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What is the relation between Diabetes and Hypertension?

Dr. Rajesh Jain
Hypertension

hypertension

What is the relation between Diabetes and Hypertension?

Hypertension is often associated with diabetes mellitus, including type-1 diabetes, type-2 diabetes, and gestational diabetes, and studies suggest that there may be a relationship between them. High blood pressure and type 2 diabetes are both aspects of the underlying syndrome, including obesity and heart disease. Both hypertension and diabetes may have some underlying causes, and they share some risk factors. They also contribute to the worsening of each other’s symptoms.

 

How to test Hypertension and Diabetes at home?

If a person is suffering from diabetes or hypertension, he must buy a blood sugar test kit to test diabetes and a blood pressure monitor for blood pressure, which they can use at home.

How To identify Hypertension?

People sometimes refer to hypertension as a “silent killer,” and many people do not know they have it. The American Heart Association (AHA) stresses that most of the time, there are no symptoms. People usually find out high blood pressure when doctors take blood pressure readings or take themselves home.

keywords: type-1 diabetes, type-2 diabetes, gestational diabetes, Hypertension

How to Identify Diabetes?

Not all people with diabetes notice symptoms until they are effectively controlling their condition. If symptoms of high blood sugar levels appear, they include:

There are three types of diabetes, all of which have different causes:

Type 1 Diabetes

Type 1 diabetes appears during childhood or adolescence, but it can occur later in life. Symptoms may emerge relatively suddenly or over several weeks. Type 1 occurs when the immune system attacks cells in the pancreas that produce insulin. There is no way to avoid type 1 diabetes.

Type2 Diabetes

Type 2 diabetes can take years to develop, and most people do not show symptoms. A person usually learns that they have diabetes or type 2 diabetes, such as neuropathy or kidney problems, by attending the screening or having diabetes. keywords: type-1 diabetes, type-2 diabetes, gestational diabetes, Hypertension

Gestational Diabetes

Gestational diabetes occurs only in pregnancy, but it may increase the risk of type 2 diabetes later in life. If regular checkups show high blood sugar levels during pregnancy, doctors will monitor the person’s condition until delivery. They will continue to do so even after a few weeks, but blood sugar levels usually fall. Gestational diabetes can lead to various complications, including pre-eclampsia, the main symptom of which is very high blood pressure. keywords: type-1 diabetes, type-2 diabetes, gestational diabetes, Hypertension

What is the similarity between diabetes and hypertension?

The authors of a 2012 study note that diabetes and high blood pressure often occur together and may share some common causes. Contains:

Can diabetes cause high blood pressure?

A person with diabetes either does not have enough insulin to process glucose or does not work effectively. Insulin is the hormone that enables the body to process glucose from food and use it as energy. As a result of insulin problems, glucose cannot enter cells to provide energy, and it accumulates in the bloodstream instead. keywords: type-1 diabetes, type-2 diabetes, gestational diabetes, Hypertension

Can high blood pressure cause diabetes?

A meta-analysis seen in the Journal of the American College of Cardiology (JACC) in 2015 looked at data from more than 4 million adults. It concluded that people with high blood pressure are at greater risk of developing type 2 diabetes. This link may be due to processes occurring in the body that affect both conditions, for example, inflammation.

What are the Complications of diabetes and hypertension?

The combined effect of diabetes and hypertension can increase heart disease, kidney disease, and other health problems. In 2012, researchers cited data that 30% of people with type 1 diabetes and 50–80% of people with type 2 diabetes have high blood pressure in the United States. High glucose levels in the blood can increase blood pressure:

ACE Inhibitors
 ACE Inhibitors are medications that belong in the class of medications known as antihypertensive medications.
 ACE Inhibitors work on the Renin-AngiotensinAldosterone System.

Renin-Angiotensin-Aldosterone System
 A system that works to increase blood pressure when the pressure within the kidneys drops.
 As a result of low blood pressure and/or oxygenation in the nephron, renin is released from the juxtaglomerular cells.
 Renin travels to the liver via the cardiovascular system and combines with angiotensinogen to form angiotensin I.
 Angiotensin I travels through the cardiovascular system and arrives at the lungs, changing into Angiotensin II.
 The alveoli use Angiotensin-Converting Enzyme, also known as kinase II to cause this conversion.
(Karch, 2012, pg. 671)

Renin-Angiotensin-Aldosterone System cont.

