Management of Hypertension Patient with Glucose Disorders from the ESH 2009 Position Statement-reappraisal of European guidelines

    The cardiovascular risk in patients with diabetes is higher than in non-diabetics even if the gap has diminished during the last decade， due to better quality of care， better drug therapy and increased motivation of the patient. Still， however， this risk is substantial and associated with impaired health-related quality of life， high societal costs and a heavy burden on the health care sector. Most patients with diabetes will develop macro- or microvascular complications after a sufficiently long duration of diabetes， because of the deleterious impact of hyperglycaemia and other risk factors， most notably smoking， hyperlipidaemia and hypertension. A similar cluster of risk factors is also found in patients with impaired glucose metabolism， many with features of the so called metabolic syndrome.

    From time to time it is necessary to update theoretical concepts related to risk mechanisms， as well as practical guidelines for cost- effective but individualized risk factor control. The theoretical understanding of risk takes into consideration a life course perspective on risk development， when fetal programming， early childhood experience and cognitive functioning are all of importance to understand the development of cardiovascular disease， a process that is often referred to as an early vascular ageing (EVA) [1].

    The most notable changes in the attitude to cardiovascular risk factor treatment and control is the current view that a flexible treatment goal should apply to control of both hyperglycaemia and hypertension， whereas the goal for smoking is still zero， even if harm reduction as a concept has also been seriously discussed. The goal for control of hyperlipidaemia， especially LDL cholesterol， is still “the lower - the better”， and more ambitious for patients at very high risk， e.g. patients with diabetes and established coronary heart disease when the goal is lower than 2.0 mmol/L for LDL cholesterol. Statins are the drugs of choice but fibrates have not proved themselves equally well

    The flexibility approach applies to the goals of both hyperglycaemia and hypertension. For younger patients with newly detected diabetes more ambitious goals should be applied (a HbA1c of below 7.0%， and a systolic blood pressure goal close to 130 mmHg)， but in older subjects with longer duration， more co-morbidities and higher susceptibility to adverse effects (hypoglycaemia， or orthostatic reactions with coronary hypoperfusion) higher goals should be recommended. This means a HbA1c goal of 8-9% and a systolic blood pressure goal of less than 140 mmHg， based on recommendations from the European Society of Hypertension (ESH) in 2009 when a reappraisal of European guidelines was published [2]. Why this changed opinion on treatment goals? First of all the experience from the ACCORD glycaemic control study in 2008 caused a lot of controversy as the total mortality risk was increased in the intensively treated arm， maybe due to risk of hypoglycaemia or just simply that so many of these patients were elderly high-risk patients with many co-morbidities and increased susceptibility. Three separate systematic reviews during 2009 have shown， on the other hand， that when all available evidence is taken into account， the increased mortality risk associated with intensive treatment is not seen any longer， mainly because studies with other designs and study participants than ACCORD were included. This was recently contradicted by observational findings from a large database in the UK. The heated debate on the blood pressure goal for patients with diabetes has been sparked by the finding that there regretfully exists a lack of evidence for the blood pressure goal of less than 130/80 mmHg that until now has been established in most international guidelines. It was therefore very important that the final data from the ACCORD Blood Pressure arm study was finally presented  at ACC 2010.