Workshop on – ABPM- Its value in the Diagnosis and Management of Hypertension in Diabetes  Dr John Cox Diabetes in Primary Care Conference Cork Wednesday 21st Sept 2016

Case study Ms Patricia G. is a 69 year old retired teacher who was diagnosed with type 2 diabetes a year ago. She is a non-smoker and drinks alcohol socially. Her diabetes control is adequate on a combination of lifestyle interventions & metformin 850 mg twice a day; fasting LDLc is 1.6 mmol/l on a statin. Her blood pressure is 148/86 mmHg in the clinic.

Clinic blood pressure What should clinic BP be in a diabetic patient?

Clinic blood pressure Systolic ≤ 140 mm/Hg Diastolic < 80 mm/Hg (below 130/80 mmHg if there is kidney, eye or cerebrovascular damage)

Accord study The Action to Control Cardiovascular Risk in Diabetes (ACCORD) blood pressure trial  investigated whether therapy targeting normal systolic pressure (i.e., <120 mm Hg) reduced major cardiovascular events in participants with type 2 diabetes at high risk for cardiovascular events.

What about the sprint study? The Systolic Blood Pressure Intervention Trial (SPRINT), compared the benefit of treatment of systolic BP to a target of <120 mmHg with treatment to a target of <140 mmHg. Average values were121 mmHg and 136 mmHg, respectively, in the first year.

Copyright © 2016 American Medical Association. All rights reserved. From: Blood Pressure Lowering in Type 2 Diabetes:  A Systematic Review and Meta-analysis JAMA. 2015;313(6):603-615. doi:10.1001/jama.2014.18574 Figure Legend: Standardized Associations Between 10–mm Hg Lower Systolic BP and All-Cause Mortality, Macrovascular Outcomes, and Microvascular Outcomes Stratified by Mean Systolic BP of Trial Participants at EntryMacrovascular outcomes include cardiovascular events, coronary heart disease, stroke, and heart failure; and microvascular outcomes include renal failure, retinopathy, and albuminuria. Mean baseline blood pressure (BP) is weighted by number of participants. The area of each square is proportional to the inverse variance of the estimate. Horizontal lines indicate 95% CIs of the estimate. SBP indicates systolic blood pressure. Date of download: 9/15/2016 Copyright © 2016 American Medical Association. All rights reserved.

Ambulatory blood pressure measurement What advantage is it?

Figure 1. Percentage incidence of CV (▪) and all-cause death (□) over an average follow-up of 148 months in subjects with various combinations of normality or elevation in office, home, and 24-hour BP. Data are adjusted for age and gender. Figure 1. Percentage incidence of CV (▪) and all-cause death (□) over an average follow-up of 148 months in subjects with various combinations of normality or elevation in office, home, and 24-hour BP. Data are adjusted for age and gender. Numbers refer to χ2 trends and related P values. Giuseppe Mancia et al. Hypertension. 2006;47:846-853 Copyright © American Heart Association, Inc. All rights reserved.

Clinical question from my inbox “I am left scratching my head sometimes as 36 readings will be perfect with 4 readings of 180/90. I just wondered was there a simple guideline- resource for interpretation. Do you go by the day time averages and ignore the spikes no matter how high?  Just wondered. Thanks.”

Thank you