 Angiotensin II is a powerful vasoconstrictor that causes a rise in peripheral resistance and increases pressure.

 Angiotensin II works to increase the release of aldosterone from the adrenal glands.

 Aldosterone causes renal retention of sodium and water, which further increases blood pressure by increasing volume. (Karch, 2012, pg. 671)

keywords: type-1 diabetes, type-2 diabetes, gestational diabetes, Hypertension

Mechanism of Action for ACE Inhibitors  ACE Inhibitors works in the lungs to inhibit Angiotensin-Converting Enzyme from turning Angiotensin I into Angiotensin II.

 These medications cause an increase in bradykinin, which inhibits kinase II, another name for Angiotensin-Converting Enzyme. (Lehne, 2007, pg. 464)Blood Pressure is decreased due to a decrease in blood volume, peripheral resistance, and cardiac load.

 ACE Inhibitors inhibit vasoconstriction and release of aldosterone, which inhibits the retention of sodium and water

Indications For Use:
 Hypertension-used especially for malignant
hypertension and hypertension secondary to renal
arterial stenosis.
 Benefits of Using an ACE Inhibitor
 Do not interfere with cardiovascular reflexes
 Do not interfere with patients who have asthma-like beta-blockers
 Do not decrease potassium levels.
 Do not cause lethargy, weakness, and sexual dysfunction.
 “ACE inhibitors reduce the risk of cardiovascular mortality
caused by hypertension.” (Lehne,2007, pg. 465)

Indications For Use cont.
 Heart Failure
 By decreasing the arteriolar tone, the region of blood flow to the heart improves.
 By decreasing afterload, cardiac output increases.
 Venous dilation increases, causing a decrease in pulmonary congestion and peripheral edema.
 It dilates the vessels of the kidneys, increasing renal flow, and helps to excrete sodium and water. This helps to decrease
edema and blood volume.
 It prevents pathologic changes in the heart that result from reducing the angiotensin II levels in the heart.
(Lehne, 2007, pg. 465)

Indications For Use cont.
 Myocardial Infarction (MI)
 Decreases the chance of heart failure after an MI.
 Should be given for 6 weeks post-MI. If heart failure occurs, it should be considered for permanent use.
 Nephropathy
 Slows renal disease of diabetic or nondiabetic origins
 Decreases glomerular filtration pressure.

Indications For Use cont.
 Type 2 Diabetes
 Decreases morbidity in high-risk patients.
 Increased levels of angiotensin II correlate to type 2
diabetes.
 ACE inhibitors increase kinin levels, which increase the production of prostaglandins and nitric oxide.
 Prostaglandins and nitric oxide improve muscular insulin sensitivity. (Solski & Longyhore, 2008, pg. 936)
 May preserve pancreatic function and prevent the onset of diabetes, especially in people who have hypertension.

Adverse Effects
 First-Dose Hypotension
 It usually occurs with the initial dose.
 Worse in patients with severe hypertension, or are on diuretics or are sodium or volume-depleted.
 Cough
 “Persistent, dry, irritating, nonproductive cough can develop with all ACE inhibitors.” (Lehne, 2007, pg. 466)
 Due to the rise in bradykinin which occurs due to inhibition of kinase II.
 Occurs in 5-10% of patients and is more common in women and the elderly

