Hypertension affects more than 70% of patients with type 2 diabetes mellitus and further increases the risk of cardiovascular disease in this high-risk population.1 While renin angiotensin system (RAS) blockers are clearly indicated in patients with heart failure, chronic kidney disease with proteinuria, and coronary artery disease (CAD), experts have come to different conclusions regarding their role as initial antihypertensive therapy for patients with diabetes.
Resistant hypertension (RH) is frequently encountered in primary care practice and often presents a significant clinical challenge because limited evidence-based guidance exists. RH is a major cause of cardiovascular disease and death, and has been associated with a 50% increased risk of myocardial infarction, stroke, congestive heart failure, and chronic kidney disease when compared to patients without RH. The American Heart Association defines RH as uncontrolled BP despite maximal treatment with a three-drug regimen, ideally including a diuretic. The exact prevalence of RH is unknown, but large randomized controlled trials suggest it affects one in five patients with elevated BP. Previous research findings suggest chlorthalidone, spironolactone, and eplerenone are all effective add-on therapies when BP remains uncontrolled with typical first line agents. The Pathway-2 study provides the first direct comparative evaluation of three different four-drug antihypertensive regimens.
The debate over the intensity of blood pressure (BP) lowering for patients with hypertension has been going on for decades. Additional fuel to the fire was recently added with the early halt and publication of the Systolic Blood Pressure Intervention Trial (SPRINT). So “how low should you go” for patients with high BP? Do lower BP goals reduce CV outcomes and death, particularly in patients at high risk? Do they cause greater adverse effects? Or perhaps even worsen CV outcomes? These questions were examined in SPRINT.