On the need of the simultaneous control of arterial hypertension and diabetes mellitus

Arterial hypertension and diabetes mellitus are two processes that are very frequently found together in the same patient. It is well established that an adequate control of blood pressure (BP) and glycemia is required in order to avoid the renal and cardiovascular damage commonly seen in hypertensive and diabetic patients. The article published by Zhang et al1 in this issue of The Journal of Clinical Hypertension refers to the importance of the simultaneous control of BP and glucose and how it relates to the prevalence of albuminuria and left ventricular hypertrophy (LVH). Increasing urine albumin or LV mass constitute two of the most relevant forms of hypertension-mediated organ damage (HMOD).2, 3 In synthesis, the article shows that the simultaneous control of BP and glucose contributes to clearly and significantly diminishing the prevalence of albuminuria, while LVH does not attain statistical significance despite showing a similar tendency. The analysis of the prevalence of albuminuria and LVH was performed by comparing uncontrolled patients (BP ≥140/90 mm Hg) with those attaining high normal BP (130-139/80-89 mm Hg) and those attaining intensive BP control (BP <130/80 mm Hg). The lowest prevalence of albuminuria was found in patients under intensive BP control and glycated hemoglobin (HbA1c) <7%. The trend of fold in LVH was similar although not significant. When HbA1c was lower than 6.5%, the strict BP control did not turn into a lower prevalence of either albuminuria or LVH. The lack of statistical significance in the decrease of LV mass in patients under intensive BP control and HbA1c <7% does not necessarily imply that the effect of the simultaneous control of BP and glycemia is not adequate to attenuate LVH. First, the sample size of patients exhibiting this alteration in the present article is very low, and second, the method to diagnose LVH is not the most sensitive. Although electrocardiography is recommended as a first step to diagnose LVH, it lacks sensitivity compared with echocardiography.2, 4 Consequently, adequate echocardiography in the present patients following consensus criteria to assess LVH and diastolic dysfunction4 would reduce the number of false negatives and add patients to the group of LVH. The thresholds used in the present article agree with the adequate goals of BP and HbA1c according to the most recent European and American Guidelines,2, 3, 5 which establish a BP goal lower than 130/80 mm Hg for hypertension in diabetes and a HbA1c goal lower than 7.0%. However, European Guidelines vary this threshold to 130-139/80-89 mm Hg in adults older than 65 years old. The fact that albuminuria is prevented and LVH might be attenuated by establishing the 130/80 mm Hg threshold indicates that the European Guidelines might underestimate the risk of HMOD in people older than 65 years old. With respect to HbA1c, data of this article indicate that lowering this parameter below 6.5% as no further effect in the prevention of renal and cardiac damage. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial showed that although intensive glycemic treatment (HbA1c <6%) reduces the incidence of albuminuria,6 the drop in HbA1c promote an increase in mortality.7 In fact, a recent publication of the ACCORD trial showed that the advantages of intensive BP control were only observed in those patients without intensive glycemic control.8 The results of the present article support that intensive glycemic control does not impede progression of renal and cardiac damage in well-controlled hypertensive diabetics. Adequate management of albuminuria is imperative in hypertensive patients as we recently showed that, both in diabetic and non-diabetic patients, the presence of albuminuria is associated with a significant increase in night-time BP.9 Increases in night-time BP are associated with high cardiovascular risk and require to be controlled. Therefore, drugs with an adequate capacity to lower night-time BP have to be considered in diabetics when albuminuria is present. As an example, a substudy of ambulatory blood pressure measurement in the Mineralocorticoid Receptor Antagonist Tolerability Study–Diabetic Nephropathy (ARTS-DN) study10 showed that, while the mineralocorticoid receptor antagonist finerenone reduces office BP by 3-6 mm Hg in patients with diabetic nephropathy, it reduces night-time BP by 12 mm Hg in the same patients.11 On the other hand, the new oral antidiabetic drugs sodium-glucose transport protein 2 (SGLT-2) inhibitors and glucagon-like peptide-1 receptor (GLP-1) agonists should be considered in the clinical application of the conclusion in this article, as they have exhibited significant protecting effects on renal and cardiovascular diseases in diabetic patients. In fact, data from the CANagliflozin cardioVascular Assessment Study (CANVAS) Program have recently shown that the SGLT2 canagliflozin ameliorates renal and cardiovascular outcomes independently of the levels of albuminuria, although patients with the highest levels of albuminuria have the greatest benefit.12 In summary, the article by Zhang et al updates the relevance of the simultaneous control of diabetes mellitus and arterial hypertension in early stages of HMOD. The data validate the application of new drugs in the management of arterial hypertension and diabetes mellitus. None.