What is the best approach to manage cardiovascular risk in a patient with Hypertension (HTN), Prediabetes, and Chronic Kidney Disease (CKD)?

Managing Cardiovascular Risk in a Patient with Hypertension, Prediabetes, and CKD

For patients with hypertension, prediabetes, and CKD, a comprehensive cardiovascular risk management approach should include blood pressure control targeting <130/80 mmHg, SGLT2 inhibitors, statins, and ACE inhibitors or ARBs as first-line antihypertensive therapy. 1

Blood Pressure Management

Target Blood Pressure

• Target systolic BP of 120-129 mmHg for patients with CKD and eGFR >30 mL/min/1.73m² 1
• For patients with eGFR <30 mL/min/1.73m², individualized BP targets are recommended 1

First-line Antihypertensive Therapy

• ACE inhibitors or ARBs are the preferred first-line agents for patients with CKD 1
  • These medications reduce albuminuria and slow CKD progression
  • They also reduce cardiovascular events in this population
  • CAUTION: Never combine ACE inhibitors with ARBs due to increased risk of hyperkalemia and acute kidney injury without additional benefits 1

Additional Antihypertensive Medications

• Add a calcium channel blocker (CCB) or thiazide-like diuretic as second-line therapy 1, 2
  • Non-dihydropyridine CCBs reduce albuminuria and slow kidney function decline
  • Dihydropyridine CCBs should not be used as monotherapy in proteinuric CKD but always in combination with a RAAS blocker 2
• Diuretic selection should be based on eGFR:
  • eGFR >30 mL/min/1.73m²: Thiazide-like diuretics (chlorthalidone, indapamide)
  • eGFR <30 mL/min/1.73m²: Loop diuretics 2

Metabolic Management

SGLT2 Inhibitors

• SGLT2 inhibitors are recommended for patients with CKD and eGFR >20 mL/min/1.73m² 1
  • These medications provide modest BP lowering effects
  • They improve cardiovascular and kidney outcomes
  • They reduce oxidative stress in the kidney 1

Mineralocorticoid Receptor Antagonists (MRAs)

• Consider finerenone (a non-steroidal MRA) for patients with type 2 diabetes and CKD 1
  • The FIGARO-DKD trial showed a 13% reduction in cardiovascular events with finerenone
  • Monitor for hyperkalemia, which occurred in 10.8% of patients but rarely led to discontinuation (1.2%) 1

Lipid Management

• Statins are recommended for all patients with CKD aged ≥50 years with eGFR <60 mL/min/1.73m² 1
• For patients aged 18-49 years with CKD, statins are suggested if they have:
  • Known coronary disease
  • Diabetes mellitus
  • Prior ischemic stroke
  • 10-year cardiovascular risk >10% 1
• Atorvastatin has been shown to reduce cardiovascular events in patients with multiple risk factors 3

Prediabetes Management

• BP-lowering drug treatment is recommended for people with prediabetes when:
  • Confirmed office BP is ≥140/90 mmHg, or
  • Office BP is 130-139/80-89 mmHg with 10-year CVD risk ≥10% 1
• Lifestyle modifications including weight loss, physical activity, and dietary changes are essential

Monitoring and Follow-up

• Regular monitoring of:
  • Blood pressure (consider ambulatory BP monitoring to assess diurnal variation) 4
  • Kidney function (eGFR and albuminuria)
  • Electrolytes, particularly potassium when using RAAS blockers
  • Glycemic control

Special Considerations

• Avoid orthostatic hypotension: Test for orthostatic hypotension before starting or intensifying BP-lowering medication 1
• Referral to nephrology is recommended when:
  • Uncertainty about kidney disease etiology exists
  • Management issues arise (anemia, hyperparathyroidism, resistant hypertension)
  • Advanced kidney disease (eGFR <30 mL/min/1.73m²) develops 1

Common Pitfalls to Avoid

1. Combining ACE inhibitors and ARBs: This combination increases adverse events without additional benefits 1
2. Inadequate diuretic dosing: Too low doses can result in fluid retention; too high doses can lead to volume contraction and renal insufficiency 1
3. Neglecting non-pharmacological approaches: Dietary salt restriction is particularly important in CKD patients 4
4. Overlooking drug interactions: Some medications may worsen kidney function or interact with antihypertensives 5

By implementing this comprehensive approach to cardiovascular risk management in patients with hypertension, prediabetes, and CKD, you can significantly reduce morbidity and mortality while preserving kidney function.