Effect of diuretic-based antihypertensive treatment on cardiovascular disease risk in older diabetic patients with isolated systolic hypertension. Systolic Hypertension in the Elderly Program Cooperative Research Group. Intensified antihypertensive therapy is associated with improved survival in type 1 diabetic patients with nephropathy Antihypertensive treatment efficacy in type II diabetes mellitus. Dissociation between casual and 24-hour ambulatory blood pressure. Spanish Multicenter Study Group. The ABCD (Appropriate Blood Pressure Control in Diabetes) trial. Rationale and design of a trial of hypertension control (moderate or intensive) in type II diabetes. Effects of intensive blood-pressure control in type 2 diabetes mellitus. A cluster randomised controlled trial of the effect of a treatment algorithm for hypertension in patients with type 2 diabetes. Effect of antihypertensive therapy on progression of carotid intima-media thickness in patients with type 2 diabetes mellitus. Dieting to reduce body weight for controlling hypertension in adults. 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. Appropriate Blood Pressure Control in NIDDM (ABCD) Trial Effects of immediate versus delayed antihypertensive therapy on outcome in the Systolic Hypertension in Europe Trial Blood pressure and glucose control in subjects with diabetes: new analyses from ADVANCE Antihypertensive therapy in type 2 diabetes: implications of the appropriate blood pressure control in diabetes (ABCD) trial. A randomized study of quality of life during multiple risk factor intervention in treated hypertensive men at high cardiovascular risk Morbidity and mortality in the Swedish Trial in Old Patients with Hypertension (STOP-Hypertension) The Anglo-Scandinavian Cardiac Outcomes Trial: blood pressure-lowering limb: effects in patients with type II diabetes Subgroup and per-protocol analysis of the randomized European Trial on Isolated Systolic Hypertension in the Elderly.
OBJECTIVE To assess the effect of low-dose , diuretic-based antihypertensive treatment on major cardiovascular disease ( CVD ) event rates in older , non-insulin-treated diabetic patients with isolated systolic hypertension ( ISH ) , compared with nondiabetic patients . DESIGN Double-blind , r and omized , placebo-controlled trial : the Systolic Hypertension in the Elderly Program ( SHEP ) . SETTING Multiple clinical and support centers in the United States . PARTICIPANTS A total of 4736 men and women aged 60 years and older at baseline with ISH ( systolic blood pressure [ BP ] , > or = 160 mm Hg ; diastolic BP , < 90 mm Hg ) at baseline , 583 non-insulin-dependent diabetic patients and 4149 nondiabetic patients ( 4 additional patients not so classifiable were r and omized but not included in these analyses ) . Diabetes mellitus defined as physician diagnosis , taking oral hypoglycemic drugs , fasting glucose level of 7.8 mmol/L or more ( > or = 140 mg/dL ) , or any combination of these characteristics . INTERVENTION The active treatment group received a low dose of chlorthalidone ( 12.5 - 25.0 mg/d ) with a step-up to atenolol ( 25.0 - 50.0 mg/d ) or reserpine ( 0.05 - 0.10 mg/d ) if needed . The placebo group received placebo and any active antihypertensive drugs prescribed by patient 's private physician for persistently high BP . MAIN OUTCOME MEASURES The 5-year rates of major CVD events , nonfatal plus fatal stroke , nonfatal myocardial infa rct ion ( MI ) and fatal coronary heart disease ( CHD ) , major CHD events , and all-cause mortality . RESULTS The SHEP antihypertensive drug regimen lowered BP of both diabetic and nondiabetic patients , with few adverse effects . For both diabetic and nondiabetic patients , all outcome rates were lower for participants r and omized to the active treatment group than for those r and omized to the placebo group . Thus , 5-year major CVD rate was lower by 34 % for active treatment compared with placebo , both for diabetic patients ( 95 % confidence interval [ CI ] , 6%-54 % ) and nondiabetic patients ( 95 % CI , 21%-45 % ) . Absolute risk reduction with active treatment compared with placebo was twice as great for diabetic vs nondiabetic patients ( 101/1000 vs 51/1000 r and omized participants at the 5-year follow-up ) , reflecting the higher risk of diabetic patients . CONCLUSION Low-dose diuretic-based ( chlorthalidone ) treatment is effective in preventing major CVD events , cerebral and cardiac , in both non-insulin-treated diabetic and nondiabetic older patients with ISH Objective : To determine