Blood pressure control in patients with comorbidities

Abstract

Hypertension frequently coexists with obesity, diabetes, hyperlipidemia, or the metabolic syndrome; their association with cardiovascular disease is well established. The identification and management of these risk factors is an important part of the overall management of hypertensive patients. Because patients in these special populations are more predisposed to target organ damage (TOD), stringent targets for blood pressure (BP) control have been set in clinical guidelines. However, clinical trial and real-life evidence suggest that these targets are difficult to achieve. Patients with these comorbidities are more likely to require combination therapy, yet physicians are often reluctant to adjust the number and doses of medications to achieve target BP. There is a particular need for effective 24-hour BP control in these patients, due to the increased likelihood of nondipping status, which is a risk factor for TOD and mortality. Not all available antihypertensives are equally effective in controlling BP over 24 hours, and some may exacerbate underlying metabolic abnormalities.

Figure 1

Prevalence of other risk factors for cardiovascular disease among 57,573 hypertensive patients (in a large managed‐care organization and aged 35 years or older) with no history of cardiovascular disease. DM indicates diabetes mellitus; HBMI, high body mass index (≥30 kg/m2); HLD, hyperlipidemia. From the Weycker et al, 2007.

Figure 2

Blood pressure (BP) control in diabetic and nondiabetic patients participating in the Anglo‐Scandinavian Cardiac Outcomes Trial‐Blood Pressure Lowering Arm (ASCOT‐BPLA). The target BP was stricter for diabetic patients (<130/80 mm Hg) than for nondiabetic patients (<140/90 mm Hg). HTN indicates hypertension; DM, diabetes; JNC VI, The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

Figure 3

Major cardiovascular events in relation to target diastolic blood pressure (DBP) in patients with hypertension and type 2 diabetes (Hypertension Optimal Treatment [HOT] study; P for trend =.005). , Reprinted from McInnes, 2004.

Figure 4

Relationship between relative risk of cardiovascular disease (CVD) and rising cholesterol and systolic blood pressure (SBP) levels among 108,879 French men younger than 55 years. Patients with SBP ≥140 mm Hg and total cholesterol ≥200 mg/dL were classified as having hypertension and dyslipidemia, respectively. , Reprinted from Cowie, 2005.