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Complex management of comorbid hypertension, diabetes and thyroid disorders

Complex management of comorbid hypertension, diabetes and thyroid disorders
  • Cardiometabolic
    Endocrinology and metabolism
  • Diabetes
    Hypertension
    Thyroid disorder

Resource type

Publication

Tags

Diabetes
Thyroid
Hypertension
management

The conference on cardiometabolic diseases management was held in Mumbai, India, on 4–5 July. It was organised by Stefano Taddei (Italy) and addressed the increasing problem of the complex management of the comorbid diseases, hypertension, diabetes and thyroid disorders.

Advances in research and the best approaches for clinical management in daily practice in these areas of cardiometabolic medicine were discussed in presentations, interactive workshops and debates.

 

Treat prehypertension in patients at high cardiovascular risk

  • Prehypertension should be treated in patients who have blood pressure (BP) in the prehypertensive range and pre-existing CV disease, to help prevent stroke and major CV events

  • Renin–angiotensin–aldosterone system (RAAS) blockers may reduce the development of hypertension

  • RAAS blockers may also benefit normotensive patients with diabetes, by reducing the progression of microalbuminuria

Claudio Borghi (Italy) made these comments in his presentation examining the risks of prehypertension or ‘high-normal’ BP, which affect ~25% of the population.

He explained that most people with prehypertension or high normal BP will develop hypertension and are at increased risk of cardiovascular (CV) morbidity. In addition, patients with additional risk factors (e.g. diabetes) are likely to experience higher rates of CV mortality compared with those who are only hypertensive.

Obstructive sleep apnoea, arterial stiffness, hypercholesterolaemia and hyperuricaemia are associated with progression to overt hypertension; therefore, these metabolic factors should be monitored in patients with prehypertension.

Most guidelines recommend just lifestyle changes, whereas Professor Borghi concluded that, ‘prehypertension should be treated in those patients who have BP in the prehypertensive range and associated with pre-existing CV disease to improve clinical outcome in terms of prevention of stroke and major CV events’.

 

Heart rate – key predictor of CV risk and hypertension that affects treatment choice

  • BP measurements should always be associated with HR measurements – resting HR values independently predict CV morbid or fatal events in several conditions, including hypertension

  • First-line treatment with beta blockers is recommended for increased HR, and can be particularly beneficial in patients with hypertension, angina, atrial fibrillation (AF) or heart failure (HF)

  • Beta-1 selectivity is important when selecting treatment for patients with chronic obstructive pulmonary disease (COPD) or asthma, peripheral artery disease, diabetes, dyslipidaemia or erectile dysfunction; bisoprolol is likely the most beta-1 selective beta blocker and most effective in reducing HR in these patients

  • If beta blocker treatment has a suboptimal effect, ivabradine (an If inhibitor) may be considered – ivabradine reduces HR and CV mortality and is associated with reductions in left ventricular (LV) volumes and improvement of LV ejection fraction

‘BP measurements should always be associated with measurement of heart rate (HR), because resting HR values independently predict CV morbid or fatal events in several conditions, including hypertension’, Paolo Palatini (Italy) quoted from the ESH/ESC guidelines in this presentation. Ambulatory HR monitoring may be useful, as night-time increase in HR is a strong predictor of CV events.

Professor Palatini considered that elevated HR is a cause of CV events, rather than an outcome, noting that high HR predates hypertension, obesity, metabolic syndrome and diabetes.

The mechanisms involved are complex; HR increases CV risk by being associated with sympathetic overactivity, and also causing mechanical vascular and cardiac damage.

First-line treatment with beta-blockers is recommended for increased HR, and can be particularly beneficial in patients with other CV conditions such as hypertension, angina, atrial fibrillation and HF.

Professor Palatini stressed that beta-1 selectivity of the drug is important for patients with COPD or asthma, peripheral artery disease, diabetes, dyslipidaemia or erectile dysfunction, with bisoprolol being the most beta-1 selective beta blocker and most effective in reducing HR.

The workshop on the management of HR by Jamshed Dalal (India) echoed Professor Palatini’s belief, namely that HR control is important in the management of angina and HF to reduce mortality.

Professor Dalal added that in cases where beta-blockers do not work optimally, ivabradine (an If inhibitor) may be considered.

Ivabradine has been shown to reduce HR and CV mortality; reductions in left ventricular (LV) volumes and improvement of LV ejection fraction have also been seen with such treatment.

Overall, Dr Dalal recommended that HR should not be reduced too far (i.e., not <50 beats per minute).

 

BP control – key to effective management of CAD

  • A BP reduction of 10 mmHg systolic blood pressure (SBP) or 5 mmHg diastolic blood pressure (DBP) reduces the rate of CAD and stroke by up to 24% and 46%, respectively

  • Evidence-based guidelines recommend BP be reduced to <140/90 mmHg, with slightly higher SBP targets in the elderly

  • As well as lifestyle changes, beta-blockers may offer great benefit for patients with hypertension and CAD

There are several risk factors for coronary artery disease (CAD), hypertension being the most important, said Professor Borghi, though dyslipidaemia, diabetes and obesity are also significant.

Most patients are asymptomatic until they experience a major CV event; therefore, all patients at high CV risk should be examined for CAD. BP control of BP is key to the management of CAD, with a BP reduction of 10 mmHg SBP or 5 mmHg DBP reducing the rate of CAD and stroke by up to 24% and 46%, respectively.

However, Professor Borghi pointed out that the target BP needs to be carefully considered, as there is a trend for J-shaped response for CV events, and the effect is different in the elderly.

Overall, the evidence has led to guidelines recommending BP be reduced to <140/90 mmHg, with slightly higher SBP targets in the elderly.

As well as lifestyle changes, beta-blockers may offer the greatest benefit for patients with hypertension and CAD, in particular after myocardial infarction (MI) and in those with angina, in which RAAS blockade (with angiotensin-converting enzyme inhibitors [ACEIs] or angiotensin II receptor blockers [ARBs]) or calcium-channel blockers, respectively, are also indicated.

Diagnosing CAD

  • Computed tomography angiogram is has high sensitivity and specificity for CAD but does not improve clinical outcomes, compared with functional testing

  • Evidence has not clarified whether a medical or an invasive approach is the best option for moderate ischaemia; percutaneous coronary intervention or coronary artery bypass grafting is indicated for severe disease

  • Moderate- to high-intensity statin treatment is mandatory, along with cardioselective beta-blockade

The workshop by Piyamitr Sritara (Thailand) emphasised that the choice of diagnostic methods is important in CAD.

However, whereas coronary computed tomography angiogram is highly sensitive and specific for CAD, it does not improve clinical outcomes, compared with functional testing.

As for treatment, taking a medical rather than an invasive approach in moderate ischaemia remains controversial, although percutaneous coronary intervention or coronary artery bypass grafting is indicated in more severe disease.

Moderate to high intensity statin treatment is mandatory, along with a cardioselective beta-blocker.

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International conference
Mumbai, India
Jul 4 - 5, 2015
Target audience
General practitioners, junior cardiologists, internists, Healthcare professionals
EACCME®
by Excemed
Cardiometabolic, Endocrinology and metabolism