What are the key considerations for managing risk factors in patients with conditions like hypertension and diabetes?

Key Considerations for Managing Risk Factors in Hypertension and Diabetes

For effective management of risk factors in patients with hypertension and diabetes, a comprehensive cardiovascular risk assessment should be performed at least annually, with systematic treatment of modifiable risk factors including obesity/overweight, hypertension, dyslipidemia, smoking, and albuminuria to reduce morbidity and mortality. 1

Cardiovascular Risk Assessment

• Systematically assess cardiovascular risk factors at least annually in all patients with diabetes and hypertension 1
• Key risk factors to evaluate include:
  • Duration of diabetes 1
  • Obesity/overweight 1
  • Hypertension 1
  • Dyslipidemia 1
  • Smoking status 1
  • Family history of premature coronary disease 1
  • Chronic kidney disease 1
  • Presence of albuminuria 1
• Consider using risk calculators (e.g., ACC/AHA ASCVD Risk Estimator Plus) to estimate 10-year ASCVD risk and guide therapy intensity 1

Blood Pressure Management

Screening and Diagnosis

• Measure blood pressure at every routine clinical visit 1
• Diagnose hypertension when blood pressure is ≥130/80 mmHg based on an average of two or more measurements on separate occasions 1
• For patients with elevated blood pressure (120-129 mmHg systolic and <80 mmHg diastolic), confirm using multiple readings 1
• Encourage home blood pressure monitoring for all hypertensive patients with diabetes 1

Treatment Targets

• For patients with diabetes and hypertension at higher cardiovascular risk (existing ASCVD or 10-year ASCVD risk ≥15%), target blood pressure <130/80 mmHg 1
• For lower-risk patients (10-year ASCVD risk <15%), target blood pressure <140/90 mmHg 1

Pharmacological Approach

• First-line therapy should include ACE inhibitors or angiotensin receptor blockers (ARBs), especially in patients with albuminuria 1
• Most patients will require multiple medications to achieve target blood pressure 1
• Consider SGLT2 inhibitors for patients with type 2 diabetes, as they reduce risk of heart failure hospitalization, cardiovascular mortality, and all-cause mortality 1
• Avoid combining ACE inhibitors with ARBs 1
• Medication selection should consider comorbidities:
  • For patients with heart failure: diuretics, beta-blockers, ACE inhibitors, ARBs, or aldosterone antagonists 1
  • For patients with previous myocardial infarction: beta-blockers, ACE inhibitors, ARBs 1
  • For patients with chronic kidney disease: ACE inhibitors or ARBs 1

Diabetes Management

• Incorporate therapies with proven cardiovascular and kidney outcomes benefit 1
• For patients with type 2 diabetes and increased cardiovascular risk, consider SGLT2 inhibitors which have shown significant reduction in heart failure hospitalization 1
• GLP-1 receptor agonists (liraglutide, semaglutide, dulaglutide) have demonstrated reduction in atherosclerotic major adverse cardiovascular events 1
• Monitor for potential drug interactions, particularly with metformin:
  • Assess renal function before initiating metformin and at least annually thereafter 2
  • Temporarily discontinue metformin during procedures with restricted food and fluid intake 2
  • Avoid excessive alcohol intake with metformin due to increased risk of lactic acidosis 2

Lifestyle Modifications

• Counsel patients with blood pressure >120/80 mmHg on lifestyle changes 1
• Recommend weight control for overweight or obese patients 1, 3
• Encourage regular physical activity 1, 3
• Advise dietary modifications, including DASH-style diet with reduced sodium and increased potassium intake 1
• Recommend moderation of alcohol intake 1

Special Considerations

• In Asian populations, hypertension control is particularly important as a 10 mmHg increase in systolic blood pressure increases risk of hemorrhagic stroke by 72% 1
• For elderly patients (≥65 years), assess renal function more frequently due to increased risk of metformin-associated lactic acidosis 2
• In patients with diabetes and established ASCVD, multiple ASCVD risk factors, or diabetic kidney disease, an SGLT2 inhibitor with demonstrated cardiovascular benefit is recommended 1

Common Pitfalls to Avoid

• Failing to recognize the clustering of risk factors, which complicates management 4
• Overlooking home blood pressure monitoring, which may better correlate with ASCVD risk than office measurements 1
• Not adjusting therapy when target blood pressure is not achieved 1
• Combining ACE inhibitors with ARBs, which should be avoided 1
• Neglecting to assess for orthostatic blood pressure changes, which may indicate autonomic neuropathy and require adjustment of blood pressure targets 1
• Continuing metformin during radiologic studies with contrast without appropriate precautions 2

By addressing these key considerations systematically, clinicians can effectively manage risk factors in patients with hypertension and diabetes, significantly reducing the risk of both microvascular and macrovascular complications.