Recommendations for special populations: diabetes mellitus and the metabolic syndrome

Cardiovascular diseases (CVD) are the major causes of mortality in persons with diabetes, and many factors, including hypertension, contribute to this high prevalence of CVD. The incidence of hypertension in patients with diabetes is approximately twofold higher than in age-matched subjects without the disease, and conversely, individuals with hypertension are at increased risk of developing diabetes compared with normotensive persons. Furthermore, because up to 75% of cases of CVD in patients with diabetes can be attributed to hypertension, aggressive management of elevated blood pressure (BP) (ie, to <130/85 mm Hg) in these patients is essential for reduction in cardiovascular morbidity and mortality. The renin-angiotensin system is an important regulator of both BP and obesity, and its pharmacologic modulation may thus translate into significant cardiovascular benefits. Apart from hypertension and obesity, the important risk factors for CVD in patients with diabetes include atherosclerosis, dyslipidemia, microalbuminuria, endothelial dysfunction, platelet hyperaggregability, and coagulation abnormalities. Therefore, effective prevention of major cardiovascular events in patients with diabetes requires combination therapy with agents that target key factors contributing to cardiovascular morbidity and mortality. The antiplatelet and anti-inflammatory effects of aspirin, the lipid-lowering activity of statins, as well as the antihypertensive effects of various agents (eg, diuretics, beta-blockers, calcium channel blockers, angiotensin-converting enzyme inhibitors, and angiotensin-II receptor blockers) have all been demonstrated to provide substantial reductions in cardiovascular events.