Cardiovascular and Renal Protection In Patients with Diabetes and Metabolic Syndrome

Cardiovascular and Renal Protection in Patients with Diabetes and Metabolic Syndrome

Figure 1. Percentage of Adults Who Achieved Recommended Levels of Vascular Risk Factors in NHANES.²
Figure 2. Multiple Antihypertensive Agents Are Often Needed to Achieve Target BP^12,24,32-35
Figure 3. Evidence-Based Treatment Algorithm
Table 1. Target BP and Initial Therapy to Reduce Cardiovasular Risk in Patients with Diabetes or Kidney Disease^36-37,45-55
Table 2. Key Points of JNC-7³⁶
Table 3. Summary of Clinical Trials with ACEIs and ARBs in Patients with Diabetes^{14-15,24-26,32,56-61}

Figure 1. Percentage of Adults Who Achieved Recommended Levels of Vascular Risk Factors in NHANES.²

Figure 2. Multiple Antihypertensive Agents Are Often Needed to Achieve Target BP^12,24,32-35

Figure 3. Evidence-Based Treatment Algorithm

*Loop diuretic for individuals with reduced glomerular filtration rate (GFR) <60 ml/min
**Carvedilol as preferred
Note: Aldosterone antagonists should be used before combining CCBs

Table 1. Target BP and Initial Therapy to Reduce Cardiovasular Risk in Patients with Diabetes or Kidney Disease^36-37,45-55

Group	Year	Target BP (mm Hg)	Initial Therapy
ADA [ADA, 2005]	2005	<130/80	ACEI or ARB*
National Kidney Foundation (NKF) Kidney Disease Outcomes Quality Initiative (KDOQI) [Kasiske et al, 2004]	2004	<130/80	ACEI or ARB*
International and European Societies of Hypertension (ESH/ISH) [European Society of Hypertension-European Society of Cardiology Guidelines Committee, 2003]	2003	<130/80	ACEI or ARB*
JNC-7 [Chobanian et al, 2003]	2003	<130/80	ACEI or ARB*
ADA	2003	<130/80	ACEI or ARB*
NKF Chronic Kidney Disease [Levey et al, 2003)	2003	=130/80	ACEI or ARB
Canadian HTN Society [Zarnke et al 2002, McAlister et al, 2002]	2002	<130/80	ACEI or ARB
ADA	2002	<130/80	ACEI or ARB
NKF [NKF, 2000]	2000	=130/80	ACEI*
British HTN Society [Ramsay et al, 1999]	1999	<140/80	ACEI
World Health Organization (WHO)/ISH [Guidelines Subcommittee, 1999]	1999	<130/85	ACEI
JNC-6 [JNC, 1997]	1997	<130/85	ACEI

* Indicates use with a diuretic

Table 2. Key Points of JNC-7³⁶

A lower BP target of <130/80 mm Hg for patients at high risk (diabetes and kidney disease)

The 20/10 rule: if BP >20/10 mm Hg over goal, start on two medications (e.g. ARB/diuretic, ACEI/diuretic, etc)

Diabetes, heart, and kidney disease or other compelling indications should start with ACEIs, ARBs, or other appropriate drugs

Diuretics should usually be the first drug in the absence of compelling indications, though other classes can be considered

Pre-hypertension: identified as a new disease

Table 3. Summary of Clinical Trials with ACEIs and ARBs in Patients with Diabetes^{14-15,24-26,32,56-61}

Study	Reference	Therapy	Cardiovascular Protection	Renal Protection
ABCD	Estacio et al, 1998	Enalapril vs. nisoldipine (n = 470)	Enalapril reduced incidence of fatal and nonfatal MI significantly better than nisoldipine	NA
Collaborative Study Group	Lewis et al, 1993	Captopril vs. placebo (n = 409)	NA	Captopril reduced risk of doubling of serum creatinine concentration by 48% and risk of combined endpoints of death, dialysis, and transplantation by 50%
FACET	Tatti et al, 1998	Fosinopril vs. amlodipine (n = 380)	Fosinopril reduced risk of combined outcome of acute MI, stroke, or hospitalized angina significantly better than amlodipine	NA
HOPE and MICRO-HOPE	Heart Outcomes Prevention Evaluation Study Investigators, 2000	Ramipril vs. placebo and vitamin E vs. placebo two-by-two factorial design (n = 3,577)	Ramipril reduced risk of combined primary outcome by 25%, MI by 22%, risk of stroke by 33%, cardiovascular death by 37%, total mortality by 24%, revascularization by 17%	Ramipril reduced risk of overt nephropathy by 24%
HOT	Hansson et al, 2000	Intensive blood pressure lowering and low dose aspirin (n = 18,790 including subpopulation with type 2 diabetes)	Patients with type 2 diabetes assigned target BP < 80 mm Hg had a 51% reduction in major cardiovascular events as compared with those assigned target BP < 90 mm Hg	NA
IDNT	Lewis et al, 2001	Irbesartan vs. amlodi-pine vs. placebo (n = 1,715)	No significant differences in composite cardiovascular endpoint or in rates of death from any cause	Irbesartan reduced risk of primary composite endpoint of doubling of serum creatinine concentration, development of ESRD, or death from any cause by 20% lower than placebo and 23% lower than amlodipine; reduced risk of doubling of serum creatinine concentration by 33% lower than placebo and 37% lower than amlodipine; and reduced risk of ESRD by 23% lower than both other groups; serum creatinine concentration increased 24% more slowly with irbesartan than with placebo and 21% more slowly than with amlodipine
LIFE	Lindholm et al, 2002	Losartan vs. atenolol (n = 1,195)	Losartan reduced cardiovascular morbidity and mortality as well as mortality from all causes more effectively than atenolol	NA
Melbourne Diabetic Nephropathy Study Group	Jerums et al, 2001	Perindopril vs. nifedipine	NA	Long-term perindopril more effectively delayed progression of diabetic nephropathy and reduced albumin excretion rate to normoalbuminuric range (<20 µg/min) than nifedipine or placebo
RENAAL	Brenner et al, 2001	Losartan vs. placebo (n = 1,513)	Composite morbidity and mortality from cardiovascular causes similar in both groups, although rate of first hospitalization for heart failure significantly lower with losartan	Losartan reduced risk of doubling of serum creatinine concentration by 25% and risk of ESRD by 28%; had no effect on death; level of proteinuria declined by 35% with losartan
IRMA-2	Parving et al, 2001	Irbesartan 150 mg or 300 mg daily vs. placebo (n = 590)	NA	5.2% patients treated with irbesartan 300 mg reached primary endpoint of time to onset of diabetes as compared to 9.7% of patients treated with irbesartan 150 mg and 14.9% of patients treated with placebo
STOP Hypertension-2	Lindholm et al, 2000	Diuretics or beta-blockers vs. CCB, vs. ACEIs (n = 6,614,719 with type 2 diabetes)	Prevention of cardiovascular mortality similar in three groups; significantly fewer MI during ACEI treatment than during CCB treatment, but nonsignificant tendency to more strokes during ACEI treatment	NA
UKPDS 39	UKPDS Group (c), 1998	Captopril vs. atenolol (n = 1,148)	Captopril and atenolol equally effective in reducing risk of macrovascular endpoints	Similar proportions of patients in two groups developed clinical grade albuminuria > 300 mg/L (5% captopril group, 9% atenolol group)

Printer settings may vary. Please use landscape layout option.
For best results we suggest using the PDF version for printing.