Progress in the treatment of diabetes and hypertension
Posted on October 12, 2009
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Diabetes and hypertension are the most common and relevant internal diseases. From 1980 to 1981, the country’s 14 provinces and cities 300,000 to investigation of standardized diabetes prevalence rate of 6.74 ‰. 1994 ~ 1995 survey of the 25 million people each diabetes and impaired glucose tolerance of 2.5%, patients 15 years ago, an increase of more than three times more than over the age of 45 a marked increase in the prevalence of 60-year-old reached the peak prevalence rate of overweight 3 times the normal weight. At present, China has reached 2000 people with diabetes million or more, of which more than 90% of type Ⅱ diabetes mellitus. 80% of people with diabetes die from heart, brain, kidney and other chronic complications, the prevalence of coronary heart disease and myocardial infarction rate was two times that of patients without diabetes and its kidney disease and blindness, respectively seven times and 25 times. China’s cerebrovascular accident was significantly higher than the incidence of coronary heart disease, among the highest. The high prevalence rate of diabetes atherosclerosis, age of onset is small, rapid progress and severe illness. In addition to the occurrence of these complications and glycemic control on the foreign, high blood pressure is a key risk factors. 13 provinces and cities nationwide survey in 1959, hypertension prevalence rate was 5.11% in 1991 to 11.88% in 1991, Beijing suburban and rural areas the prevalence of hypertension 9.6%.
Type Ⅱ diabetes mellitus patients with hypertension prevalence rate was 20% to 40%, 1-fold higher than normal patients, even before the appearance of diabetes for many years, hyperinsulinemia moment, already high blood pressure, diabetes, high blood pressure in patients suffering from a peak of 10 earlier than normal years, with rising blood pressure, diabetes, progression of the disease has been reported over the age of 60 diabetic patients 60% to 100% have varying degrees of high blood pressure. Death due to high blood pressure 10% of patients with diabetes. Two kinds of disease in combination to accelerate the heart, brain and kidney blood vessels serious illness of the important reasons for the occurrence and development, so prevention and treatment of diabetes to control high blood pressure also can not be ignored.
World Health Organization and the International Society of Hypertension will be a (mild) hypertension or blood pressure at 140 ~ 159/90 ~ 99 mm Hg (1 mm Hg = 0.133 kPa) of patients with diabetes mellitus were defined as high cardiovascular risk group, whose 10 years after the risk of cardiovascular events was 20% ~ 30%, and severe hypertension (≥ 180/110 mm Hg) of the same subject, which is based on risk of stroke and the risk of myocardial infarction developed. Quite a number of elderly diabetics with isolated systolic hypertension (≥ 140 / <90 mm Hg), also need attention.
Diabetes causes high blood pressure
Type Ⅱ diabetes and kidney damage related to the type Ⅱ diabetes mellitus combined with hypertension are mostly primary, the two diseases are polygenic hereditary diseases, insulin resistance plays an important role. In 1988 Reaven proposed the concept of metabolic syndrome refers to a high-fat, together with hyperinsulinemia, diabetes or impaired glucose tolerance, hypertension and abnormal lipid metabolism in a group of clinical phenomena, also known as insulin resistance syndrome. As the cells decreased sensitivity to insulin, thereby stimulating the pancreas to increase insulin secretion compensatory and cause hyperinsulinemia. Many studies explain the hypertension and hyperinsulinemia. For example, high blood pressure and hyperinsulinemia often have long existed for many years before; non-diabetic population hyperinsulinemia average of systolic and diastolic blood pressure were higher than those of non-high insulin persons; diabetes in offspring with high insulin and high blood pressure trends in ; oral glucose tolerance test to have high insulin-persons, 5 years, the high incidence of high blood pressure; insulin resistance in either obese or thin patients with high blood pressure is still there.
When insulin resistance decreased activity of lipoprotein lipase, high blood lipids to promote arteriosclerosis, high blood pressure. High insulin also affects the Na +-K +-ATP enzyme, increasing renal tubular sodium and water re-absorption, to promote sodium retention. Reduce the Ca2 +-ATP activity, so that the concentration of intracellular Ca2 + increase, increase sympathetic nerve activity, increases vascular responsiveness of angiotensin Ⅱ. Insulin and insulin-like growth factor on endothelial cells of protein kinase C levels increased vascular resistance, so that a small artery smooth muscle hyperplasia, intimal thickening.
