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DRUGINDUCEDDIABETESDURINGANTIHYPERTENSIVETHERAPYISIMPORTANT-BUT,CHINESESOCIETYOFHYPERTENSIONMICHAELALDERMANMAY22,2008,PrevalenceofdiabetesamongChineseadultsaged35–64yearsinthe1994ChineseNationalSurvey(10)and2000–2001InterASIAStudy,GuetalDiabetologia.2003;46:1190.,,,Percentofdeaths,GeissLS,etal.In:DiabetesinAmerica.NationalInstitutesofHealth;1995.,65%ofMortalityinpeoplewithDiabetesisCVD,Ischemicheartdisease,Otherheartdisease,Diabetes,Malignantneoplasms,Cerebrovasculardisease,Pneumonia/influenza,Allother,,,,,,,,,,,,,CVmortalityrateper10,000person-years,SystolicBPandCVDeathinMRFIT,,Nondiabetic(n=342,815),,Diabetic(n=5,163),<120,120-139,SystolicBP(mmHg),140-159,160-179,180-199,?200,StamlerJ,etal.DiabetesCare.1993;16:434-444.,,BP=bloodpressureCV=cardiovascularMRFIT=MultipleRiskFactorInterventionTrial,AnnualIncidenceofDiabetesinHypertensivePatients,SHEPuntreatedcontrols=2.7%SHEPtreated=3.9%,Lancet.2006,368;1673-1679,AmJCardiol.2005;95:29,Hypertension.2007;50:467,JAMA2002;288:2981-2997,NHANES18yearFollow-upNODinUSWomenbyBaselineBP,Conen,D.etal.EurHeartJ200728:2937-2943,140,mmHg,.,Conen,D.etal.EurHeartJ200728:2937-2943,Age-adjustedincidencerates(A)andHRs(B)ofNODaccordingtobloodpressurecategory,stratifiedbybaselinebodymassindex,THEISSUES,CONSEQUENCESOFNODCVDANDnon-CVDHOWDOANTIHYPERTENSIVEDRUGSEFFECTINCIDENCEOFNODANDCVDONSEQUENCES?HOWSHOULDNODEFFECTMANAGEMENTFORCVDPROTECTION?,Non-CVDConsequencesofNOD,ImpairedBPcontrolBehavioralandPsychologicalMicrovascularconsequences(?)?MedicalcaredemandsTreatmentchanges,CVDConsequences,ShortandLongtermAntihypertensiveDrugRelated,.,Whelton,P.K.etal.ArchInternMed2005;165:1401-1409.,ALLHATIncidenceofCoronaryheartdiseasebytreatmentgroupaccordingtobaselinediabetesmellitus,impairedfastingglucoselevel,ornormoglycemia,Barzilay,J.I.etalALLHAT.ArchInternMed2006;166:2191-2201.,HR’sofa10-mg/dL(0.56-mm)?FBGat2yearsforsubsequentCVDandRenalDisease,,,EffectofACEIsandARBsonCVDMortality,,Gillespie,etal.DiabetesCare28:2261-2266,2005,Age-gender–adjustedintreatmentCVDandnon-CVDbybaselineFBGamonghypertensivepatients.,Alderman,Hypertension.1999;33:1130-1134,Myocardialinfarction(fatalandnonfatal)inhypertensivepatientsaccordingtoDMstatus,Aksnes,T.A.etal.Hypertension2007;50,DiabetesIncidence-4Years(follow-upFBS?126mg/dLforthose<126mg/dLatbaseline),*,*,*p<.05comparedtochlorthalidone,JAMA2002;288:2981-2997,Ramiprilv.PlaceboinhighriskpatientswithIGTatbaseline,Dream.NEJM;355:1551-1562,2006,Ramiprilv.PlaceboCVD355:1551-1562,2006,,.,Whelton,P.K.etal.ArchInternMed2005;165:1401-1409.,ALLHAT:RR(and6-yearratesper100fornondiureticcomparedwithdiureticfordiabetesmellitus(A),impairedfasingglucoselevel(B),andnormoglycemia(C)atbaseline,forCHD,all-causemortality,combinedCHD,stroke,HF,allCVD,andESRD,CVdeath(%),,,,PLACEBO,ACTIVE,*=p<0.05vsnodiabetes,SHEP-14YEARFOLLOW-UP,CONCLUSIONSFROMSHEP+,ChlorthalidoneRxofhypertensionimproveslong-termoutcomes.Thediabetesrelatedtochlorthalidonetherapyhasbetterprognosisthandiabetesatbaseline.Thebenefitofchlorthalidone-basedtherapyonlong-termtotalandCVmortalityismostpronouncedinhypertensivepatientswithdiabetes.,ReductioninmajorCVDamong6,000DMinHPSassociatedwith38/89?LDL/CHOLbyStatin,Mazzone,T.TheAmericanJournalofMedicine120;2007,S26-S32,,IncidenceofMIandMicrovascularEndpointsbyMeanSBPandHbA1cinUKPDS,Adjustedincidenceper1000person-years(%),UpdatedmeanHbA1cconcentration(%),MeanSBP(mmHg),Adjustedincidenceper1000person-years(%),5,6,7,8,9,10,11,110,120,130,140,150,160,170,Myocardialinfarction,Microvascularendpoints,Microvascularendpoints,Myocardialinfarction,,AdlerAI,etal.BMJ.2000;321:412-419.StrattonIM,etal.BMJ.2000;321:405-412..,MI=myocardialinfarctionSBP=systolicbloodpressure,UNCERTAINTYCONTINUESACCORDANDADVANCE,ACCORD-MortalitygreaterwithHbAlc<6.4v.7.0-7.9%ADVANCE-Noevidenceof?mortalitywithHbAlc6.4v.7,5%,MajorCVEventRateInHOT,HOT,Lancet1998;351:1755,p=0.00551%riskreduction,GoalDiastolicmmHg,Diabeticpopulation,Non-Diabeticsubjects,,CONCLUSIONS,DMseriouswheneveritoccursMorecommoninhypertensiveRxParticularlywithdiureticsNODhasconsequencesNon-CVDinshorttermCVDlongtermNeitherfearof,norNOD,requiresD/CDiuretic,CLINICALIMPLICATIONS,SCREENFORNODATTEMPTTOREVERSEHYPERGLCEMIACORRECTHYPOKAELMIAKSPARINGDIURETICADDACEORARBOPTIMIZEBPANDLIPIDCONTROLTREATHYPERGLYCEMIA(?)NOEVIDENCEOFCVDBENEFITPREVENTIONOFMICROVASCULAREFFECTS,