Adverse Effects cont.
 Hyperkalemia
 Potassium levels rise due to the inhibition of aldosterone, which causes potassium to be retained by the
kidneys.
 Renal Failure
 It can cause renal insufficiency in people with bilateral renal artery stenosis because dropping the pressure in the
renal arteries in these patients can cause glomerular filtration to fail.
 Fetal Injury
 In the second and third trimesters, a fetus can experience hypotension, hyperkalemia, skull hypoplasia, renal
failure, and death.
Drug Interactions
 Antihypertensive agents
 Can cause an increased effect of medications, especially with diuretics.
 Potassium increasing medications
 Cause an increased risk of hyperkalemia due to the suppression of aldosterone.
 Lithium
 Increases the risk of lithium toxicity.
 Allopurinol
 Increases hypersensitivity to the medication
 NSAIDs
 Reduce the antihypertensive effects of medication.
Nursing Considerations
 Encourage lifestyle changes
 Weight loss
 Quit smoking
 Decrease alcohol intake
 Encourage exercise to help lower blood pressure
 Monitor Renal Function
 BUN, Creatinine, and Potassium levels
 Monitor for decreased fluid volume, which can bottom our
blood pressure
 Excessive sweating
 Diarrhea
 Vomiting
 Dehydration
Nursing Considerations cont.
 Monitor for 1st
-dose hypotension
 May have to stop other antihypertensive medications at the initiation of
ACE inhibitors.
 I may have to give these medications in lower doses in the future.
 Discontinue diuretics for 2-3 days before starting an ACE inhibitor.
 Monitor BP for several hours, and if the patient becomes a hypotensive, lay
patient supine and consider discussing IV bolus of saline with the
MD.
 Educate Patient
 Teach the patient about the medication, including name adverse
effects, drug interactions.
 Teach the patient about the signs of hypotension, hyperkalemia, and
renal failure. If the patient is taking lithium, discuss the signs of lithium
toxicity.
Test Questions
1. Which of these patients would most likely be treated
with an ACE inhibitor?
a) A 38-year older woman who has become hypertensive in
the last trimester of her pregnancy.
b) A 78-year older man who just had a heart attack and is in
renal failure.
c) A 60-year older man who has diabetes and suffers from
hypertension.
d) A 72-year old female with a history of hypertension
comes to the ER in septic shock.
Test Questions
2. Which statement by a patient taking ACE inhibitors
demonstrates the patient’s understanding of the
medication?
a) “I don’t need to exercise because the medication will
make me better.”
b) “If I feel weak or faint, I should take my
medication because it will make me feel better.”
c) “I can use salt substitutes instead of the real thing.”
d) “If I develop a cough that does not go away, I should
call my doctor.”
Test Questions
1. Which of these lab values would be a
contraindication for taking an ACE inhibitor?
a) Potassium 3.3
b) Potassium 5.6
c) BUN 10
d) Creatinine 1.2
Test Answers with Rationale
1. c is the correct answer. a, b, and d all have
contraindications for giving an ACE inhibitor.
2. d is the correct answer. A is wrong because exercise
should be encouraged. Bi’s wrong because weakness
and syncope are signs that the patient may be
hypotensive. C is wrong because salt substitutes are
high in potassium and should be used with caution
in patients on ACE inhibitors.
3. a is the right answer. Hyperkalemia is a
contraindication for ACE inhibitors.
References
 Karch, A. (2011). Focus on nursing pharmacology (5th
ed.). Philadephia, PA: Wolters Kluwer | Lippincott
Williams & Wilkins.
 Lehne, R. (2007). Pharmacology for nursing care (6th ed.).
St. Louis, MO: Saunders|Elsevier.
 Solski, L. V. & Longyhore. (2008). Prevention of type 2
diabetes mellitus with angiotensin-converting enzyme inhibitors. American Journal of HealthSystem Pharmacy, 65(10): 935-40.
 Waterfield, J. (2008). ACE inhibitors: use, action, and
prescribing rationale. Nurse Prescribing, 6(3): 110-4

 

Practice Essentials

High blood pressure (BP), or hypertension, is defined by two levels by 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines [1, 2] : (1) elevated BP, with a systolic pressure (SBP) between 120 and 129 mm Hg and diastolic pressure (DBP) less than 80 mm Hg, and (2) stage 1 hypertension, with an SBP of 130 to 139 mm Hg or a DBP of 80 to 89 mm Hg.

Hypertension is the most common primary diagnosis in the United States. [3] It affects approximately 86 million adults (≥20 years) in the United States [4] and is a major risk factor for stroke, myocardial infarction, vascular disease, and chronic kidney disease. See the image below.

Hypertension. Anteroposterior x-ray from a 28-year old woman who presented with congestive heart failure secondary to her chronic hypertension or high blood pressure. The enlarged cardiac silhouette on this image is due to congestive heart failure due to the effects of chronic high blood pressure on the left ventricle. The heart then becomes enlarged, and fluid accumulates in the lungs, known as pulmonary congestion.