Caused by high blood sugar is elevated blood pressure reasons: (1) protein non-enzymatic glycosylation glycation end products so that gathered in the plasma and tissues, the most commonly found in the glomerular basement membrane and mesangium. (2) high blood sugar goals the renal arteries, high-reperfusion injury in endothelial and mesangial. (3)-activated protein kinase C, increased endothelial cell synthesis of endothelin, angiotensin-converting enzyme (ACE) and other vasoconstrictor substances. (4) stimulation of vascular smooth muscle cell proliferation, damage vascular endothelial cells to increase the synthesis of type Ⅳ collagen, fibronectin increased hardening of the arteries and high blood pressure prompted the occurrence and development.
Diabetic patients the importance of strict control of blood pressure
Extremely dissatisfied with the status of blood pressure control. More than 70% of high blood pressure does not control or control are not satisfied. China’s treatment of hypertensive patients less than 1 / 4, while in the treatment of high blood pressure control in only about 10 percent below 160/95 mm Hg. The strict control of blood pressure and avoid the delay caused by high blood pressure and diabetes, cardiovascular and cerebrovascular complications in the role, there are more large-scale prospective randomized controlled study have important clinical guidance.
1. Application of diuretics and β-blockers on 47 000 hypertensive patients randomized control study, the average observed five years, diastolic blood pressure decreased 5 ~ 6 mm Hg, can reduce cerebral vascular accident, 38% decline in elderly patients with cerebral vascular accident 34% , middle-aged down 43%, but lower absolute value for young people aged 2 times. Risk of fatal and non-fatal coronary heart disease dropped 16%, coronary heart disease risk fell 19% in the elderly, young people fell by 14%.
2. In elderly with systolic hypertension (SHEP) observed the average age of 70 years the effect of antihypertensive therapy in the elderly. One type Ⅱ diabetes, 583 / 4 736 12.3% 568 to enter observations, treatment of 4.5 years, diabetes and non-diabetic risk of major cardiovascular events were reduced 34%.
3.Syst-Eur trial application of nitrendipine decreased blood pressure 10 / 5 mm Hg, cerebral vascular accident reduction of 42%. Diabetic sub-group of even more useful. Including 492 cases of diabetes (10.5%) all-cause mortality by 55%, 76% reduction in death from cardiovascular disease, cardiovascular events decreased 63%. Stone and Syst-CHINA test was carried out in our observations. Syst-China is to use placebo-controlled trial, 1253 patients with systolic hypertension (> 160 / <90 mm Hg) 60 years of age or older with the calcium channel blocker nitrendipine, or captopril plus clothing or (and) dihydrocodeine g urine thiophene treatment, cerebral vascular accident risk decreased significantly.
4. Hypertension Optimal Treatment (HOT) from 31 countries observed the 18790 patients, with an average follow-up of 3.8 years to study lasted for six years in an attempt to find the extent of blood pressure in the end reduced to minimize the risk of cardiovascular discussed 80,85,90 mm Hg diastolic blood pressure goal of the incidence of cardiovascular events. Study confirmed that, when the average diastolic blood pressure from 105 mm Hg fell to 82.6 mm Hg risk of heart tube dropped by 30%, the average systolic pressure from 170 mm Hg reduced to 138.5 mm Hg, cardiovascular risk reduction 22%. Sub-group of 501 hypertensive patients, 1 diabetes, diastolic blood pressure decreased control to ≤ 80 mm Hg, cardiovascular events, cardiovascular mortality reduction is more significant. The study hypertension prevention and control guidelines to support the U.S. standard, that is blood pressure control should be maintained at <140/90 mm Hg, diabetes mellitus should blood pressure <130/85 mm Hg that is ideal or normal range. This study is mainly used calcium channel blocker (felodipine, Plendil), blood pressure control is not satisfied with Canada with the angiotensin-converting enzyme inhibitor (ACEI), β blockers, diuretics. Once believed to reduce blood pressure to cardiovascular risk to a certain degree, may be too low blood pressure is detrimental. In this study 1501 patients with diabetes strict control of blood pressure and cardiovascular events were significantly reduced as well as 43 000 people without myocardial infarction 5.6 years the strict control of blood pressure, stroke dropped 40%, myocardial infarction decreased by 10%, respectively, shows blood pressure to normal levels ( ” 130/85 mm Hg) or even a satisfactory level (<120/80 mm Hg) had no adverse effects on the cardiovascular.
