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© Borgis - New Medicine 4/2003, s. 87-89
Zygmunt Chodorowski1, Jacek Sein Anand1, Barbara Cylkowska2, Marek Wisniewski1, Adam Hajduk1, Wojciech Waldman1
Assessment of antihypertensive treatment in elderly patients with type 2 diabetes
1 1st Department of Internal Medicine and Toxicology, The Medical University of Gdansk, Poland
Head: prof. Zygmunt Chodorowski, MD, PhD
2 Outpatient Department of Diabetology, Elblag, Poland
Head: Barbara Cylkowska, MD
Summary
Introduction: Type 2 diabetes and concominant hypertension are common medical phenomenon. More than half of the patients with type 2 diabetes have accompanying hypertension, which results in an almost threefold increase in the frequency of main cardiovascular event.
Methods: The study included 927 patients with type 2 diabetes referred to the outpatient Department of Diabetology from general outpatient clinics and hospitals of the former Elbląg district over the years 1993-2002.
Results: The patients were divided into 2 groups, according to age. Group I included 421 patients (276 women and 145 men, aged from 65 to 94; mean 72.6 yes.). Group II consisted of 506 patients (239 women and 267 men aged from 33 to 64; mean 54.9 yrs.).
The arterial blood pressure <130/80 were found in 6.4% of patients in group I, and in 12.6% of cases in group II. In both groups the precentages of efficiency treated patients were similar. The extent of single-drug therapy was similar in both groups. The most frequently administered drugs were ACE inhibitors (72.5%), calcium channel blockers (42%) and thiaside and thiazide-derivatives diuretics (40%).
Conclusions: The recommended antihypertensive treatment was offered to contiously, and was threrefore hardly effective.
Type 2 diabetes and concomitant hypertension are a common medical phenomenon. According to Kaplan, more than half of the patients with type 2 diabetes have accompanying hypertension, which results in an almost threefold increase in the frequency of main cardiovascular events, including, first of all, complications of ischaemic heart disease, and cerebral strokes (1). Many extensive research programmes have provided unquestionable evidence of multifactorial benefits of antihypertensive treatment in patients with hypertension complicating diabetes (2-7). The United Kingdom Diabetes Prospective Study (UKDPS) showed that a reduction in the mean systolic pressure by each 10 mmHg, resulted in decreased incidence of myocardial infarction by 11%, fatal and nonfatal cerebral strokes by 19%, microangiopathic diabetic complications by 13% (8). Some authors, however, emphasize that in the antihypertensive treatment, a wide range of available antihypertensive drugs is not used sufficiently, and the arterial pressure levels obtained in many patients, exceed, to a different extent, the projected target values (9, 10).
The objective of the present study was to assess the frequency of occurence of arterial blood pressure defined as normal in patients with diabetes (<130/80 mmHg). The assessment also covered the type and the number of antihypertensive agents administered.
Table 1. Distribution of arterial blood pressure values in both age groups of patients treated and untreated with antihypertensive drugs.
Numbers and percentcel  Patients with RR<130/80 mmHgPatients with RR 130-139/80-89 mmHgPatients with RR 140-159/90-99 mmHgPatients with RR>160/100 mmHg
no treatment reguiredtreateduntreatedtreateduntreatedtreateduntreatedtreated
gr INo of patients27233647481262193
%6.45.58.511.211.429.95.022.1
gr IINo of patients6431965668931781
%12.66.119.011.113.418.43.416.0
Table 2. The number of antihypertensive drugs recommended in the treatment of hypertension in both study groups.
Age groups 1 drug2 drugs3 drugs4 drugs
Group I Patients No941067217
%32.536.724.95.9
Group II Patients No91905921
%34.934.522.68.0
p 0.660.660.680.8
Table 3. Frequency of administration of different classes of antihypertensive drugs.
Type of drugAngiotensyn inhibitorsCalcium antagonistsThiazides and thiazide derivativesBeta blockersAlfa 1 blockersAntagonistsreceptor AT1Other
Group IPatinets No207127123105422
Patients treated %71.643.942.636.31.40.70.7
Group IIPatients treated %19210698114813
Patients treated %73.640.637.543.73.10.41.2
p (gr. I vs gr. II)NSxNSxNSx< 0.05NSxNSxNSx
Total populationPatients No3992332212191235
Patients treated %72.542.040.039.82.20.50.9
NS* not significant statistically
MATERIALS AND METHODS
The study included 927 patients with type 2 diabetes divided into two groups according to age. The elderly group (I) included 421 patients (276 women and 145 men aged from 65 to 94 years (mean age 72.6 years)). Group II consisted of 506 patients (239 women and 267 men aged from 33 to 64 years (mean age 54.9 years)). The assessment was performed in patients referred from general outpatient clinics and hospitals of the former Elbląg district to the Outpatient Department of Diabetology, Elbląg, over the years 1993-2002. In the statistical analysis of the results the test of proportions was used.
RESULTS
Distribution of patients´ blood pressure values in both groups is shown in Table 1.
Table 1 shows that the arterial blood pressue values <130/80 mmHg not requiring antihypertensive treatment were found in 6.4% of patients in group I, and in 12.6% of cases in group II. In patients with diabetes and hypertension, the antihypertensive treatment did not yield the target values in 5.5% of patients in group I, and in 6.1% in those of group II.
In both groups (I and II), the percentages of efficiently treated patients (RR <130/80 mmHg) were similar and represented 5.5% and 6.1% respectively.
The number of antihypertensive agents administered in the treatment of hypertension is shown in Table 2.
The extent of single-drug therapy was similar in both groups and included approximately one third of patients treated with antihypertensive drugs. Combination therapy of 2-3 drugs was administered in 195 patients (67.5%) of group I and in 170 patients (65.1%) of group II. No significant differences were found between the study groups with respect to the number of antihypertensive drugs administered. On average, one patient in the total patient population on combined therapy was given 2.5 hypotensive agents (group I – 2.5 agents; group II – 2.5 agents).