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Signs and symptoms of hypertension

Hypertension is defined as systolic blood pressure (SBP) of 140 mm Hg or more, or diastolic blood pressure (DBP) of 90 mm Hg or more, or taking antihypertensive medication. [5]

Based on recommendations of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), the classification of BP for adults aged 18 years or older has been as follows [5] :

  • Normal: Systolic lower than 120 mm Hg, diastolic lower than 80 mm Hg

  • Prehypertension: Systolic 120-139 mm Hg, diastolic 80-89 mm Hg

  • Stage 1: Systolic 140-159 mm Hg, diastolic 90-99 mm Hg

  • Stage 2: Systolic 160 mm Hg or greater, diastolic 100 mm Hg or greater

The 2017 ACC/AHA guidelines eliminate the classification of prehypertension and divide it into two levels [1, 2] :

  • Elevated blood pressure with systolic pressure between 120 and 129 mm Hg and diastolic pressure less than 80 mm Hg

  • Stage 1 hypertension, with a systolic pressure of 130 to 139 mm Hg or a diastolic pressure of 80 to 89 mm Hg

Hypertension may be primary, which may develop as a result of environmental or genetic causes, or secondary, which has multiple etiologies, including renal, vascular, and endocrine causes. Primary or essential hypertension accounts for 90-95% of adult cases, and secondary hypertension accounts for 2-10% of cases.

See Presentation for more detail.

Diagnosis of hypertension

The evaluation of hypertension involves accurately measuring the patient’s blood pressure, performing a focused medical history and physical examination, and obtaining results of routine laboratory studies. [5, 6] A 12-lead electrocardiogram should also be obtained. These steps can help determine the following [5, 6, 7] :

  • Presence of end-organ disease

  • Possible causes of hypertension

  • Cardiovascular risk factors

  • Baseline values for judging biochemical effects of therapy

Other studies may be obtained on the basis of clinical findings or in individuals with suspected secondary hypertension and/or evidence of target-organ diseases, such as CBC, chest radiograph, uric acid, and urine microalbumin. [5]

See Workup for more detail.

Management of hypertension

Many guidelines exist for the management of hypertension. Most groups, including the JNC, the American Diabetes Associate (ADA), and the American Heart Association/American Stroke Association (AHA/ASA), recommend lifestyle modification as the first step in managing hypertension.

Lifestyle modifications

JNC 7 recommendations to lower BP and decrease cardiovascular disease risk include the following, with greater results achieved when 2 or more lifestyle modifications are combined [5] :

  • Weight loss (range of approximate systolic BP reduction [SBP], 5-20 mm Hg per 10 kg)

  • Limit alcohol intake to no more than 1 oz (30 mL) of ethanol per day for men or 0.5 oz (15 mL) of ethanol per day for women and people of lighter weight (range of approximate SBP reduction, 2-4 mm Hg)

  • Reduce sodium intake to no more than 100 mmol/day (2.4 g sodium or 6 g sodium chloride; the range of approximate SBP reduction, 2-8 mm Hg) [8]

  • Maintain adequate intake of dietary potassium (approximately 90 mmol/day)

  • Maintain adequate intake of dietary calcium and magnesium for general health

  • Stop smoking and reduce intake of dietary saturated fat and cholesterol for overall cardiovascular health

  • Engage in aerobic exercise at least 30 minutes daily for most days (range of approximate SBP reduction, 4-9 mm Hg)

The AHA/ASA recommends a low in sodium diet, is high in potassium, and promotes the consumption of fruits, vegetables, and low-fat dairy products for reducing BP and lowering the risk of stroke. Other recommendations include increasing physical activity (30 minutes or more of moderate-intensity activity on a daily basis) and losing weight (for overweight and obese persons).

The 2018 European Society of Cardiology (ESC) and the European Society of Hypertension (ESH) guidelines recommend a low-sodium diet (limited to 2 g per day) as well as reducing body-mass index (BMI) to 20-25 kg/m2 and waist circumference (to < 94 cm in men and < 80 cm in women). [9]

Pharmacologic therapy

If lifestyle modifications are insufficient to achieve the goal of BP, there are several drug options for treating and managing hypertension. Thiazide diuretics, an angiotensin-converting enzyme inhibitor (ACEI) /angiotensin receptor blocker (ARB), or calcium channel blocker (CCB) are the preferred agents in nonblack populations, whereas CCBs or thiazide diuretics are favored in black hypertensive populations. [10] These recommendations do not exclude the use of ACE inhibitors or ARBs in the treatment of black patients or CCBs or diuretics in non-black persons. Often, patients require several antihypertensive agents to achieve adequate BP control.

Compelling indications for specific agents include comorbidities such as heart failure, ischemic heart disease, chronic kidney disease, and diabetes. Drug intolerability or contraindications may also be factors. [5]

The following are drug class recommendations for compelling indications based on various clinical trials [5] :

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