5. Diabetic nephropathy accounts for terminal kidney disease causes 1 / 3, more than 40% and 20% Ⅱ Type Ⅰ diabetes develop kidney disease, diabetes and hypertension in combination to accelerate the deterioration of renal function. High blood pressure level was significantly correlated with the degree of kidney disease, urinary protein, blood pressure and predictable progress, such as type Ⅱ diabetes, high blood pressure are the 1st follow-up of 38% had proteinuria, with normal blood pressure, only 3% had proteinuria. Antihypertensive treatment can reduce urinary albumin and glomerular filtration rate (GFR) rate of decline slowed. Some studies when the blood pressure from 160/95 mm Hg fell to 135/85 mm Hg, GFR decline in speeds from 1 ml.min-1. Month -1 down to 0.35 ml.min-1. On -1, step-down treatment of pre-diabetes 50% ~ 70% mortality rate after treatment, case fatality rate fell to 18%. Lewis Research captopril treatment of choice of type Ⅰ diabetes prevention and treatment of diabetic nephropathy in delaying the role of research time of 2.7 years, 30 centers, group 3 / 4 of patients have hypertension, compared with the placebo control group, terminal kidney disease, including dialysis , transplantation, and mortality dropped by 50%. Captopril may also delay the progression of the disease, urinary albumin excretion rate has dropped. As the two groups is basically the same decrease in blood pressure, indicating Capoten have renal protective effects beyond blood pressure.
6. Recently published United Kingdom Prospective Diabetes Study (UKPDS), in 4 054 people with type Ⅱ diabetes, 38% suffering from high blood pressure, 1 148 cases of hypertension into this observation, were randomly divided into two groups, strict blood pressure control group with ACEI Card Topley and β-blocker atenolol therapy, strict blood pressure control group of non-use of these two drugs, with an average follow-up of 8.4 years, the results of captopril and atenolol equally effective, can be reduced to achieve blood pressure diabetes related death and related events. Treatment of the final mean blood pressure in the treatment group was 144/82 mm Hg, control group was 154/87 mm Hg, mean short of the two groups of 10 / 5 mm Hg. Strict blood pressure control group in any occurrence of diabetes-related endpoint 24% risk reduction, micro-vascular risk reduction 37%, significantly reduced type Ⅱ diabetic retinopathy and prevention of kidney disease and renal failure in progress. Reduce the risk of stroke by 44%. Sudden death, myocardial infarction, stroke and peripheral vascular disease and other major diseases total reduction of 34%. With diabetes-related deaths dropped 32%.
7. Captopril Prevention Program (CAPPP) in 10 985 cases of hypertension observed a preventive effect of captopril, and diuretics, β blockers compared the role of an average 5-year observation, diastolic blood pressure decreased by 5 ~ 6 mm Hg. The results 14% lower risk of coronary heart disease, cerebral vascular accident reduction of 42%, significantly reduced its mortality.
One application of captopril treatment of 310 cases of diabetes, compared with the control group, captopril can delay deterioration of renal function in type Ⅰ diabetes mellitus, there are few trends in fatal cardiovascular events (P> 0.05), but the incidence of diabetes significantly reduced.
Diabetes, hypertension drug treatment when
Strict control of blood sugar that intensive treatment in the prevention of the occurrence and development of diabetic chronic complications of great significance. And positive control of high blood pressure to effect more visible. Applied to non-diabetic patients with a variety of antihypertensive drugs can be used for diabetic patients, but must seriously consider the pros and cons of choices.
1. Diuretics: thiazide diuretic hydrochlorothiazide used for diabetes, hypertension achieved the benefits and risks are related to dose-dependent, non-preferred. Drug damage to islet β-cell secretion, reduced insulin sensitivity, increase glycogen produce and to stimulate glucagon secretion, the negative control of diabetes. These effects loop diuretic furosemide smaller, but less for the step-down purposes. Thiazide-type drugs was also elevated cholesterol, triglyceride and uric acid, causing potassium loss. Careful attention to these adverse factors in the circumstances, with other antihypertensive drugs with the purpose of applications can be to achieve the desired blood pressure, to prevent the serious complications of diabetes is good.
