Current Hypertension Reports

, Volume 5, Issue 3, pp 192–198 | Cite as

Optimizing target-organ protection in patients with diabetes mellitus: Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers?

  • Wei X. Lu
  • Jay Lakkis
  • Matthew R. Weir
Article

Abstract

High blood pressure in the setting of type 1 and type 2 diabetes is commonly associated with the earlier development of target-organ damage, including cardiovascular and cerebrovascular disease and progressive renal insufficiency. The major goal of treating high blood pressure in this population is to prevent or reduce the likelihood of targetorgan damage. The treatment goal for high blood pressure, therefore, has to be defined based on optimal means of preventing cardiovascular and renal events. The reduction of high blood pressure with pharmacologic therapy is associated with reduction of cardiovascular events, renal disease, and associated mortality. However, many questions remain. Some of the basic and important questions include the following: What should be the goal of treated blood pressure in the diabetic, and are there preferred agents that should be used in the hypertensive diabetic population? How do angiotensin-converting enzyme inhibitors and angiotensin receptor blockers fit in? Are there advantages of one class over the other? The goal of this review is to summarize the recent clinical trial findings and try to provide recommendations based on the evidence of these trials to help the clinician better choose blood pressure goals and treatment strategies in the diabetic population.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    Geiss L, Rolka D, Engelgau M: Elevated blood pressure among U.S. adults with diabetes 1988–1994. Am J Prev Med 2002, 22:42–48.PubMedCrossRefGoogle Scholar
  2. 2.
    Harris M: Health care and health status and outcomes for patients wtih type 2 diabetes. Diabetes Care 2000, 23:754–758.PubMedCrossRefGoogle Scholar
  3. 3.
    Franklin S, Gustin W, Wong N, et al.: Hemodynamic patterns of age-related changes in blood pressure: the Framingham Heart Study. Circulation 1997, 96:308–315.PubMedGoogle Scholar
  4. 4.
    Franklin S, Shehzad A, Khan B, et al.: Is pulse pressure useful in predicting risk for coronary heart disease ? The Framingham Heart Study. Circulation 1999, 100:354–360.PubMedGoogle Scholar
  5. 5.
    National high blood pressure education program working group: National high blood pressure education program working group report on hypertension in the elderly. Hypertension 1994, 23:275–285.Google Scholar
  6. 6.
    UKPDS Study Group: United Kingdom Prospective Diabetes Study: a multicenter study III. Prevalence of hypertension and hypotension therapy in patients with newly diagnosed diabetes. Hypertension 1985, 7(Suppl II):II8-II13.Google Scholar
  7. 7.
    Mogensen C, Keane W, Bennett P, et al.: Prevention of diabetic renal disease with special reference to microalbuminuria. Lancet 1995, 346:1080–1084.PubMedCrossRefGoogle Scholar
  8. 8.
    Mogensen C: Diabetic nephropathy: natural history and management. In Mechanisms and Clinical Management of Chronic Renal Failure, edn 2. Edited by MeguidEl Nahas A, Harris KPG, Anderson S. New York: Oxford University Press; 2000:211–240.Google Scholar
  9. 9.
    Mogensen C: Microalbuminuria predicts clinical proteinuria and early mortality in maturity-onset diabetes. N Engl J Med 1984, 310:356–360.PubMedCrossRefGoogle Scholar
  10. 10.
    Ruggenenti P, Remuzzi G: Nephropathy of type 2 diabetes mellitus. J Am Soc Nephrol 1998, 9:2157–2169.PubMedGoogle Scholar
  11. 11.
    Agrawal B, Berger A, Wolf K, Luft F: Microalbuminuria screening by reagent predicts cardiovascular risk in hypertension. J Hypertens 1996, 14:223–228.PubMedCrossRefGoogle Scholar
  12. 12.
