate of Oma. E-mail: kawther@squ.edu.om El-Shafie K, et al. OMJ. 25, 32-36 (2010); doi:10.5001/omj.2010.8 Itroductio Hypertesio i patiets with diabetes is a well recogized cardiovascular risk factor. 1 Accordig to the itervetio studies, the beefit of its treatmet is evidece based. 2,3 Recetly the 7 th Report of the Joit Natioal Committee o prevetio, detectio, evaluatio ad treatmet of high blood pressure (JNC 7) cocluded that BP measuremet i diabetic patiets should be 130/80 mm Hg or less. 4 Primary healthcare physicias play a very importat role i treatig hypertesive patiets, as most of them are beig followed up at primary healthcare cliics. 5 Data from the recet Uited Kigdom Prospective Diabetes Study (UKPDS) hypertesio study, demostrated that aggressive lowerig of diastolic blood pressure (BP) i diabetes to levels < 85 mm Hg ad 80 mm Hg, were accompaied by a reductio of macrovascular evets by oe third ad oe half. 2 The aim of this study work is to determie the degree of BP cotrol i hypertesive diabetics ad to study the appropriate types of atihypertesive agets used to cotrol the BP. Methods This study was coducted at a Primary Health Care Cliic at Sulta Qaboos Uiversity Hospital (SQUH) (FAMCO cliic), Oma. The diabetic cliic is specialized i the maagemet ad follow ups of diabetic patiets. This is a retrospective study of medical records of type 2 diabetic patiets see at the cliic durig the period of Jue 2006-July 2007. Hypertesio was diagosed as blood pressure >140/90; the patiets were either kow hypertesives or were receivig atihypertesive agets, with o obvious cause for secodary hypertesio. The mea systolic ad diastolic BP readigs of the last 3 cliic visits were calculated. The followig iformatio was recorded for the study group; age, sex, duratio of diabetes ad the degree of cotrol, duratio of hypertesio as well as the type of atihypertesive agets used. Patiets were classified accordig to the degree of their systolic ad diastolic BP cotrol ito 4 groups: Systolic BP groups: I: ( 120 mm Hg), II: (121-130) mm Hg), III: ( 131-140 mm Hg), IV: >140 mm Hg) ad diastolic BP groups: I: ( 80 mm Hg), II: (81-85 mm Hg), III: ( 86-90 mm Hg), ad IV: ( >90 mm Hg). The degree of BP cotrol was determied, ad a compariso was made betwee the groups accordig to the type of atihypertesive agets used ad the degree of blood glucose cotrol. The blood pressure was cosidered to be cotrolled if the curret readig was foud to be less tha 130/85 mm Data was etered ito a computer, ad the statistical package for Social Scieces (SPSS versio 16) was used for appropriate statistical aalysis. The Chi-square test was used to test the associatio betwee the categorized variables ad a p-value of 0.05 or less was cosidered as the idicatio for statistical sigificace.
Results A total of 210 patiets were icluded i the study with a mea age of 53.7±9.1 years with a male to female ratio of 2:5. The mea duratio of diabetes was 9 years. A poor cotrol of diabetes was observed amog 60.8% of cases (63.6% males ad 59.7% females). Oly 30% of the diabetic patiets were foud to have ormal blood pressure. The mea duratio of hypertesio was 7 years. It was observed that a small percetage (34.4%) of patiets had their systolic blood pressure cotrolled, while a high percetage (76.1%) of patiets had ucotrolled diastolic BP, ad the differece was foud to be statistically sigificat (p<0.001). (Table 1) Table 1: Degree of Blood Pressure Cotrol i 210 Patiets Blood pressure (BP) Degree of cotrol Systolic BP <120 mm 121-130 mm 131-140 mm >140 mm 22(10.5) 50(23.9) 50(23.9) 87(41.6) Diastolic BP <80 mm 81-85 mm 86-90 mm >90 mm 118(56.5) 41(19.6) 34(16.3) 16(7.7) The most frequetly used aget was agiotesi covertig ezyme ihibitor (ACE) which was used by 48% of patiets, followed by agiotesi