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Abstract

In clinical practice, hypertensive patients with type 2 diabetes have the greatest risk for cardiovascular complications. Prospective morbidity and mortality trials in these patients have demonstrated that more intensive blood pressure control improves cardiovascular prognosis. Current treatment guidelines recommend a target blood pressure of >130/85 mmHg in patients with hypertension and diabetes. The recommended treatment of choice for patients with heart disease, kidney disease, or diabetes is an angiotensin converting enzyme (ACE) inhibitor plus additional medications as necessary to reach goal blood pressure. Although ACE inhibitors have demonstrated morbidity and mortality reduction in patients post-MI and with congestive heart failure and provide secondary cardiovascular risk reduction in patients over the age of 55 with heart disease, peripheral vascular disease, or diabetes, there is limited data in patients with type 2 diabetes and evidence of renal disease demonstrating consistent risk reduction. The majority of available data with ACE inhibitors and renal protection is limited to studies incorporating patients with type 1 diabetes. Consequently, there is a need to demonstrate that specific therapies may provide risk reduction in patients with hypertension and type 2 diabetes and/or established renal disease (either increased serum creatinine or evidence of macroproteinuria).

Optimally, one should prevent renal damage rather than treat it once it has already occurred. Preventing renal damage also reduces the risk for cardiovascular disease that is always associated with renal dysfunction.

Both the PRIME program (IDNT and IRMA-2) and the RENAAL trial demonstrated the important utility of angiotensin II receptor blockers in both preventing and protecting against progressive renal disease in patients with type 2 diabetes with microalbuminuria or clinical proteinuria. Although much focus has been placed on the protection trials (IDNT and RENAAL), the ability of the angiotensin II receptor blocker (irbesartan 300 mg) to prevent progression to clinical proteinuria in microalbuminuric patients with type 2 diabetes is of significant clinical importance. This trial illustrates the important need for early identification and treatment of high risk hypertensives so as to prevent nephropathy and probably also cardiovascular disease. Thus, these trials provide important new insight for risk reduction in patients with type 2 diabetes and hypertension.

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© American Journal of Hypertension, Ltd. 2002
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