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Abstract

Hypertension is common in association with diabetes mellitus and recent studies have confirmed the primacy of BP control in reducing cardiovascular morbidity in this high risk group of patients. The British Hypertension Society (BHS) has recently published revised guidelines on the management of hypertension which include a target clinic BP of < 140/80 mm Hg in the diabetic population. The target for daytime or awake ABPM was set at < 130/75 mm Hg. Such targets are arbitrary but have the potential to influence large numbers of doctors within the UK and we have assessed how they might be used and interpreted in diabetic patients.

Between 1997 and 1999, ABPM was performed 582 times on 542 patients referred from the diabetic clinic at our hospital for evaluation of clinic hypertension. Patients were aged 24 to 85 years (54% male) and comprised a mixture of treated and non-treated patients. Spacelabs monitors were fitted to the non-dominant arm by a trained nurse. The second BP measurement (recorded by the monitor after at least 5 min rest) was checked against a mercury manometer using a two-way tap and was taken as the clinic BP.The monitor was worn for 24 hours with recordings made at 30 min intervals throughout. Awake and sleep periods were defined according to patient diaries. There is evidence to suggest that an absence of a nocturnal fall in BP might increase cardiovascular risk so we identified the proportion of non-dippers using the conventional criterion of a nocturnal BP fall of < 10%. We examined the number of times a carefully obtained clinic BP would be above the BHS target but the ABPM would be below target implying that treatment was unnecessary or adequate.

342 patients had a clinic BP >140/80 and only 6 of these had an awake ABP < 130/75. Of 93 who had clinic systolic or 73 with clinic diastolic hypertension only 7 and 3 respectively were <130/75 on ABP. On 508 (87%) occasions both the clinic and awake ABPM were both above the BHS target implying that ABPM added nothing to the decision making process. Disparity occurred only in only 3% of patients. Non-dipping was noted in 48% of patients, well in excess of the prevalence found in non-diabetic hypertensive subjects. These data suggest that ABPM is unnecessary in the evaluation of awake BP in diabetic patients, providing careful clinic measurements are made. However, as evidence of the importance of no-dipping increases nocturnal BP recordings will play an increasingly important part in the management of diabetic patients.

Diabetes mellitus, Non dippers, Ambulatory blood pressure
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© American Journal of Hypertension, Ltd. 2001
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