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Searching for optimal blood pressure targets in type 2 diabetic patients with coronary artery disease

Cardiovascular Diabetology Nov 23, 2019

Shen Y, Dai Y, Wang XQ, et al. - Given the controversies concerning the optimal blood pressure (BP) level that is safe and affords cardiovascular protection in patients with type 2 diabetes mellitus (T2DM) and coexistent coronary artery disease, researchers sought to describe the possible mechanisms of heightened risk of hypertension in T2DM and assess the possible optimal BP levels based upon recommendations on the management of hypertension by the current guidelines for type 2 diabetic patients with coronary artery disease. Multiple processes are involved in the development of hypertension in T2DM, including heightened sympathetic output, inappropriate activation of renin-angiotensin- aldosterone system, endothelial dysfunction provoked through insulin resistance, and abnormal sodium handling by the kidney. Activativation of intracellular signaling pathways, an increase in oxidative stress, and aggravation in vascular inflammation were observed in correlation to both advanced glycation end-products (AGE)-receptor for AGE (RAGE) axis and adipokine dysregulation. They identified implication of pancreatic β-cell specific microRNAs in gene expression and diabetic complications. BP control improves with non-pharmacological intervention with lifestyle changes. Achievement of a decrease in mortality and prevention of major adverse cardiovascular events was observed in correlation to using anti-hypertensive medications with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, calcium antagonists, β-blockers, diuretics and new hypoglycemic agent SGLT2 inhibitors. They suggest controlling BP < 130/80 mmHg but not < 120/70 mmHg as reasonable for hypertensive patients with T2DM and stable coronary artery disease. However, for those with chronic total occlusion or acute coronary syndromes, an ideal BP target seemed to be slightly higher (< 140/90 mmHg). They recommend practicing caution with the aggressive lowering of diastolic BP to a critical threshold (< 60 mmHg).
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