Diabetes and hypertension: pathogenesis, prevention and treatment

Hypertension occurs in approximately 30% of patients with type 1 diabetes and from 50 to 80% of patients with type 2 diabetes. Although the pathogenesis of hypertension is distinct in each type, hypertension markedly enhances the already high risk of cardiovascular and renal disease in types 1 and 2 and implications for treatment are similar in both. The threshold for blood pressure treatment in diabetic patients is generally agreed to be 140/90 mm/hg with a target BP of < 130/80. So-called "lifestyle modifications" play an important role in therapy, particularly in type 2 patients, by decreasing blood pressure and improving other risk factors for cardiovascular disease. Indeed non-pharmacologic interventions have been demonstrated to prevent the development of type 2 diabetes in patients at high risk to develop the disease. Aggressive anti-hypertensive drug treatment is warranted given the high risk associated with the combination of diabetes and hypertension and the demonstrated effectiveness of anti-hypertensive treatment in reducing cardiovascular morbidity and mortality in this group of patients. ACE inhibitors and ARBs are the cornerstones of pharmacologic management, in no small part because of the renoprotective effects of these agents in antagonizing the development and progression of diabetic renal disease. Multiple agents, including diuretics, will usually be required to attain target blood pressure levels.