Léčba hypertenze u pacientů s diabetem v roce 2010

Číslo: 4 / 2010 (Obsah)
Rubrika: Farmakoterapeutické postupy
Obor: Diabetologie
Autoři: Prof. MUDr. Hana Rosolová, DrSc.
Autoři - působiště: Centrum preventivní kardiologie, 2. interní klinika LF UK a FN, Plzeň
Klíčová slova: arteriální hypertenze, diabetes mellitus, kardiovaskulární riziko, diabetická nefropatie
Citace: 1 Osler JR, Materson BJ, Epstein M. Diabetes mellitus and hypertension. Cardiovasc Risk Factors 1990;1:25–46. 2 Morrish NJ, Stevens LK, Head J, et al. A prospective study on mortality among middle-aged diabetic patients (WHO Multinational Study of Vascular Disease in Diabetics) II: Associated risk factors. Diabetologia 1990;33:542–8. 3 Cífková R. Hypertenze a diabetes mellitus. In: Widimský J a kolektiv. Hypertenze. Triton: Praha, 2002:291–301. 4 Reaven GM, Lithell L, Landsberg L. Hypertension and associated metabolic abnormalities – the role of insulin resistance and the sympathoadrenal system. N Engl J Med 1996;334:374–81. 5 UK Prospective Diabetes Study Group: Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. Br Med J 1998; 317:703–13. 6 Weber MA, Bakfiš GL, Jamerson K, et al. Cardiovascular events during differing hypertension therapies in patients with diabetes. J Am Coll Cardiol 2010;56:77–85. 7 Bakris G, Molitch M, Hewkin A, et al. Differences in glucose tolerance between fixed-dose antihypertensive drug combinations in people with metabolic syndrome. Diabetes Care 2006;29:2592–7. 8 ADVANCE Collaborative Group. Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial. Lancet 2007;370:829–40. 9 Chobanian AV, Bakris GI, Black HI, et al. The Seventh Report of the Point National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC VII Report. JAMA 2003;289:2560–72. 10 Guidelines Committee: 2003 European Society of Hypertension – European Society of Cardiology guidelines for the management of arterial hypertension. J Hypertens 2003;21:1011–53. 11 PROGRESS Collaborative Study Group: Randomised trial of perindopril based blood pressure-lowering regimen among 6108 individuals with previous stroke or transient ischaemic attack. Lancet 2001;358:1033–41. 12 The Heart Outcomes Prevention Evaluation Study Investigators. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med 2000;342:145–53. 13 Schrier RW, Estacio RO, Esler A, et al. Effects of agressive blood pressure control in normotensive type 2 diabetic patients on albuminuria, retinopathy and stroke. Kidney Intern 2002;61:1086–97. 14 Hansson L, Zanchetti S, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet 1998;351: 1755–62. 15 Mancia G, DeBacker G, Dominiczak A, et al. 2007 Guidelines for the Management of Arterail Hypertension: The Task Force for the Management of Arterial Hypertension of the ESH and ESC. J Hypertens 2007;25:1106–87. 16 Mancia G, Laurent S, Agabiti-Rosei E, et al. Reappraisal of European guidelines on hypertension management: a European Society of Hypertension Task Force document. J Hypertens 2009;27:2121–58. 17 Holman RR, Paul SK, Bethel MA, et al. Long-term follow-up after tight control of blood pressure in type 2 diabetes. N Engl J Med 2008;359:1565–76. 18 Holman RR, Paul SJ, Bethel MA, et al. Ten-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008;359:1577–89. 19 The ADVANCE collaborative group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008;358:2560–72. 20 The ACCORD Study Group. Effects of intensive blood pressure control in type 2 diabetes mellitus. N Engl J Med 2010;362: 1575–85. 21 The ACCORD Study Group. Effects of combination lipid therapy in type 2 diabetes mellitus. N Engl J Med 2010; 362:1563–74. 22 The ACCORD Study Group and ACCORD Eye Study Group. Effects of medical therapies on retinopathy progression in type 2 diabetes. N Engl J Med 2010;363:233–44. 23 Cooper-DeHoff RM, Gong Y, Handberg EM, et al. Tight blood pressure control and cardiovascular outcomes among hypertensive patients with diabetes and coronary artery disease. JAMA 2010;304:61–8. 24 Rosolová H, Petrlová B, Šimon J, et al. Makrovaskulární a mikrovaskulární komplikace u diabetiků 2. typu. Vnitř Lék 2008;54:229–37. 25 The Heart Outcomes Prevention Evaluation Study Investigators. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: resultas of the HOPE study and MICRO-HOPE substudy. Lancet 2005;355:253–9. 26 Ruggenenti P, Perna A, Ganeva M, et al. BENEDICT Study Group: Impact of blood pressure control and ACE inhibitor therapy on new-onset microalbuminuria in type 2 diabetes: a post hoc analysis of the BENEDICT trial. J Am Soc Nephrol 2006;17:3472–81. 26 Mann JE, Schmieder RE, McQueen M, et al. Renal outcomes with telmisartan, ramipril, or both, in people at high vascular risk (the ONTARGET study): a multicentre, randomised, double-blind, controlled trial. Lancet 2008;372:547–53. 28 Golubnitschaja O. Time for new guidelines in advanced diabetes care: Paradigma change from delayed interventional approach to predictive, preventive & personalized medicine. EPMA Journal 2010;1:3–12. 29 Sleight P, Redon J, Verdechia P, et al. Prognostic value of blood pressure in patients with high vascular risk in the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial (ONTARGET) Study. J Hypertens 2009;27:1360–9.