the prognosis of treated hypertensive type 1 ( insulin-dependent ) diabetic patients with overt nephropathy . Design : A controlled , prospect i ve , parallel , 5-year follow-up trial . Setting : The tertiary care centre of the Heinrich Heine University Hospital in Dusseldorf , Germany . Patients and interventions : A sequential sample of 91 hypertensive patients with overt diabetic nephropathy participated in a diabetes treatment programme . Thereafter 45 patients received intensified antihypertensive therapy including blood pressure self-monitoring and self-adjustment of antihypertensive drug treatment with the goal of permanent normalization of blood pressure values below 140/90 mmHg . The remaining 46 patients were administered routine antihypertensive therapy and formed the control group . At baseline both groups were comparable in age , sex , metabolic control and renal function . The groups differed at baseline in their duration of diabetes and blood pressure values , which were higher in the intensified antihypertensive therapy group . Outcome measures : Total mortality and the need for renal replacement therapy . Main results : Blood pressure control was significantly improved in patients who were subjected to intensified antihypertensive therapy , whereas it deteriorated in the group of patients who received routine antihypertensive therapy . At follow-up , primary end points of the study occurred in five ( 11 % ) patients of the intensified therapy group and in 19 ( 41 % ) patients of the routine therapy group . According to life table analysis , intensified antihypertensive therapy was associated with less frequent primary end points ( P= 0.0058 ) and longer survival ( P=0.01 ) . The differences between the groups remained significant after adjustment for covariates in the proportional hazards model . Conclusion : Participation in a treatment programme aim ed at intensification of antihypertensive therapy is associated with a reduction of mortality in hypertensive type 1 diabetic patients with overt nephropathy Whole-day ambulatory blood pressure monitoring is used to confirm the diagnosis of hypertension and assess the response to antihypertensive therapy .  Neither of these has been applied to patients with type II diabetes mellitus , in whom it has been proposed that the desirable blood pressure should be lower than in nondiabetics . This multicenter study was design ed to examine whether there are differences in the efficacy of a first-line antihypertensive drug when assessed by casual and ambulatory blood pressure determinations in patients with type II diabetes mellitus in whom 24-hour ambulatory monitoring confirms or fails to confirm the diagnosis of hypertension . Forty-three patients ( mean age , 57.7 years ) with stable type II diabetes mellitus and mild hypertension ( casual diastolic pressure , 90 to 104 mm Hg on at least two visits ) were treated with an angiotensin-converting enzyme inhibitor ( benazepril , 10 to 20 mg , once a day ) for 8 weeks . Antihypertensive drug efficacy was assessed by casual ( trough ) and 24-hour ambulatory blood pressure monitoring . Diabetic patients were classified as nonconfirmed hypertensive if the mean 24-hour ambulatory diastolic pressure was below 85 mm Hg . Antihypertensive treatment significantly decreased both systolic and diastolic pressures when determined by either casual measurement ( from a mean of 162.7/98.0 to 153.9/89.2 mm Hg ; P < .001 ) or ambulatory monitoring ( from a mean of 143.1/84.4 to 137.0/81.5 mm Hg ; P < .05 ) . Twenty-one patients ( 49 % ) were classified as confirmed hypertensive and 22 as nonconfirmed hypertensive . In confirmed hypertensive patients benazepril significantly reduced systolic and diastolic pressures when assessed by either casual or 24-hour ambulatory monitoring . ( ABSTRACT TRUNCATED AT 250 WORDS OBJECTIVE The primary objective of the ABCD ( Appropriate Blood Pressure Control in Diabetes ) Trial is to determine the efficacy of intensive versus moderate antihypertensive control on the outcome of type II diabetic end-organ complications in normotensive and hypertensive population s. The secondary objective is to determine whether any differential effect on end-organ complications exists between an angiotensin converting enzyme inhibitor ( enalapril ) and a calcium channel blocker ( nisoldipine ) . DESIGN The ABCD Trial is a prospect i ve , controlled , r and omized , double-blind trial , with a planned follow-up of 5 years . SETTING All patients are seen at the Colorado Prevention Center , site of the ABCD Trial , for follow-up visits . PATIENTS Patients are type II diabetic males and females between the ages of 40 and 74 years with entry diastolic blood pressures > or = 80 mmHg . Patients were recruited from University of Colorado-affiliated hospitals , several health maintenance organizations , and mailing lists from the Colorado affiliate of the American Diabetes Association . INTERVENTIONS Patients were r and omized to intensive antihypertensive drug therapy or moderate antihypertensive drug therapy . Patients were also r and omized to nisoldipine or enalapril , with open-label medications added if further blood pressure control was necessary . MAIN OUTCOME MEASURES The primary outcome measure is glomerular filtration rate as assessed by 24-hour creatinine clearance . Secondary outcome measures are microalbumin urinary excretion , left ventricular hypertrophy , retinopathy , and neuropathy . Cardiovascular morbidity and mortality will also be evaluated . CONCLUSION Given the data showing the impact of hypertension on diabetic complications , the ABCD Trial was design ed to determine if intensive antihypertensive therapy will be more efficacious than moderate antihypertensive therapy on the outcome of these complications . Results from the ABCD Trial are expected to lend interpretable and clinical ly relevant findings with regards to the treatment of hypertension in type II diabetes BACKGROUND There is no evidence from r and omized trials to support a strategy of lowering systolic blood pressure below 135 to 140 mm Hg in persons with type 2 diabetes mellitus . We investigated whether therapy targeting normal systolic pressure ( i.e. , < 120 mm Hg ) reduces major cardiovascular events in participants with type 2 diabetes at high risk for cardiovascular events . METHODS A total of 4733 participants with type 2 diabetes were r and omly assigned to intensive therapy , targeting a systolic pressure of less than 120 mm Hg , or st and ard therapy , targeting a systolic pressure of less than 140 mm Hg . The primary composite outcome was nonfatal myocardial infa rct ion , nonfatal stroke , or death from cardiovascular causes . The mean follow-up was 4.7 years . RESULTS After 1 year , the mean systolic blood pressure was 119.3 mm Hg in the intensive-therapy group and 133.5 mm Hg in the st and ard-therapy group . The annual rate of the primary outcome was 1.87 % in the intensive-therapy group and 2.09 % in the st and ard-therapy group ( hazard ratio with intensive therapy , 0.88 ; 95 % confidence interval [ CI ] , 0.73 to 1.06 ; P=0.20 ) . The annual rates of death from any cause were 1.28 % and 1.19 % in the two groups , respectively ( hazard ratio , 1.07 ; 95 % CI , 0.85 to 1.35 ; P=0.55 ) . The annual rates of stroke , a prespecified secondary outcome , were 0.32 % and 0.53 % in the two groups , respectively ( hazard ratio , 0.59 ; 95 % CI , 0.39 to 0.89 ; P=0.01 ) . Serious adverse events attributed to antihypertensive treatment occurred in 77 of the 2362 participants in the intensive-therapy group ( 3.3 % ) and 30 of the 2371 participants in the st and ard-therapy group ( 1.3 % ) ( P<0.001 ) . CONCLUSIONS In patients with type 2 diabetes at high risk for cardiovascular events , targeting a systolic blood pressure of less than 120 mm Hg , as compared with less than 140 mm Hg , did not reduce the rate of a composite outcome of fatal and nonfatal major cardiovascular events . ( Clinical Trials.gov number , NCT00000620 . BACKGROUND Good blood pressure ( BP ) control reduces the risk of complications in people with type 2 diabetes , yet many do not achieve this . Guidelines for managing hypertension recommend increasing antihypertensive medications until control is achieved , but the effect of such recommendations in routine primary care is unknown . AIM To evaluate the effectiveness of a BP treatment algorithm in primary care patients with type 2 diabetes . DESIGN OF STUDY A cluster r and omised controlled trial of 1534 patients with type 2 diabetes . SETTING Forty-two practice s in Nottingham , UK . METHOD Practice s were r and omised to continue usual care or to use a treatment algorithm design ed so that practice nurses and GPs would increase antihypertensive treatment in steps until the target of 140/80 mmHg was reached . Participants were assessed by a clinical interview and case note review at recruitment and at 1 year . The primary outcome measure was the proportion of participants achieving target BP at 1 year . RESULTS At 1 year there was no difference between the