The frequency of administration of different classes of antihypertensive drugs is shown in Table 3.
The most frequently administered drugs were angiotensin inhibitors (72.5%), calcium channel blockers (42%), and thiazide and thiazide-derivatives diuretics (40%); angiotensin receptor antagonists were given least frequently. The percentages of drugs administered in patient groups were similar, nevertheless, beta-adrenolytics were given much less frequently to patients of group I than to those of group II.
DISCUSSION
So far, the present epidemiological studies conducted over the last six years included almost exclusively patients with diabetes type 2 with concomitant arterial hypertension as defined according to the six criteria in the JNC report (11). Only a few studies reported the frequency of arterial blood pressure <130/80 mmHg in patients with type 2 diabetes not treated with antihypertensive drugs (15). In our study material, the blood pressure <130/80 mmHg was found only in 6.4% of cases in group I, and in 12.6% of patients <65 years of age. It may only be presumed that almost twice as frequent desired blood pressure values in group II resulted from a significantly lower mean age of patients (54.9 years vs 72.6 years).
The administration of antihypertensive drugs reduced the target blood pressure values to <130/80 mmHg in 5.5% of the elderly patients receiving the therapy, and in 6.1% of patients <65 years of age. Many authors claim that reaching the target blood pressue values in patients with diabetes is very difficult, and it frequently requires combination treatment with 3-5 agents (12-15).
In our study, 286 patients (30.9%) with blood pressure values of 130/80 mmHg did not receive antihypertensive drugs, and 496 patients (53.5%) were treated with antihypertensive agents, inluding combination therapy with 2-4 drugs in 365 cases (39.4%). A significantly large number of untreated patients was due to the fact that the patients, on having been being diagnosed as having diabetes, had been immediately referred to the Outpatient Department of Diabetology to receive specialist treatment. Inadequate antihypertensive treatment was also the matter of concern for Pellegrini et al (10). In their report they assessed the diagnostic and therapeutic approach presented by physicians; they found out that merely 12% of patients with diabetes type 2 and arterial hypertension were given 3 and more drugs (10).
In spite of the fact that according to the present recommendations, angiotensin converting enzyme inhibitors, angiotensin receptor blockers and thiazide diuretics are preferred as equally effective, patients´ preferences included, in a decreasing order, angiotensin converting enzyme inhibitors, calcium free-channel antagonists and thiazide diuretics, and a small percentage of angiotensin receptor blockers. It seems that the latter agents are not popular among medical doctors owing to high costs, and may be also to their inadequate experience in the drug administration.
CONCLUSIONS
1.The frequency of desired arterial blood pressure <130 mmHg in patients with type 2 diabetes not treated with antihypertensive drugs was 9.8% (group I – 6.4%; group II – 12.6%).
2.The antihypertensive treatment with the target blood pressure values <130/80 mmHg proved to be effective in only 5.8% of patients in the assessed population and was similar in both age groups (group I – 5.5%; group II – 6.1%).
3.Antihypertensive single-drug therapy was offered in 33.6% of cases, combination therapy with 2-4 agents was given in 66.4% cases.
4.The most frequently administered antihypertensive drugs included angiotensin converting enzyme inhibitors (42%) (72 <5%), calcium antagonists and thiazide diuretics (40%); angiotensin receptor antagonists were found to be the least frequent drugs (0.5%). The percentages of the antihypertensive drug classes administered in both age groups were similar.
5.The recommended antihypertensive treatment was offered too cautiously, and was therefore hardly effective.
Piśmiennictwo
1. Kaplan N.M.: Management of hypertension in patients with type 2 diabetes mellitus: guidelines based on current evidence. Ann. Intern. Med. 2001; 135:1079-83. 2. UKPDS Group: Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes (UKPDS 38). Br. Med. J. 1998; 317:703-13. 3. Hansson L. 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. HOT Study Group. Lancet 1998; 351:1755-62. 4. Heart Outcomes Prevention Evaluation Study Investigators: Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Lancet 2000; 355:253-59. 5. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic. JAMA 2002; 288:2981-97. 6. Chobanian A.V. et al.: National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Progrem Coordination Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003; 289:2560-72. 7. Guidelines Committee. 2003 European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension. J. Hypertens. 2003; 21:1011-53. 8. Adler A.I. et al.: Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): prospective observational study. Br. Med. J. 2000; 321:412-19. 9. Berlowitz D.R. et al.: Hypertension management in patients with diabetes: the need for more aggressive therapy. Diabetes Care. 2003; 26:355-9. 10. Pellegrini F. et al.: for QuED Study Group. Role of organizational factors in poor blood pressure control in patients with type 2 diabetes: the QuED Study Group – quality of care and outcomes in type 2 diabetes. Arch. Intern. Med. 2003; 163:473-80. 11. The sixth report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Arch. Intern. Med. 1997; 157:2413-46. 12. Bakris G.L.: A practical approach to acheving recommended blood pressure goals in diabetic patients. Arch. Intern. Med. 2001; 161:2661-7. 13. Basta E., Bakris G.: Choices and goals in the treatment of the diabetic hypertensive patient. Curr. Hypertens. Rep. 2001; 3:387-91. 14. Weir M.R.: Diabetes and hypertension: how low should you go and with which drugs? Am. J. Hypertens. 2001; 14:17S-26S. 15. Vijan S., Hayward R.A.: Treatment of hypertension in type 2 diabetes mellitus: blood pressure goals, choice of agents, and setting priorities in diabetes care. Ann. Intern. Med. 2003; 138:593-602.
New Medicine 4/2003
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