THE DIABETIC PATIENT WITH HYPERTENSION

Hypertension and diabetes co-exist more commonly than would be expecte d from their individual prevalences. Elevated blood pressure is most c ommonly due to coexisting essential hypertension, or diabetic renal di sease. Early stages of diabetic renal disease can be identified by det ecting microalbuminuria. Standard measures of blood pressure are not n ecessarily raised, but 24-hour ambulatory measures frequently identify a loss of nocturnal drop in blood pressure. Treating hypertension agg ressively is important in slowing the inexorable decline in glomerular filtration rate. In diabetes there appears to be no 'J'-shaped relati onship between blood pressure and cardiovascular events, thus removing any concern about attaining low blood pressures as long as the patien t is asymptomatic. Morbidity and mortality in these patients is usuall y associated with cardiovascular events, and it is important to assess the effect of drugs on left ventricular hypertrophy and metabolic par ameters. Many drugs are effective at lowering blood pressure, but angi otensin-converting enzyme inhibitors may have an additional renoprotec tive action. cr-Adrenergic antagonists may improve lipid profiles and calcium antagonists are probably lipid neutral, making these drugs use ful alternatives. Dihydropyridine calcium antagonists (eg, nifedipine) may augment protein-uria, and hence non-dihydropyridine calcium antag onists (eg, verapamil, diltiazem) would be preferred. beta-Blockers an d thiazide diuretics have the disadvantage of causing a deterioration in glycaemic and lipid profiles, but can be useful on occasions.