proportions of participants with well controlled BP in the intervention and control arms ( 36.6 % versus 34.3 % ; P = 0.27 ) . Mean systolic and diastolic blood pressures were identical in the two arms ( 143/78 mmHg ) . There was some evidence that participants in the intervention arm were more likely to be receiving higher doses of their antihypertensive drugs , although there was no significant difference in the number of different antihypertensive drugs prescribed . Participants in the intervention arm had a higher rate of primary care BP-related consultations over 12 months than those receiving usual care ( rate ratio = 1.55 , 95 % confidence interval [ CI ] = 1.26 to 1.88 , P<0.001 ) . CONCLUSION Despite increased monitoring and possibly higher doses of medication there was no improvement in blood pressure control . Improvements achieved by specialist nurse-led clinics in secondary care may not translate to people with type 2 diabetes in primary care setting Antihypertensive therapy reduces the incidence of cardiovascular events in people with diabetes mellitus ( DM ) . However , the effects of treatment on sub clinical atherosclerosis are less well studied . Results of a post hoc cohort analysis of the association between antihypertensive treatment and carotid artery intima-media thickness ( CIMT ) in the Troglitazone Atherosclerosis Regression Trial ( TART ) , a r and omized trial design ed to evaluate the impact of troglitazone treatment on CIMT progression in adults with insulin-requiring type 2 DM , are reported . CIMT , blood pressure ( BP ) , and use of antihypertensive agents  were measured throughout the 2-year treatment period . In multivariable mixed-effects models , the annual rate of change in CIMT in relation to BP and duration of antihypertensive agent use , adjusting for covariates , was evaluated . Higher systolic BP was associated with a higher CIMT progression rate ( p=0.03 ) . This association was reduced by antihypertensive treatment in a duration -dependent manner ( p for interaction=0.035 ) . Adjustment for age , treatment assignment , and change in fasting glucose during the trial did not attenuate these associations . In conclusion , regular use of antihypertensive agents reduces the harmful impact of increased BP on atherosclerosis progression in patients with DM . The antiatherogenic effect of antihypertensive agents , including BP normalization and possible direct vascular wall protection , can be detected by CIMT progression using B-mode ultrasound in patients with DM OBJECTIVES : Evaluate whether weight-loss diets are more effective than regular diets or other antihypertensive therapies in controlling blood pressure and preventing morbidity and mortality  in hypertensive adults . SEARCH STRATEGY : MEDLINE and The Cochrane Library were search ed through November 1997 . Trials known to experts in the field were included through June 1998 . SELECTION CRITERIA : For inclusion in the review , trials were required to meet each of the following criteria : 1 ) r and omized controlled trials with one group assigned to a weight-loss diet and the other group assigned to either normal diet or antihypertensive therapy ; 2 ) ambulatory adults with a mean blood pressure of at least 140 mm Hg systolic and /or 90 mm Hg diastolic ; 3 ) active intervention consisting of a  calorie-restricted diet intended to produce weight loss ( excluded studies simultaneously implementing multiple lifestyle interventions where the effects of weight loss could not be disaggregated ) ; and 4 ) outcome measures included weight loss and blood pressure . DATA COLLECTION AND ANALYSIS : Studies were dual abstract ed by two independent review ers using a st and ardized form design ed specifically for this review . The primary mode of analysis was qualitative ; graphs of effect sizes for individual studies were also used . MAIN RESULTS : Eighteen trials were found . Only one small study of inadequate power reported morbidity and mortality outcomes . None addressed quality of life or general well being issues . In general , participants assigned to weight-reduction groups lost weight compared to control groups . Six trials involving 361 participants assessed a weight-reducing diet versus a normal diet . The data suggested weight loss in the range of 4 % to 8 % of body weight was associated with a decrease in blood pressure in the range of 3 mm Hg systolic and diastolic . Three trials involving 363 participants assessed a weight-reducing diet versus treatment with antihypertensive medications . These suggested that a stepped-care approach with antihypertensive medications produced greater decreases in blood pressure ( in the range of 6/5 mm Hg systolic/diastolic ) than did a weight-loss diet . Trials that allowed adjustment of participants ' antihypertensive regimens suggested that patients required less intensive antihypertensive drug therapy if they followed a weight-reducing diet . Data was insufficient to determine the relative efficacy of weight-reduction versus changes in sodium or potassium intake or exercise . REVIEW ER 'S CONCLUSIONS : Weight-reducing diets in overweight hypertensive persons can affect modest weight loss in the range of 3 - 9 % of body weight and are probably associated with modest blood pressure decreases of roughly 3 mm Hg systolic and diastolic . Weight-reducing diets may decrease dosage requirements of persons taking antihypertensive medications OBJECTIVE The Captopril Prevention Project ( CAPPP ) evaluated the effects of an ACE inhibitor-based therapeutic regimen on  cardiovascular mortality and morbidity in hypertension .  One planned sub analysis of the CAPPP was to evaluate the outcome in the diabetic patient group . RESEARCH DESIGN AND METHODS In the CAPPP , 572 ( 4.9 % of 10,985 hypertensive patients ) had diabetes at baseline and were studied according to a prospect i ve , r and omized , open , blinded , end point trial design . Patients aged 25 - 66 years with diastolic blood pressure > or = 100 mmHg were included and r and omized to receive either captopril or conventional antihypertensive treatment ( diuretics and /or beta-blockers ) . RESULTS The primary end point , fatal and nonfatal myocardial infa rct ion and stroke as well as other cardiovascular deaths , was markedly lower in the captopril than in the conventional therapy group ( relative risk [ RR ] = 0.59 ; P = 0.018 ) . Specifically , cardiovascular mortality , defined as fatal stroke and myocardial infa rct ion , sudden death , and other cardiovascular death , tended to be lower in the captopril group ( RR = 0.48 ; P = 0.084 ) , and no difference was observed between the study groups for stroke ( RR = 1.02 ; P = 0.96 ) . Myocardial infa rct ions were less frequent in the captopril group than in the conventional therapy group ( RR = 0.34 ; P = 0.002 ) . Furthermore , total mortality was lower in the captopril as compared with the conventional therapy group ( RR = 0.54 ; P = 0.034 ) . Patients with impaired metabolic control seemed to benefit the most from ACE inhibitor-based therapy . CONCLUSIONS Captopril is superior to a diuretic/beta-blocker antihypertensive treatment regimen in preventing cardiovascular events in hypertensive diabetic patients , especially in those with metabolic decompensation Summary The ABCD ( Appropriate Blood Pressure Control in Diabetes ) Trial is a large , prospect i ve , r and omized clinical trial of 950 patients with non-insulin-dependent diabetes mellitus ( NIDDM ) design ed to compare the effects of intensive blood pressure control with moderate control on the prevention and progression of diabetic nephropathy , retinopathy , cardiovascular disease , and neuropathy in NIDDM . The secondary objective is to determine equivalency of the effects of a calcium channel blocker ( nisoldipine ) and an angiotensin-converting-enzyme inhibitor ( enalapril ) as a first-line antihypertensive agent in the prevention and /or progression of these diabetic vascular complications . The study consists of two study population s aged 40–74 years , 470 hypertensive patients ( diastolic blood pressure of ≥ 90.0 mmHg at time of r and omization ) and 480 normotensive patients ( diastolic blood pressure of 80.0 mmHg at time of r and omization ) . The study duration is 5 years and is scheduled to end in May of 1998 . Patients are r and omized to receive either intensive antihypertensive drug therapy or moderate antihypertensive drug therapy . Patients are also r and omized to nisoldipine or enalapril , with open-label medications added if further blood pressure control is necessary . The primary outcome measure is glomerular filtration rate as assessed by 24-h creatinine clearance . Secondary outcome measures are urinary albumin excretion , left ventricular hypertrophy , retinopathy , and neuropathy . Cardiovascular morbidity and mortality will also be evaluated . Given the data showing the impact of hypertension on complications in NIDDM , the ABCD Trial is design ed to determine if intensive antihypertensive therapy will be more efficacious than moderate antihypertensive