    Mann J, Gerstein H, Pogue J, et al.: Renal insufficiency as predictor of cardiovascular outcomes and impact of ramipril: The HOPE randomization trial. Ann Intern Med 2001, 134:629–636.PubMedGoogle Scholar
  13. 13.
    Schiffrin E: Beyond blood pressure: the endothelium and atherosclerosis progression. Am J Hypertens 2002, 15:S115.CrossRefGoogle Scholar
  14. 14.
    Deckert T: Nephropathy and coronary death: the fatal twins in diabetes mellitus. Nephrol Dial Transplant 1994, 19:1069–1071.Google Scholar
  15. 15.
    Parving H, Nielsen F, Bang L, et al.: Endothelial dysfunction in NIDDM patients with and without nephropathy (abst). J Am Soc Nephrol 1994, 5:380.Google Scholar
  16. 16.
    Ruilope L, Rodicio J: Microalbuminuria in clinical practice: a current survey of world literature. Kidney 1995, 4:211–216.Google Scholar
  17. 17.
    Connel S, Hollis S, Tieszen K, et al.: Gender and the clinical usefulness of the albumin creatinine ratio. Diabet Med 1994, 11:32–36.CrossRefGoogle Scholar
  18. 18.
    Houlihan C, Tsalamandris C, Akdeniz A, Jerums G: Albumin to creatinine ratio: a screening test with limitations. Am J Kidney Dis 2002, 39:1183–1189.PubMedCrossRefGoogle Scholar
  19. 19.
    Keane W, Eknoyan G: Proteinuria, albuminuria, risk, assessment, detection, elimination (PARADE): a position paper of the National Kidney Foundation. Am J Kidney Dis 1999, 33:1004–1010.PubMedGoogle Scholar
  20. 20.
    Niskanen L, Hedner T, Hansson L, et al.: Reduced cardiovascular morbidity and mortality in hypertensive diabetic patients on first-line therapy with an ACE inhibitor compared with a diuretic/beta-blocker-based treatment regimen: a subanalysis of the Captopril Prevention Project. Diabetes Care 2001, 24:2091–2096.PubMedCrossRefGoogle Scholar
  21. 21.
    Tatti P, Pahor M, Byington R, et al.: Outcome results of the Fosinopril versus Amlodipine cardiovascular events trial (FACET) in patients with hypertension and NIDDM. Diabetes Care 1998, 21:597–603.PubMedCrossRefGoogle Scholar
  22. 22.
    Heart Outcomes Prevention Evaluation (HOPE) Study Investigators: Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and micro-HOPE substudy. Lancet 2000, 355:253–259. The use of an ACE inhibitor (ramipril) in diabetic patients significantly lowered the risk of cardiovascular and overt nephropathy.CrossRefGoogle Scholar
  23. 23.
    Lurbe E, Redon J, Kesani A, et al.: Increase in nocturnal blood pressure and progression to microalbuminuria in type 1 diabetes. N Engl J Med 2002, 347:797–805.PubMedCrossRefGoogle Scholar
  24. 24.
    Ravid M, Savin H, Jutrin I, et al.: Long-term stabilizing effect of angiotensin-converting enzyme inhibition on plasma creatinine and on proteinuria in normotensive type II diabetic patients. Ann Intern Med 1993, 118:577–581.PubMedGoogle Scholar
  25. 25.
    Viberti G, Mogensen C, Groop L, Pauls J, European Microalbuminuria Captopril Study Group: Effect of captopril on progression to clinical proteinuria in patients wtih insulindependent diabetes mellitus and microalbuminuria. JAMA 1994, 271:275–279.PubMedCrossRefGoogle Scholar
  26. 26.
    Parving H, Lehnert H, Brochner-Mortensen J, et al.: The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes. N Engl J Med 2001, 345:870–878.PubMedCrossRefGoogle Scholar
  27. 27.
    Viberti G, Wheeldon N, Microalbuminuria Reduction with Valsartan (MARVAL) Study Investigators: Microalbuminuria reduction with valsartan in patients with type 2 diabetes mellitus; a blood pressure-independent effect. Circulation 2002, 106:672–678. Compared with amlodipine, valsartan is more effective in lowering proteinuria in patients with type 2 diabetes and microalbuminuria, including those with normal blood pressure.PubMedCrossRefGoogle Scholar
  28. 28.
    Vasan R, Larson M, Leip E, et al.: Impact of high-normal blood pressure on the risk fo cardiovascualr disease. N Engl J Med 2001, 345:1291–1297.PubMedCrossRefGoogle Scholar
