Diabetes and cardiovascular outcomes in elderly subjects treated with ace-inhibitors or diuretics: findings from the 2ND Australian national blood pressure study

Elderly hypertensives treated with ACE-inhibitors have reduced cardiovascular outcomes in comparison to those treated with diuretics. The aim of the present study was to determine whether there was a difference in a) cardiovascular outcomes for elderly diabetic subjects and b) the onset of new diabetes in subjects treated with ACE or diuretic based therapy. 6083 subjects with hypertension aged 65–84 years were randomised to antihypertensive therapy based on ACE-inhibitor (3044) or diuretic (3039) and monitored for a median period of 4.1 years by their family practitioner. At study entry, 7% were diabetic and average blood pressure was 167/91 mmHg. Diabetes at study entry was associated with a 43% increase in risk of any cardiovascular event or death (P<0.001). ACE inhibitor treatment in diabetic subjects in comparison to diuretic treatment was associated with a 26% reduction in all cardiovascular events or death (P=0.13).The hazard ratio for ACE versus diuretic groups for first cardiovascular events was 0.66 (p=0.05), for first non-fatal cardiovascular events was 0.59 (p=0.02), and for first heart failure was 0.40 (p=0.04). 338 subjects were diagnosed with new onset-diabetes by their family practitioner (138 in the ACE group and 200 in the diuretic group (P<0.001) - a 31% reduction in the risk of new onset diabetes in ACE inhibitor treated subjects. In addition, there was a 15% reduction in the risk of any cardiovascular event or death in new onset diabetes subjects treated with ACE inhibitor in comparison to diuretic based therapy. These findings suggest that ACE-inhibitor based therapy for the management of hypertension in elderly subjects is particularly beneficial for patients with diabetes and is likely to reduce the burden of future diabetes in this population.