receptor blockers (ARB) combied with diuretics i 38.57% of the patiets, while B-blockers (Ateolol) were used i 36.6% of patiets, calcium chael blockers were used by 16.6%, ad diuretics (Bedrofluizide) were used i 15.2% of patiets. (Fig. 1) Figure 1: Use of Atihypertesive Agets amog Studied Group I the study group, more tha half of the patiets (55.7%) were usig atihypertesives as a sigle aget for the cotrol of BP. A total of 101 (48%) patiets were foud to take ACE ihibitors (Fig. 1). Amog them, 58.4% used these agets as mootherapy ad 41.6% used it i combiatio with other drugs. ACE ihibitors were more effective as mootherapy i the systolic blood pressure group, where 85% of cases exhibited BP below 130 mm Hg (Table 2). However, ACE ihibitors were foud to be more effective i diastolic blood pressure whe combied with other medicatios, 73% of cases i the diastolic blood pressure group exhibited BP values below 85 mm (Table 3) Table 2: Atihypertesive used as a Sigle Aget out of 116 i Differet Systolic Blood Pressure Groups. Ati hypertesive agets <120 mm Hg N=22 121-130 mm Hg N=50 131-140 mm Hg N=50 >140 mm Hg N=87 (%) ACE-ih 60 37(61.7) 14(23.3) 4(6.7) 5 (8.3) B-blockers 17 3(17.6) 4(23.5) 6(35.3) 4 (23.5) Ca-blockers Diuretics 2 2 (2.0) Methyl Dopa Prazoci Codiova 37 4(10.8) 9(24.3) 10(27) 14(37.8) Table 3: Atihypertesives used as oe or more Aget out of 209 i Differet Diastolic Blood Pressure Groups Ati hypertesive agets <80 mm Hg N=118 81-85 mm Hg N=41 86-90 mm Hg N=34 >90 mm Hg N=16 ACE-ih 101 52(51.5) 22(21.8) 17(16.8) 10(9.9) B-blockers 77 45(58.4) 9(11.7) 17(22.1) 6(7.8) Ca-blockers 35 14(40) 8(22.9) 10(28.6) 3(8.6) Diuretics 32 9(28.1) 6(18.8) 12(37.5) 5(15.6) Methyl Dopa 1 1(100) Prazoci 1 1(100) Codiova (17.3) 81 48(59.3) 14 13(16) 6(7.4)
Co-diova was effective i the diastolic BP whether used as a sigle aget (i 83% of patiets, diastolic BP was below 85 mm Hg) (Table 4), or whe combied with other medicatios, (76.6% of patiets s BP was below 85 mm (Table 3) Table 4: Atihypertesive used as a Sigle Aget out of 116 i Differet Diastolic Blood Pressure Groups. Ati hypertesive agets <80 mm Hg N=118 81-85 mm Hg N=41 86-90 mm Hg N=34 (%) >90 mm Hg N=16 (%) ACE-ih 60 9(15.0) 21(35.0) 13(21.7) 17(28.3) B-blockers 17 12(70.6) 3(17.6) 2(11.8) Ca-blockers Diuretics (2.0) 2 1(50) 1(50) 2(100) Methyl Dopa Prazoci Codiova 37 24(64.9) 7(18.9) 5(13.5) 1(2.7) B blockers were more effective as a sigle aget i the diastolic BP group. 88% of patiets exhibited BP values below 85 mm Hg (Table 4), or whe combied with other drugs. I 70% of the patiets, the diastolic BP was below 85 m Hg, (Table 3). All hypotesive medicatios were more effective i cotrollig diastolic BP (Table 5), while they were less effective i cotrollig systolic BP. ( Table 6) Table 5: Atihypertesives used as oe or more aget out of 209 i Differet Systolic Blood Pressure Groups Ati hypertesive agets <120 mm Hg N=22 121-130 mm Hg N=50 131-140 mm Hg N=50 >140 mm Hg N=87 ACE-ih 101 13(12.9) 29(28.7) 23(22.8) 36(35.6) B-blockers 77 6(7.8) 11(14.3) 21(27.3) 39(50.6) Ca-blockers 35 1(2.9) 4(11.4) 8(22.9) 22(62.9) Diuretics 32 2(6.3) 2(6.3) 6(18.8) 22(68.8) Methyl Dopa 1 1(100) Prazoci 1 1(100) Codiova 81 6(7.4) 19(23.5) 21(25.9) 35(43.2) Table 6: Types of Atihypertesive Agets used for Blood Pressure Cotrol Atihypertesive aget Number Percet ACE-ihibitors 101 48% B-blockers 77 36% Ca-blockers 35 16% Diuretics 32 15% Methyl Dopa 1 0.5% Prazoci 1 0.5% Codiova 81 38% *Some patiets were o combied atihypertesive agets. ACE agiotesi covertig ezyme Ca-blockers Calcium chael blockers 60.8% of patiets from the studied group had ucotrolled blood sugar, (Table 7). Patiets with ucotrolled systolic BP (group III ad IV) were more likely to have poorly cotrolled blood glucose. (Table 8)
