Hypertension in the patient with diabetes

What it is

In an adult with hypertension, lifestyle interventions run throughout, and the blood pressure goal and the first drug are set by age, diabetes, and chronic kidney disease (CKD).

• General population, no diabetes and no CKD: goal SBP <140 mm Hg and DBP <90 mm Hg under 60 years, SBP <150 mm Hg and DBP <90 mm Hg at 60 and over
• Diabetes present, no CKD, all ages: goal SBP <140 mm Hg, DBP <90 mm Hg
• CKD present with or without diabetes, all ages and all races: goal SBP <140 mm Hg, DBP <90 mm Hg

A goal of 140/90 mm Hg comes from JNC 8, and 130/80 mm Hg from the more recent American College of Cardiology and American Heart Association recommendations. For blood pressure control in CKD the two pages do not give the same systolic number: one sets the goal at SBP <140 mm Hg and DBP <90 mm Hg for CKD present with or without diabetes, all ages and all races, while the other sets the systolic target at SBP <120 and adds that higher targets, for example <130-140 mm Hg, are considered for selected patients. A second target, set by age rather than by diabetes alone, runs alongside it: in the patient with diabetes, pharmacologic therapy is initiated in addition to lifestyle therapy once the blood pressure is confirmed at 140/90 mmHg or above, and the aim is 130/80 or lower in patients less than 65 years of age and in those at high risk for CVD, and below 140/80 in elderly patients, that is 65 years and over, if tolerated. Hypertension, defined as a BP of 140/90 mmHg or more, is an extremely common co-morbid condition in patients with diabetes, and the blood pressure should be checked during each clinic visit. It substantially increases the risk of both macro- and micro-vascular complications, including stroke, coronary artery disease, peripheral vascular disease, retinopathy and nephropathy.