  29. 29.
    Schrier R, Estacio R, Esler A, Mehler P: Effect of aggressive blood pressure control in normotensive type 2 diabetic patients on albuminuria, retinopathy and strokes. Kiney Int 2002, 61:1086–1097. Intensive blood pressure control (128/75 mm Hg) in normotensive type 2 diabetes slows progression to diabetic nephropathy and reduces incidence of stroke.CrossRefGoogle Scholar
  30. 30.
    O’Hare P, Bilbous R, Mitchell T, et al., The ACE-Inhibitor Trial to Lower Albuminuria in Normotensive Insulin-Dependent Subjects Study Group: Low-dose ramipril reduces microalbuminuria in type 1 diabetic patientswithout hypertension: results of a randomized controlled trial. Diabetes Care 2000, 23:1823–1829.PubMedCrossRefGoogle Scholar
  31. 31.
    Svensson P, de Faire U, Sleight P, et al.: Comparative effects of ramipril on ambulatory and office blood pressures: a HOPE substudy. Hypertension 2001, 38:E28-E32.PubMedGoogle Scholar
  32. 32.
    The LIFE Study Group: Cardiovascular morbidity and mortality in the losartan intervention for endoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet 2002, 359:995–1003. In patients with high blood pressure and left ventricular hypertrophy, an antihypertensive regimen containing losartan is more effective than atenolol in reducing the risk of primary outcomes including death, myocardial infarction, or stroke.CrossRefGoogle Scholar
  33. 33.
    The LIFE study group: Cardiovascular morbidity and mortality in patients with diabetes in the Losartan intervention for endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet 2002, 359:1004–1010. Compared with atenolol, losartan significantly reduces cardiovascular morbidity and mortality and all-cause mortality in patients with hypertension, diabetes, and left ventricular hypertrophy.CrossRefGoogle Scholar
  34. 34.
    Shahinfar S, Dickson T, Ahmed T, et al., RENAAL Investigators: Losartan in patients with type 2 diabetes and proteinuria: observations from the RENAAL study. Kidney Int 2002, 82(Suppl):64–67. Losartan significantly reduces the risk of cardiorenal outcomes in patients with proteinuric type 2 diabetes, including those with elevated creatinine over 2 mg/dL.CrossRefGoogle Scholar
  35. 35.
    Lewis E, Hunsicker L, Clarke W, et al., Collaborative Study Group: Reno-protective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med 2001, 345:851–860. Landmark clinical trial showing the advantage of ARB therapy (irbesartan) versus a calcium channel blocker or traditional regimen in patients with diabetic nephropathy.PubMedCrossRefGoogle Scholar
  36. 36.
    Pourdjabbar A, Lapointe N, Rouleau J: Angiotensin receptor blockers:powerful evidence with cardiovascular outcomes ? Can J Cardiol 2002, 18(Suppl A):7A-14A.PubMedGoogle Scholar
  37. 37.
    ALLHAT Collaborative Research Group: Major outcomes in highrisk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002, 288:2981–2997. Head-to-head comparison of calcium channel blockers, ACE inhibitors, and diuretics in lowering the incidence of cardiovascular events. Overall, the diuretic is the most effective.CrossRefGoogle Scholar
  38. 38.
    Perry HJ, Davis B, Price T, et al.: Effect of treating isolated systolic hypertension on the risk of developing various types and subtypes of stroke: the Systolic Hypertension in the Elderly Program (SHEP). JAMA 2000, 284:465–471.PubMedCrossRefGoogle Scholar
  39. 39.
    Bakris G, Weir M, Shanifar S, et al.: Effects of blood pressure level on progression of diabetic nephropathy: results from the RENAAL trial. Arch Intern Med 2003, In press.Google Scholar
  40. 40.
    Atkins R, Briganti E, Wiegmann T: Effect of baseline proteinuria and change in proteinuria with treatment on the risk of renal endpoints in the irbesartan diabetic nephropathy trial (IDNT). J Am Soc Nephrol 2002, 13:112A.CrossRefGoogle Scholar
