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High Blood Pressure and Diabetes Mellitus
Are All Antihypertensive Drugs Created Equal?
Ehud Grossman, MD;
Franz H. Messerli, MD;
Uri Goldbourt, PhD
Arch Intern Med. 2000;160:2447-2452.
Objective To analyze the available data to assess the benefits of antihypertensive therapy in hypertensive patients with diabetes mellitus.
Methods A MEDLINE search of English-language articles published until June 1999 was undertaken with the use of the terms diabetes mellitus, hypertension or blood pressure, and therapy. Pertinent articles cited in the identified reports were also reviewed. Included were only prospective randomized studies of more than 12 months' duration that evaluated the effect of drug treatment on morbidity and mortality in diabetic hypertensive patients. We estimated the risk associated with combination of diabetes mellitus and hypertension and the effect of treatment on morbidity and mortality.
Results The coexistence of diabetes mellitus doubled the risk of cardiovascular events, cardiovascular mortality, and total mortality in hypertensive patients (approximate relative risk of 1.73-2.77 for cardiovascular events, 2.25-3.66 for cardiovascular mortality, and 1.73-2.18 for total mortality). Intensive blood pressure control to levels lower than 130/85 mm Hg was beneficial in diabetic hypertensive patients. All 4 drug classes—diuretics,  -blockers, angiotensin-converting enzyme inhibitors, and calcium antagonists—were effective in reducing cardiovascular events in diabetic hypertensive patients. In elderly diabetic patients with isolated systolic hypertension, calcium antagonists reduced the rate of cardiac end points by 63%, stroke by 73%, and total mortality by 55%. In more than 60% of diabetic hypertensive patients, combination therapy was required to control blood pressure.
Conclusions Intensive control of blood pressure reduced cardiovascular morbidity and mortality in diabetic patients regardless of whether low-dose diuretics, -blockers, angiotensin-converting enzyme inhibitors, or calcium antagonists were used as a first-line treatment. A combination of more than 1 drug is frequently required to control blood pressure and may be more beneficial than monotherapy.
From Internal Medicine D (Dr Grossman) and Neufeld Cardiac Institute (Dr Goldbourt), Chaim Sheba Medical Center, Tel-Hashomer, Israel; Department of Internal Medicine, Section on Hypertensive Diseases, Ochsner Clinic and Alton Ochsner Medical Foundation, New Orleans, La (Dr Messerli); and Division of Epidemiology and Preventive Medicine, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel (Dr Goldbourt). Dr Messerli or the Ochsner Medical Institutions have received honoraria or financial grants from various pharmaceutical companies. Dr Messerli is on the Speaker's List of the following companies: Merck, West Point, Pa; Bristol-Myers Squibb, New York, NY; Pfizer, Inc, New York; Knoll Pharmaceutical Company, Mount Olive, NJ; G. D. Searle & Co, Chicago, Ill; Astra Pharmaceuticals, L.P., Wayne, Pa; Roche Pharmaceuticals, Nutley, NJ; Novartis Pharmaceuticals Corp, East Hanover, NJ; and Bayer Corporation, West Haven, Conn.
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