Antihypertensive treatment of patients with diabetes and hypertension

Whereas individual research papers about antihypertensive treatment in diab etics might be somewhat confusing, the weight of the evidence strongly sugg ests that: 1) In patients with type I diabetes, it is advantageous to use a ngiotensin-converting enzyme (ACE) inhibitors as primary treatment. 2) In t ype 2 diabetics, aggressive blood pressure (BP) lowering is warranted and, the calcium antagonist controversy notwithstanding, all drugs appear to be similarly useful in reducing cardiovascular mortality. Specifically, in the Systolic Hypertension in Europe study, compared with placebo, a calcium an tagonist dramatically reduced cardiovascular (CV) events in elderly diabeti cs. The Hypertension Optimal Treatment study showed that, using a calcium a ntagonist-based regimen, the degree of BP lowering determines the degree of CV event reduction. Furthermore, the United Kingdom Prospective Diabetes S tudy (UKPDS) did not find a difference in CV events reduction in patients t reated with beta -blockers or with ACE inhibitors. In the UKPDS, the effect of BP lowering on reduction in CV events was more substantial than the deg ree of CV reduction by blood sugar lowering. 3) Both the CAPtopril Preventi on Project (CAPPP) and the Heart Outcomes Prevention Evaluation (HOPE) stud ies found that treatment with an ACE inhibitor may be useful in reducing th e incidence of new-onset type 2 diabetes mellitus. 4) Finally, insulin resi stance, a precursor of diabetes mellitus and a strong predictor of future C V disease, is differentially affected by antihypertensive treatment. beta - Blockers and diuretics worsen insulin resistance, whereas alpha -adrenergic blockers; and central imidazoline binding agents increase insulin sensitiv ity. The effect of ACE inhibitors and angiotensin blockers may also positiv ely affect insulin resistance, but the results are not uniformly positive. It stands to reason that the differential effect of various drugs on insuli n resistance and primary CV events may be clinically relevant particularly in the course of the longterm prevention of mild hypertension. All current trials investigate the effect of the treatment on secondary prevention of C V events among patients with advanced complicated diabetes and hypertension . (C) 2001 American Journal of Hypertension, Ltd.