  41. 41.
    Jafar T, Stark P, Schmid C, et al.: Proteinuria as a modifiable risk factor for the progression of non-diabetic renal disease. Kidney Int 2001, 60:1131–1140.PubMedCrossRefGoogle Scholar
  42. 42.
    Hemmelder M, de Zeeuw D, Buter H, de Jong P: Hydrochlorothiazide (HCTZ) potentiates teh antiproteinuric efficacy of ACE inhibition (ACEI) comparable to dietary salt restriction. J Am Soc Nephrol 1995, 6:420.Google Scholar
  43. 43.
    Laverman G, Navis G, Henning R, et al.: Dual renin-angiotensin system blockade at optimal doses for proteinuria. Kidney Int 2002, 62:1020–1025. A clinical trial studying the combined effects of ACE inhibitors and ARBs in patients with proteinuria and renal insufficiency.PubMedCrossRefGoogle Scholar
  44. 44.
    Ruilope L, Barrios V, Volpe M: Renal implications of the reninangiotensin-aldosterone system blockade in the heart faiure. J Hypertens 2000, 18:1545–1551.PubMedCrossRefGoogle Scholar
  45. 45.
    Brenner B, Cooper M, de Zeeuw D, et al., RENAAL Study Investigators: Effectis of losartan on renal and cardiovascular outcomes in patinets with type 2 diabetes and nephropathy. N Engl J Med 2001, 345:861–869. Landmark clinical trial demonstrating the advantage of ARB therapy in proteinuric type 2 diabetic patients in reducing proteinuria, the incidence of doubling of the serum creatinine, and ESRD.PubMedCrossRefGoogle Scholar
  46. 46.
    Bakris G, Weir M: Angiotensin-converting enzyme inhibitorassociated elevations in serum creatinine: is this a cause for concern? Arch Intern Med 2000, 160:685–693.PubMedCrossRefGoogle Scholar
  47. 47.
    Ahuja T, Freeman DJ, Mahnken J, et al.: Predictors fo the development of hyperkalemia in patients using angiotensin-converting enzyme inhibitors. Am J Nephrol 2000, 20:268–272.PubMedCrossRefGoogle Scholar
  48. 48.
    Heeg J, de Jong P, van der Hem G, de Zeeuw D: Efficacy and variability of the antiproteinuric effect of ACE inhibition by lisinopril. Kidney Int 1989, 36:272–279.PubMedGoogle Scholar
  49. 49.
    Mallamaci F, Leonardis D, Bellizzi V, Zoccali C: Does high salt intake cause hyperfiltration in patinets with essential hypertension ? J Hum Hypertens 1996, 10:157–161.PubMedGoogle Scholar
  50. 50.
    Allen T, Waldron M, Casley D, et al.: Salt restriction reduces hyperfiltration, renal enlargement, and albuminuria in experimental diabetes. Diabetes 1997, 46:19–24.PubMedCrossRefGoogle Scholar
  51. 51.
    Walker J, Bending J, Dodds R, et al.: Restriction of dietary protein and progression of renal failure in diabetic nephropathy. Lancet 1989, 16:1411–1415.CrossRefGoogle Scholar
  52. 52.
    Pedrini M, Levey A, Lau J, et al.: The effect of dietary protein restriction on the progression of diabetic and nondiabetic renal diseases: a meta-analysis. Ann Intern Med 1996, 124:627–632.PubMedGoogle Scholar
  53. 53.
    Hansen H, Tauber-Lassen E, Jensen B, Parving H: Effect of dietary protein restriction on prognosis in patinets with diabetic nephropathy. Kidney Int 2002, 62:220–228.PubMedCrossRefGoogle Scholar
  54. 54.
    ETDRS Investigators: Aspirin effects on mortality and morbidity in patients with diabetes mellitus. Early treatment diabetic retinopathy study report. JAMA 1992, 268:1292–1300.CrossRefGoogle Scholar
  55. 55.
    Gaede P, Vedel P, Larsen N, et al.: Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med 2003, 348:383–393.PubMedCrossRefGoogle Scholar
  56. 56.
    Mooradian A: Cardiovascular disease in type 2 diabetes mellitus: current management guidelines. Arch Intern Med 2003, 163:33–40.PubMedCrossRefGoogle Scholar

Copyright information

© Current Science Inc 2003

Authors and Affiliations

  • Wei X. Lu
  • Jay Lakkis
  • Matthew R. Weir
    • 1
  1. 1.BaltimoreUSA

Personalised recommendations