Table 7: Percetage of Hb A1c amog Studied Group Hb A1c (mmol/l) <6.1 6.1-7.0 7.1-8.0 8.0-10.0 >10 Percetage 9.5% 29.9% 23.9% 16.4% 20.4% Table 8: Prevalece of Ucotrolled Blood Glucose amog Ucotrolled Blood Pressure Blood Pressure Degree of cotrol Systolic 131-140 mm Hg (=49) >140 mm Hg (=83) Cotrolled blood glucose 15(30.6) 35(42.2) Ucotrolled blood glucose 34(69.4) 48(57.8) Diastolic 86-90 mm Hg (=34) >90 mm Hg (=15) Cotrolled blood glucose 18(52.9) 05(33.3) Ucotrolled blood glucose 16(47.1) 10(66.7) Discussio Hypertesio is twice as commo i persos with diabetes as it is i others. 6 Hypertesio is kow to cotribute to diabetic micro-ad macro-vascular complicatios. 7,8 To reduce the risk, hypertesio must be diagosed accurately ad promptly, ad the patiet must receive adequate treatmet. However, ew guidelies have bee published to stress o the importace of aggressive blood pressure cotrol i diabetics. 4 This study attempted to evaluate the blood pressure cotrol i diabetic patiets i primary healthcare. A review of 1137 hypertesive diabetics showed that oly 21% of the patiets met the curretly recommeded BP for diabetes of <130/85 mm 9 I this curret group, the frequecy of patiets who met this recommedatio was oly 30%. This idicates that more effort is eeded to cotrol BP i diabetics. I this study, it was observed that the predomiat part of blood pressure which was poorly cotrolled was the systolic blood pressure (>130 mm Hg) which accouted for 65.5% of cases, (Table 1). Results from the Systolic Hypertesio i Elderly Program (SHEP), ad Systolic Hypertesio i Europe (Sys-Eur) trial, favored the aggressive treatmet of diabetics with isolated systolic hypertesio. 10,11 Therefore, more effort is eeded to address this aspect of BP. I this study, Agiotesi lowerig ezyme ihibitors (ACE), were foud to be the most frequetly used atihypertesive agets (used by 48% of the patiets), followed by Agiotesi Receptor Blockers (ARB), which were used by 38.57% of the patiets, (Fig. 1). Recet trials have suggested that for the prevetio of cardiovascular evets, ACE ihibitors may be superior to alterative atihypertesive agets. 12,13 Results from the Heart Outcome Prevetio Evaluatio (HOPE) study showed that a reductio of cardiovascular evets with ACE ihibitors was much greater tha that expected for BP reductio aloe compared with placebo. 14,15 Agiotesi covertig ezyme ihibitors had favorable effects ot oly o cardiovascular evets, but also o real ad quality of life as compared with other regimets. 16,17 I this study, almost half of the patiets used atihypertesive as a agets as mootherapy. It was observed that ACE-ihibitors were more effective at reducig the systolic blood pressure, but out of the 101 who used ACE-ihibitors, 60 patiets used it as a sigle aget. It seems that it is advisable to combie ACE-ihibitors with other medicatios i order to have a more potet effect. The JNC 7 favors the combiatio of drugs for a more potet reductio of BP. However, it does ot favor the combiatio of ACE ihibitors with B blockers, or diuretics with calcium chael blockers. Therefore, for patiets with ucotrolled BP, it is advisable to observe the type of drugs used i combiatio before takig the decisio of addig aother drug. 4 Aother factor agaist the cotrol of BP with combied medicatio is o compliace. The Caadia Coalitio for Blood Pressure Cotrol, reported a o compliace rate of 50%. 18 No-adherece is the major cause of treatmet failure. Patiets see i this cliic may get fed up from takig log term medicatio for their BP ad blood glucose cotrol. It was observed that most patiets with ucotrolled hypertesio had poorly cotrolled blood glucose (Table 2). Good blood glucose cotrol was defied as glycosylated hemoglobi <7%, fastig blood glucose <7 mmol/l, or 2 hours post-pradial blood glucose <11 mmol/l.
