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1、DRUG INDUCED DIABETES DURING ANTIHYPERTENSIVE THERAPY IS IMPORTANT - BUTCHINESE SOCIETY OF HYPERTENSIONMICHAEL ALDERMAN MAY 22, 2008Prevalence of diabetes among Chinese adults aged 3564 years in the 1994 Chinese National Survey (10) and 20002001 InterASIA StudyGu et al Diabetologia. 2003;46:1190.Per
2、cent of deathsGeiss LS, et al. In: Diabetes in America. National Institutes of Health;1995.65% of Mortality in people with Diabetes is CVD Ischemic heart diseaseOther heart diseaseDiabetesMalignant neoplasmsCerebrovascular diseasePneumonia/ influenzaAll otherCV mortality rate per 10,000 person-years
3、Systolic BP and CV Death in MRFITNondiabetic (n=342,815)Diabetic (n=5,163)140mmHg.Conen, D. et al. Eur Heart J 2007 28:2937-2943Age-adjusted incidence rates (A) and HRs (B) of NOD according to blood pressure category, stratified by baseline body mass indexTHE ISSUES CONSEQUENCES OF NOD CVD AND non-C
4、VD HOW DO ANTIHYPERTENSIVE DRUGS EFFECT INCIDENCE OF NOD AND CVD ONSEQUENCES? HOW SHOULD NOD EFFECT MANAGEMENT FOR CVD PROTECTION?Non-CVD Consequences of NOD Impaired BP control Behavioral and Psychological Microvascular consequences (?) Medical care demands Treatment changesCVD Consequences Short a
5、nd Long term Antihypertensive Drug Related.Whelton, P. K. et al. Arch Intern Med 2005;165:1401-1409.ALLHAT Incidence of Coronary heart disease by treatment group according to baseline diabetes mellitus, impaired fasting glucose level, or normoglycemiaBarzilay, J. I. et al ALLHAT. Arch Intern Med 200
6、6;166:2191-2201.HRs of a 10-mg/dL (0.56-mm) FBG at 2 years for subsequent CVD and Renal DiseaseEffect of ACEIs and ARBs on CVD MortalitySource # studies #subjectsOR (95% CI)All11109,0520.96(0.91-1.01)ACEI674,6260.93(0.81-1.06)ARB534,4260.93 (0.81-1.06)HTN786,4140.99 (0.93- 1.06)Gillespie, et al. Dia
7、betes Care 28:2261-2266, 2005Age-genderadjusted in treatment CVD and non-CVD by baseline FBG among hypertensive patients.Alderman, Hypertension. 1999;33:1130-1134Myocardial infarction (fatal and nonfatal) in hypertensive patients according to DM statusAksnes, T. A. et al. Hypertension 2007;50Diabete
8、s Incidence - 4 Years (follow-up FBS 126 mg/dL for those 126 mg/dL at baseline)* * * * * p.05 compared to chlorthalidonep.05 compared to chlorthalidoneALLHATALLHATJAMA 2002;288:2981-2997Ramipril v. Placebo in high risk patients with IGT at baselineDream. NEJM;355:1551-1562,2006Ramipril v. Placebo CV
9、D 355:1551-1562,2006.Whelton, P. K. et al. Arch Intern Med 2005;165:1401-1409.ALLHAT: RR (and 6-year rates per 100 for nondiuretic compared with diuretic for diabetes mellitus (A), impaired fasing glucose level (B), and normoglycemia (C) at baseline, for CHD, all- cause mortality, combined CHD, stro
10、ke, HF, all CVD, and ESRDCV death (%)CV death (%)PLACEBOACTIVE* = p 0.05 vs no diabetesSHEP - 14 YEAR FOLLOW-UPCONCLUSIONS FROM SHEP + Chlorthalidone Rx of hypertension improves long- term outcomes. The diabetes related to chlorthalidone therapy has better prognosis than diabetes at baseline. The be
11、nefit of chlorthalidone-based therapy on long-term total and CV mortality is most pronounced in hypertensive patients with diabetes.Reduction in major CVD among 6,000 DM in HPS associated with 38/89 LDL/CHOL by StatinMazzone, T.The American Journal of Medicine 120;2007, S26-S32 Incidence of MI and M
12、icrovascular Endpoints by Mean SBP and HbA1c in UKPDSAdjusted incidence per 1000 person-years (%)Updated mean HbA1c concentration (%)Mean SBP (mmHg)Adjusted incidence per 1000 person-years (%)5678910 11110120130140150160170Myocardial infarctionMicrovascular endpointsMicrovascular endpointsMyocardial
13、 infarctionAdler AI, et al. BMJ. 2000;321:412-419. Stratton IM, et al. BMJ. 2000;321:405-412. .MI=myocardial infarction SBP=systolic blood pressureUNCERTAINTY CONTINUES ACCORD AND ADVANCE ACCORD - Mortality greater with HbAlc 6.4 v. 7.0-7.9% ADVANCE - No evidence of mortality with HbAlc 6.4 v. 7,5%M
14、ajor CV Event Rate In HOTHOTLancet 1998;351:1755 90 85 80 90 85 80 85.283.281.1 DBP achievedp = 0.005 51% risk reductionGoal Diastolic mmHgDiabetic populationNon-Diabetic subjectsCONCLUSIONS DM serious whenever it occurs More common in hypertensive Rx Particularly with diuretics NOD has consequences
15、 Non-CVD in short term CVD long term Neither fear of, nor NOD, requires D/C Diuretic CLINICAL IMPLICATIONS SCREEN FOR NOD ATTEMPT TO REVERSE HYPERGLCEMIA CORRECT HYPOKAELMIA K SPARING DIURETIC ADD ACE OR ARB OPTIMIZE BP AND LIPID CONTROL TREAT HYPERGLYCEMIA (?) NO EVIDENCE OF CVD BENEFIT PREVENTION OF MICROVASCULAR EFFECTS