Souhrn

Nemocných s diabetes mellitus (DM) přibývá téměř na celém světě. Současný výskyt hypertenze a DM mnohonásobně zvyšuje riziko makro- i mikrovaskulárních komplikací v závislosti na přítomnosti dalších rizikových faktorů. Souhrnný článek uvádí řešení dvou hlavních otázek v léčbě hypertenze u diabetiků: zaprvé, jakými antihypertenzivy léčit nemocného s hypertenzí a DM, a zadruhé, jakých cílových hodnot krevního tlaku je třeba dosáhnout v léčbě hypertenze u diabetiků. Jsou uvedeny výsledky studií léčby hypertenze u nemocných s DM, např. studie UKPDS po 10 letech, studie ADVANCE, ACCORD, podskupina diabetiků s hypertenzí ve studii ACCOMPLISH a INVEST aj. Ze studií vyplývá, že z hlediska prevence cévních komplikací je vhodné snižovat krevní tlak u diabetiků na hodnoty pod 140/90, ale ne níže než 130/80 mm Hg. V blízké budoucnosti nebude zřejmě cílová hodnota krevního tlaku pro všechny diabetiky stejná. V léčbě hypertenze u diabetiků upřednostňujeme novější antihypertenziva, především inhibitory renin-angiotenzinového systému, který hraje hlavní roli v kardio-renálním kontinuu (tj. ve vývoji rizika kardiovaskulárních a renálních komplikací u pacientů s hypertenzí a DM). Zvláštní pozornost je věnována léčbě a prevenci diabetické nefropatie; jsou uvedeny studie MICRO-HOPE, ADVANCE a BENEDICT, které prokazují, že inhibitory ACE významně snižují rozvoj albuminurie nebo již přítomnou albuminurii, která je důležitým markerem diabetické nefropatie i kardiovaskulárního rizika a celkové úmrtnosti. Studie ONTARGET vyřešila otázku kombinace inhibitorů ACE a sartanů. I když tato kombinace redukuje proteinurii více než monoterapie, není lepší pro rozvoj chronické nefropatie. V současné době se upřednostňuje personalizovaný přístup v prevenci a léčbě chorob.