Ispite of this fact, the message from both ACCORD ad ADVANCE trials is that ear-ormal glycemic cotrol for a media of 3.5 to 5 years does ot reduce cardiovascular evets withi that time frame. 19 Physicias educatio with regards to the importace of BP cotrol i diabetics ad the better selectio of drugs for combiatio therapy should be cosidered promptly ad efficietly. Coclusio Oly 30% of BP of the hypertesive diabetics met the recommeded BP values for diabetes. More effort should be addressed to cotrol the BP i diabetics. Physicias should be careful i selectig hypertesive medicatios, because some combiatios are ot useful. Ackowledgemets The authors reported o coflict of iterest ad o fudig has bee received o this work. Refereces 1. Turer RC, Mills H, Neil HA, Stratto IM, Maley SE, Matthews DR, et al. Risk factors for coroary artery disease i o-isuli depedet diabetes mellitus: Uited Kigdom Prospective Diabetes. BMJ 1998 Mar; 316(7134):823-828. 2. UK Prospective Diabetes Study group. Tight blood pressure cotrol ad risk of macro ad micro vascular complicatios i type 2 diabetes. BMJ 1998 Sep; 317(7160):703-713. 3. The ALLHAT officers ad coordiators for the ALLHAT Collaborative Research Group. Major outcomes i high-risk hypertesive patiets radomized to agiotesi-covertig ezyme ihibitor or calcium chael blocker vs. diuretic. The Atihypertesive ad Lipid Lowerig Treatmet to prevet Heart Attack Trial (ALLHAT). JAMA 2002 Dec; 288(23):2981-2997. 4. Chobaia AV, Bakris GL, Black HR, Cushma WC, Gree LA, Izzo JL JR, et al. The Seveth Report of the Joit Natioal Committee o Prevetio, Detectio, Evaluatio, ad Treatmet of High Blood Pressure: The JNC 7 report. JAMA 2003 May; 289(19):2560-2572. 5. Goral AH, Mully AG Jr. Hypertesio. 4 th ed. Joit Natioal Committee the seveth. Philadelphia: Lippicott; 2001. 6. Epstei M, Sowers JR. Diabetes Mellitus ad hypertesio. Hypertesio 1992 May; 19(5):403-418. 7. AL-Nozha MM, AL-Maatoug MA, AL-Mazroie YY, AL Harthi SS, Arafah MR, Khalil MZ, et al. Diabetes Mellitus i Saudi Arabia- Saudi Med J 2004 Nov; 25(11):1603-1610. 8. Al Mustafa BA, Abulrahi HA. The role of primary health care ceter i maagig hypertesio. How far are they ivolved? Saudi med J 2003 May; 24(5):460-465. 9. Maue SK, Farrely EW, Frech F. The eed for improved blood pressure cotrol withi the diabetic hypertesive populatio. Program ad abstracts of the 61st Scietific Sessio of the America Diabetes Associatio. 2001 Jue 22-26. Philadelphia: Uited States of America. Diabetes 2001 Ju; 50(2):12. 10. Curb JD, Pressel SL, Cutler JA, Savage PJ, Applegate WB, Black H, et al. Effect of diuretic-base atihypertesive treatmet o cardiovascular disease risk i older diabetic patiets with isolated systolic hypertesio: Systolic Hypertesio i Elderly Program Cooperatio Research Group. JAMA 1996; 76:1886-1892. 11. Tuomile hto J, Rasteyte D, Brikehager WH, Thijs L, Atikaie R, Bulpitt CJ, et al. Effects of calcium-chael blockade i older patiets with diabetes ad systolic hypertesio. N Eg J Med 1999; 340:677-684. 12. Pahor M, Psaty BM, Furberg CD. Treatmet of hypertesive patiets with diabetes. Lacet 1998 Mar; 351(9104):689-690. 13. Pahor M, Psaty BM, Furberg CD. New evidece o the prevetio of cardiovascular evets i hypertesive patiets with type 2 diabetes. J cardiovascular pharmacol 1998; 32(2):518-523. 14. The Heart Outcomes Prevetio Educatio Study Ivestigators. Effects of a agiotesi-covertig ezyme ihibitor ramipril o cardiovascular evets i high-risk patiets. N Eg J Med 2000 Ja; 342(3):145-153. 15. Heart Outcomes Prevetio Evaluatio Study Ivestigators. Effects of ramipril o cardiovascular outcomes i people with diabetes mellitus: results of the HOPE study ad MICRO-HOPE substudy. Lacet 2000 Ja; 355(9200):253-259. 16. Lewis EJ, Husicker LG, Bai RP, Rohde RD. for the Collaborative Study Group: The effect of agiotesi-covertig ezyme ihibitor o diabetic ephropathy. N Eg J Med 1993 Nov; 329(20):1456-1462. 17. Croogh SH, Levie S, Testa MA, B Bulpitt CJ, Jekis CD, et al. The effect pf atihypertesive therapy o the quality of life. N Egl J Med 1984; 314: 1655-1664. 18. Chockaligam A, Bacher M, Camphell N, Cutler H, Drover A, Feldma R, et al. Adherece to maagemet of high blood pressure: recommedatios of the Caadia Coalitio for High Blood Pressure Prevetio ad cotrol. Ca J Public Health 1998; 89:15-111. 19. Dluhy RG. Itesive Glycemic Cotrol i the ACCORD ad ADVANCE Trials. N Eg J Med 2008 Ju; 358(24):2630-2633.