2020 ADA guidelines: blood pressure care in adults with diabetes

Here is a concise summary of the 2020 ADA guidelines on the approach of hypertension in patients with diabetes. The authors discuss lifestyle, medications, drug side-effects, and blood pressure (BP) targets. Goals are to achieve BP <130/80, <135/85, and <140/90 mmHg in adults at high risk for ASCVD, gestational diabetes, and low-ASCVD risk, respectively.

Dr. Tashko

Primary hyperaldosteronism in obesity

In this retrospective study, investigators analyzed a group of 400 adults with hypertension due to primary hyperaldosteronism. The study found that obese patients had smaller aldosterone-producing tumors than lower BMI counterparts. It appears that obese individuals had more aggressive – higher functioning – tumors in spite of their smaller size. Adrenalectomy led to a similar clinical outcome – blood pressure improvement – in patients with or without high BMI. Although these results need to be confirmed, it would be useful for endocrinologists, radiologists, and surgeons to be aware of this phenotype.


Blood pressure and cardiovascular disease

This major observational study affirms the notion that the lower the blood pressure the lower the cardiovascular outcomes. A group of 1.3 million outpatient adults was observed and analyzed over 8 years. The study finds that both systolic and diastolic blood pressure are independent contributors to increased CVD. In addition to guideline-driven blood pressure targets, the BP goal should be individualized based on the patient’s comorbidities, medication burden, and side effects.


More evidence of Metformin benefits in early prediabetes

More good news for metformin. MET-REMODEL trial tested patients with known cardiovascular disease and insulin resistance, but without gross diabetes. Patients received metformin or placebo for 12 months.

Compared to the placebo group, subjects receiving metformin experienced the following improvements in 12 months: Less left ventricular mass index,  less LVM, lower systolic BP, decreased body weight and less oxidative stress.

Early start of metformin could be useful in adults with insulin resistance.  Long term side effects of metformin, however, need to be discussed thoroughly with patients.


Jardiance lowers blood pressure significantly in African American adults

Jardiance shows positive outcomes in African American adults. It reduces the A1c by 0.8%, body weight by 2.7 pounds and more interestingly the systolic blood pressure by 8 mmHg, similar to a standard blood pressure medication.

A group of 150 African American participants were randomized to receive Jardiance 25 mg daily or placebo for 6-months.

The SGLT2 inhibitor would be a great choice for patients with concomitant hyperglycemia and systolic hypertension.


Systolic Blood Pressure and Dementia Risk

About 9,000 adults were randomized to receive tight or less-tight systolic blood pressure control. They were followed for about 5 years for cognition and dementia outcomes.

Although the primary outcome was almost significant, the secondary outcomes were truly significant for improvement of mild cognitive impairment or probable dementia with intensive systolic blood pressure <120 mmHg over those who achieved sBP <140 mmHg.

While further trials are needed to clarify the above findings, there appears to be no harm of lowering the sBP down to <120 mmHg in this study.


Ambulatory blood pressure monitoring (higher awareness is needed)

Ambulatory blood-pressure measurement (ABPM) refers to home assessments of blood pressure every 20-30 minutes over a 24 hour period. In this study about 64,000 adults were followed for 5 years.

Authors found that ABPM is a better predictor of cardiovascular deaths or deaths from any cause, compared to clinic BP measurements. These results are in accordance with recent American Heart Association guidelines published in December 2017 and common sense approach that more data is better then less in reaching statistically meaningful results.


SPRINT trial: customized blood pressure goals

Further sub-analysis of SPRINT trial uncovers the point of balance between treatment benefit and harm in the setting of cardiovascular illness. The higher the baseline CVD risk, the more benefit is achieved by intensive blood pressure therapy; while the lower the risk, the higher the harm. Baseline cardiovascular status is obtained by the 10 year ASCVD risk estimator, which can be found online here.


Systolic blood pressure in heart failure

The study finds that low systolic blood pressure in the hospital is associated with increased re-hospitalization and mortality rates among patients with heart failure but preserved ejection fraction (EF>50%). Mortality disadvantage was seen as far out as in 1 month, 1 year and 2.6 years after discharge in those with hospital systolic BP < 120 mmHg. These results could change hospitalists’ approach to blood pressure management in heart failure.


Merit-based payment for blood pressure care

I am happy to contribute to the editorial by Lisa Eramo published in Medical Economics, January 2018. The article is important as it raises physician awareness of Merit-based Incentive Payment System (MIPS) under which hypertension management falls. MIPS, part of 2015 MACRA, will go into effect in 2019.


The other aldosterone blocker, eplerenone, helps with hypertension

The aim of this review was to determine the effectiveness of eplerenone for reducing blood pressure, its side effect profile, and its impact on clinically meaningful outcomes such as mortality and morbidity.

Clinicians have used eplerenone to treat high blood pressure since 2002. It is important to determine the clinical impact of all antihypertensive medications used in patients to support their continued use in essential hypertension.

The eplerenone dose ranged from 25-400 mg daily. Patients were followed for 8-16 weeks while on therapy. There is currently no evidence that eplerenone has a beneficial effect on life expectancy or complications related to hypertension.

The study finds that eplerenone 50-200 mg/day reduces systolic BP by approximately 9 mmHg and diastolic BP by 4 mmHg compared to taking no medication.