Grad: Managing hypertension in patients with renal disease and diabetes [CMAJ

Managing hypertension in patients with renal disease and diabetes

CMAJ 2000;162:1555-6

See response from: R.D. Feldman, et al

The authors of the 1999 Canadian recommendations for the management of hypertension state that "hypertension in people with diabetes should be treated to obtain target blood pressure lower than 130/80 mm Hg" [Supplement]¹ This grade C recommendation is supported by evidence from the HOT² and UKPDS 38³ studies insofar as the diastolic target is concerned. However, we question the systolic target of 130 mm Hg given our review of the evidence from these 2 studies.

In the HOT study, the mean systolic blood pressure achieved by the group randomized to a diastolic target of < 80 mm Hg was 139.7 mm Hg. In the UKPDS 38 study, the mean systolic blood pressure achieved in the group randomized to "tight" blood pressure control was 144 mm Hg. Therefore, the evidence with regard to the systolic target for control of blood pressure in diabetic patients with hypertension points to 140 mm Hg rather than 130 mm Hg less.

The high prevalence of systolic blood pressures in the range of 130 to 140 mm Hg would mandate additional treatment for a large number of people if the Canadian guidelines were to be closely followed. Of note, the British Hypertension Society recommends that clinicians attempt to achieve a target of less than 140 mm Hg systolic blood pressure in hypertensive patients with type II diabeties.⁴ Is there additional evidence that led the authors to recommend a lower systolic target of 130 mm Hg?

Roland Grad
Department of Family Medicine
McGill University
Montreal, Que.
Stephen Hanley
Division of Clinical Epidemiology
Royal Victoria Hospital
Montreal, Que.
shanle2@po-box.mcgill.ca

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References

Feldman RD, Campbell N, Larochelle P, Bolli P, Burgess ED, Carruthers SG, et al, for the Task Force for the Development of the 1999 Canadian Recommendations for the Management of Hypertension. 1999 Canadian recommendations for the management of hypertension. CMAJ 1999;161(12 Suppl):S1-22. [MEDLINE]
Hansson L, Zanchetti A, Carruthers SG, Dahlof B, Elmfeldt D, Julius S, et al. Effects of intensive blood pressure lowering and low-dose aspirin in patients with hypertension: principal results of the hypertension optimal treatment (HOT) randomized trial. Lancet 1998;351:1755-62. [MEDLINE]
UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes (UKPDS 38). BMJ 1998;7160:703-13.
Ramsay L, Williams B, Johnston G, MacGregor G, Poston L, Potter J, et al. Guidelines for management of hypertension: report of the Third Working Party of the British Hypertension Society. J Hum Hypertens 1999;13:569-92. [MEDLINE]