Literatura

1 Osler JR, Materson BJ, Epstein M. Diabetes mellitus and hypertension. Cardiovasc Risk Factors 1990;1:25–46. 2 Morrish NJ, Stevens LK, Head J, et al. A prospective study on mortality among middle-aged diabetic patients (WHO Multinational Study of Vascular Disease in Diabetics) II: Associated risk factors. Diabetologia 1990;33:542–8. 3 Cífková R. Hypertenze a diabetes mellitus. In: Widimský J a kolektiv. Hypertenze. Triton: Praha, 2002:291–301. 4 Reaven GM, Lithell L, Landsberg L. Hypertension and associated metabolic abnormalities – the role of insulin resistance and the sympathoadrenal system. N Engl J Med 1996;334:374–81. 5 UK Prospective Diabetes Study Group: Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. Br Med J 1998; 317:703–13. 6 Weber MA, Bakfiš GL, Jamerson K, et al. Cardiovascular events during differing hypertension therapies in patients with diabetes. J Am Coll Cardiol 2010;56:77–85. 7 Bakris G, Molitch M, Hewkin A, et al. Differences in glucose tolerance between fixed-dose antihypertensive drug combinations in people with metabolic syndrome. Diabetes Care 2006;29:2592–7. 8 ADVANCE Collaborative Group. Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial. Lancet 2007;370:829–40. 9 Chobanian AV, Bakris GI, Black HI, et al. The Seventh Report of the Point National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC VII Report. JAMA 2003;289:2560–72. 10 Guidelines Committee: 2003 European Society of Hypertension – European Society of Cardiology guidelines for the management of arterial hypertension. J Hypertens 2003;21:1011–53. 11 PROGRESS Collaborative Study Group: Randomised trial of perindopril based blood pressure-lowering regimen among 6108 individuals with previous stroke or transient ischaemic attack. Lancet 2001;358:1033–41. 12 The Heart Outcomes Prevention Evaluation Study Investigators. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med 2000;342:145–53. 13 Schrier RW, Estacio RO, Esler A, et al. Effects of agressive blood pressure control in normotensive type 2 diabetic patients on albuminuria, retinopathy and stroke. Kidney Intern 2002;61:1086–97. 14 Hansson L, Zanchetti S, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet 1998;351: 1755–62. 15 Mancia G, DeBacker G, Dominiczak A, et al. 2007 Guidelines for the Management of Arterail Hypertension: The Task Force for the Management of Arterial Hypertension of the ESH and ESC. J Hypertens 2007;25:1106–87. 16 Mancia G, Laurent S, Agabiti-Rosei E, et al. Reappraisal of European guidelines on hypertension management: a European Society of Hypertension Task Force document. J Hypertens 2009;27:2121–58. 17 Holman RR, Paul SK, Bethel MA, et al. Long-term follow-up after tight control of blood pressure in type 2 diabetes. N Engl J Med 2008;359:1565–76. 18 Holman RR, Paul SJ, Bethel MA, et al. Ten-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008;359:1577–89. 19 The ADVANCE collaborative group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008;358:2560–72. 20 The ACCORD Study Group. Effects of intensive blood pressure control in type 2 diabetes mellitus. N Engl J Med 2010;362: 1575–85. 21 The ACCORD Study Group. Effects of combination lipid therapy in type 2 diabetes mellitus. N Engl J Med 2010; 362:1563–74. 22 The ACCORD Study Group and ACCORD Eye Study Group. Effects of medical therapies on retinopathy progression in type 2 diabetes. N Engl J Med 2010;363:233–44. 23 Cooper-DeHoff RM, Gong Y, Handberg EM, et al. Tight blood pressure control and cardiovascular outcomes among hypertensive patients with diabetes and coronary artery disease. JAMA 2010;304:61–8. 24 Rosolová H, Petrlová B, Šimon J, et al. Makrovaskulární a mikrovaskulární komplikace u diabetiků 2. typu. Vnitř Lék 2008;54:229–37. 25 The Heart Outcomes Prevention Evaluation Study Investigators. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: resultas of the HOPE study and MICRO-HOPE substudy. Lancet 2005;355:253–9. 26 Ruggenenti P, Perna A, Ganeva M, et al. BENEDICT Study Group: Impact of blood pressure control and ACE inhibitor therapy on new-onset microalbuminuria in type 2 diabetes: a post hoc analysis of the BENEDICT trial. J Am Soc Nephrol 2006;17:3472–81. 26 Mann JE, Schmieder RE, McQueen M, et al. Renal outcomes with telmisartan, ramipril, or both, in people at high vascular risk (the ONTARGET study): a multicentre, randomised, double-blind, controlled trial. Lancet 2008;372:547–53. 28 Golubnitschaja O. Time for new guidelines in advanced diabetes care: Paradigma change from delayed interventional approach to predictive, preventive & personalized medicine. EPMA Journal 2010;1:3–12. 29 Sleight P, Redon J, Verdechia P, et al. Prognostic value of blood pressure in patients with high vascular risk in the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial (ONTARGET) Study. J Hypertens 2009;27:1360–9.

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