Management of Diabetes Mellitus and Hypertension

Blood Pressure Targets

The European Society of Cardiology recommends targeting a systolic BP of 130 mmHg (and lower if tolerated, but not below 120 mmHg) and diastolic BP below 80 mmHg (but not below 70 mmHg) for patients with diabetes and hypertension 1, 2
In older diabetic patients (≥65 years), the systolic BP goal should be 130-139 mmHg if tolerated 2, 3
Optimal BP control significantly reduces the risk of both microvascular and macrovascular complications in diabetic patients 2
BP targets should be adjusted based on comorbidities, duration of diabetes, and age 1
Avoiding hypoglycemia in all diabetic patients is crucial, as it may increase cardiovascular risk 1, 2

The European Society of Cardiology recommends lifestyle modifications, including reduced calorie intake, moderate-to-vigorous physical activity, reduced sodium intake, increased consumption of vegetables, fruits, and low-fat dairy products, and smoking cessation, for all patients with diabetes and hypertension 1, 2
Initiating pharmacological treatment with a combination of a RAAS blocker (ACE inhibitor or ARB) and a calcium channel blocker or thiazide-like diuretic is recommended 1, 2, 3
RAAS blockers (ACE inhibitors or ARBs) are strongly recommended as first-line therapy, particularly in patients with microalbuminuria, albuminuria, proteinuria, or left ventricular hypertrophy 1, 2

In black patients with diabetes, thiazide diuretics and calcium channel blockers are more effective as first-line agents 4
For patients with stage 2 hypertension (≥160/100 mmHg), initiation with two antihypertensive agents from different classes is recommended 4
BP control often requires multiple drug therapy, typically a combination of two or three agents 5
Monthly evaluation of adherence and therapeutic response is necessary until control is achieved 4

For patients with metabolic syndrome, a RAAS blocker should be the first choice, followed by calcium antagonists or low-dose thiazide diuretics if needed 6
Beta-blockers should be avoided in patients with metabolic syndrome unless specifically indicated, due to their adverse effects on insulin sensitivity, body weight, and lipid profile 6
Newer vasodilating beta-blockers (carvedilol, nebivolol) may have fewer metabolic adverse effects 6

Patients with diabetes on combined antihypertensive treatments should be encouraged to self-monitor BP 2, 3

Statins are recommended as first-choice lipid-lowering treatment in patients with diabetes and high LDL-C levels 1
For patients with T2DM at very high CV risk, an LDL-C target of <1.4 mmol/L (<55 mg/dL) and LDL-C reduction of at least 50% is recommended 1
If target LDL-C is not reached with maximum tolerated statin dose, combination therapy with ezetimibe is recommended 1

Target HbA1c <7.0% (<53 mmol/mol) to decrease microvascular complications 1
HbA1c targets should be individualized according to diabetes duration, comorbidities, and age 1

Hypertension and diabetes frequently coexist (in approximately 80% of patients with DM) and dramatically increase cardiovascular risk compared to either condition alone 5