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Pharmacologic therapy of mild to moderate hypertension: possible generalizability to diabetics
P R Hebert1, J E Manson, C H Hennekens
1Department of Medicine, Channing Laboratory, Harvard Medical School, Boston, MA.
Insights
Pharmacologic therapy for hypertension significantly reduces stroke and coronary heart disease (CHD) risks. However, benefits for diabetics are less clear, and some treatments may negatively impact glucose and lipid metabolism.
Area of Science:
- Cardiovascular Medicine
- Pharmacology
Background:
- Hypertension is a major risk factor for stroke and coronary heart disease (CHD).
- Pharmacologic therapy is a cornerstone in managing hypertension.
- Evidence for treatment benefits in diabetics remains less clear.
Purpose of the Study:
- To review evidence on pharmacologic therapy for hypertension in reducing stroke and CHD morbidity/mortality.
- To assess the generalizability of these findings to diabetic patients.
- To explore the impact of antihypertensive drugs on lipid and glucose metabolism in diabetics.
Main Methods:
- Review of evidence from randomized trials and meta-analyses on hypertension pharmacotherapy.
- Analysis of subgroup data from the Hypertension Detection and Follow-Up Program (HDFP) for diabetic patients.
- Consideration of adverse effects of antihypertensive drugs on metabolic parameters.
Main Results:
- Meta-analyses show significant reductions in stroke (42%) and CHD (14%) with hypertension treatment.
- Benefits for malignant and severe hypertension are well-established.
- Diabetics in HDFP showed a smaller mortality reduction (5%) compared to non-diabetics (17%), though significance is uncertain.
- Antihypertensive drugs can adversely affect lipid and glucose metabolism.
Conclusions:
- Pharmacologic therapy effectively reduces cardiovascular risk in hypertensive individuals.
- The generalizability of these benefits to diabetics requires further investigation.
- Newer antihypertensive agents with improved metabolic profiles may enhance risk-benefit ratios, particularly for diabetic patients with elevated cardiovascular risk.
Abstract:
This article reviews the evidence on pharmacologic therapy of hypertension in reducing morbidity and mortality from stroke and coronary heart disease (CHD) and considers the possible generalizability of these findings to diabetics. For malignant hypertension, benefits are large and obvious from uncontrolled case series. For severe hypertension, conclusive benefits have been shown in several randomized trials. For mild to moderate hypertension, however, it is necessary to consider meta-analyses of all individual trials. The most comprehensive of these shows reductions of 42% for total stroke (95% Cl, -33 to -50%; P < 0.0001) and 14% for all CHD (95% Cl, -4 to -22%; P < 0.01). The applicability to diabetics is unclear because they were excluded from most of the trials. The Hypertension Detection and Follow-Up Program included diabetics and reported subgroup analyses. The reduction in mortality among the actively treated diabetics of 5% was less than the 17% achieved in nondiabetics. It is unclear, however, whether the mortality reductions are truly different or reflect the play of chance. Because of the higher incidence of CHD events among diabetics with hypertension, a similar relative benefit would result in a much greater absolute risk reduction. Further, the drugs used adversely affect lipid and glucose metabolism. New antihypertensive drugs without these side effects may further improve the risk-to-benefit ratio of antihypertensive treatment, especially in diabetics, who are at a several-fold absolute increased risk or cardiovascular disease.(ABSTRACT TRUNCATED AT 250 WORDS)