2.β blockers such as propranolol, atenolol, etc. to reduce the risk of diabetic chronic complications equally effective. Has bronchial asthma, obstructive airway disease is disabled. Long-term use can reduce insulin sensitivity, increase glycogen output, on glucose metabolism have a negative impact. β-blockers inhibit glycogenolysis and gluconeogenesis, impeding catecholamine-stimulated glycogen output and glucagon responses to hypoglycemia in patients with difficult to restore, and low blood sugar to cover up the symptoms of sympathetic nervous excitement : sweating, heart palpitations and so on. The role of the non-selective β-blocker propranolol is more significant. The drug will also enable increased triglycerides, decreased high-density lipoprotein.
3. Calcium channel blockers: its role in vascular smooth muscle cells against excessive Ca2 + channel opening, Ca2 + influx to intracellular Ca2 + increase in vascular smooth muscle tension and thus increase peripheral vascular resistance caused by increased blood pressure mechanism. Because it does not affect insulin sensitivity and blood lipid levels, diabetes, high blood pressure often result in the application. From the HOT study found that 22% of patients can not tolerate, but Asian people including my own, the vast majority of patients Ca2 + channel blocker tolerance very well. UKPDS study the application of nifedipine in patients with attention, and no potential harmful effects of the heart, but myocardial infarction there is a decreasing trend.
4.ACEI: ACE angiotensin Ⅱ, in particular the production of angiotensin Ⅱ vessel wall in order to reduce peripheral vascular resistance, to achieve blood pressure goals. Of abnormal glomerular hemodynamics useful, it gives us glomerular efferent arteries, thereby improving the resistance of afferent arterioles, reducing glomerular capillary pressure, prevent glomerular hypertrophy caused by angiotensin Ⅱ Mesangial matrix accumulation and to prevent and delay the occurrence and development of diabetic nephropathy and reduce proteinuria. The protection of their right kidney does not depend on the blood pressure effect, but must be used with caution with renal insufficiency, is generally not with the use and protection of potassium-sparing diuretics. Thus, diabetic nephropathy and diabetic high blood pressure often use. As the cause dry cough, clinical application subject to certain restrictions, without reducing insulin sensitivity and blood lipid changes caused by, others favor its can improve insulin sensitivity.
5. Angiotensin Ⅱ receptor antagonist: its effect with ACEI the same as blocking the role of angiotensin Ⅱ, without affecting the bradykinin system, fewer side effects, does not cause cough.
6.α adrenergic blockers: prazosin, etc. In addition to blood pressure, this may have cholesterol-lowering effect, high incidence of orthostatic hypotension, the elderly should be used with caution. The elderly isolated systolic hypertension could use a small dose of Ca2 + channel blocker, or ACEI, in general be used with caution α receptor blocker in order to avoid orthostatic hypotension, a severe impact on the heart and brain. In short, the initial mild hypertension can choose a blood pressure drug, small doses gradually adjust. Simply a kind of antihypertensive drugs is difficult to make long-term blood pressure decreased substantially and remained at a satisfactory level, often take two or more different types of drugs in combination.
HOT study patients who achieve the target blood pressure 70% of combination therapy to increase efficacy and reduce side effects, the same types of drugs are not used in combination. Continuous day and night blood pressure control on target organ protective effect of better sustained-release or controlled release of the antihypertensive drugs to reduce blood pressure fluctuations, easy to achieve this purpose. Ambulatory blood pressure monitoring can be observed a 24-hour blood pressure changes, but should pay attention to their blood pressure lower than the general determination of the clinical results of 10 ~ 15 / 5 ~ 10 mm Hg, of about 125/80 mm Hg is equivalent to the hospital measured 140/90 mm Hg, using dynamic blood pressure monitoring should pay attention to adjust the target blood pressure values. Have made it clear right to treat a variety of risk factors include: smoking bans and restrictions on sodium intake, daily sodium intake should be less than 6 g. Obesity increased risk of coronary heart disease, male body mass index (BMI) is 25 ~ 29 when the increased risk of coronary heart disease 70%, BMI 29 ~ 33, when the three-fold increased risk of coronary heart disease. Type Ⅱ diabetes are overweight a lot, reducing body weight on blood glucose control, improve insulin sensitivity and improve blood pressure are good, and can improve the lipid disorders and reducing the burden of the left heart, right to reduce or slow down the occurrence and development of various vascular complications good.
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