therapy on the outcome of diabetic complications in NIDDM . [ Diabetologia ( 1996 ) 39 : 1646–1654 Background To assess the impact of immediate versus delayed antihypertensive treatment on the outcome of older patients with isolated systolic hypertension  , we extended the double-blind placebo-controlled Systolic Hypertension in Europe ( Syst-Eur ) trial by an open-label follow-up study lasting 4 years . Methods The Syst-Eur trial included 4695 r and omized patients with minimum age of 60 years and an untreated blood pressure of 160–219 mmHg systolic and below 95 mmHg diastolic . The double-blind trial ended after a median follow-up of 2.0 years ( range 1–97 months ) . Of 4409 patients still alive , 3517 received open-label treatment consisting of nitrendipine ( 10–40 mg daily ) with the possible addition of enalapril ( 5–20 mg daily ) , hydrochlorothiazide ( 12.5–25 mg daily ) , or both add-on drugs .  Non- participants ( n = 892 ) were also followed up . Results Median follow-up increased to 6.1 years . Systolic pressure decreased to below 150 mmHg ( target level ) in 2628 participants ( 75.0 % ) . During the 4-year open-label follow-up , stroke and cardiovascular complications occurred at similar frequencies in patients formerly r and omized to placebo and those continuing active treatment . These rates were similar to those previously observed in the active-treatment group during the double-blind trial . Considering the total follow-up of 4695 r and omized patients , immediate compared with delayed antihypertensive treatment reduced the occurrence of stroke and cardiovascular complications by 28 % ( P = 0.01 ) and 15 % ( P = 0.03 ) , respectively , with a similar tendency for total mortality ( 13 % , P = 0.09 ) . In 492 diabetic patients , the corresponding estimates of long-term benefit ( P < 0.02 ) were 60 , 51 and 38 % , respectively . Conclusions Antihypertensive treatment can achieve blood pressure control in most older patients with isolated systolic hypertension . Immediate compared with delayed treatment prevented 17 strokes or 25 major cardiovascular events per 1000 patients followed up for 6 years . These findings underscore the necessity of early treatment of isolated systolic hypertension Objectives To evaluate among individuals with diabetes whether major microvascular and macrovascular events are reduced by : ( 1 ) blood pressure lowering with a perindopril/indapamide combination compared with placebo ; ( 2 ) intensive glucose control ( targeting a haemoglobin A1c level of ≤6.5 % ) with a gliclazide MR-based regimen , compared with usual care . Methods Participants with diabetes aged 55 years and older with at least one additional vascular risk factor were r and omly assigned , using a 2 × 2 factorial design , to additional blood pressure lowering versus placebo and intensive versus st and ard glucose control . The primary outcomes were macrovascular ( cardiovascular death , non-fatal myocardial infa rct ion or non-fatal stroke ) and microvascular ( new or worsening nephropathy or retinopathy ) events jointly and separately . Results A total of 11 140 participants were r and omly assigned to the blood pressure and glucose-lowering arms , which ended after 4.3 and 5.5 years , respectively . The effects of the two interventions were independent and additive on prespecified endpoints . Compared with placebo , additional blood pressure lowering of 5.6/2.2 mmHg was associated with reductions of 9 % in the primary endpoint ( P = 0.041 ) , 18 % in cardiovascular death ( P = 0.027 ) , 14 % in total mortality ( P = 0.025 ) , and 21 % in total renal events ( P < 0.01 ) . Compared with st and ard glucose control , intensive control ( mean in-trial 0.67 percentage point reduction in haemoglobin A1c level ) was associated with reductions of 10 % in the primary endpoint ( P = 0.013 ) , 14 % in major microvascular events ( P = 0.01 ) and 11 % in total renal events ( P < 0.001 ) . Conclusion Additional blood pressure lowering and intensive glucose control , as achieved in ADVANCE , produce independent benefits and , when combined , substantially reduced cardiovascular mortality and all-cause mortality and improved renal outcomes As the population ages , the incidence of type 2 diabetes will increase as will the incidence of concomitant vascular complications . Hypertension substantially increases the risk of cardiovascular disease in patients with diabetes . Results from the recent Appropriate Blood Pressure Control in Diabetes ( ABCD ) trial demonstrated an advantage of an angiotensin-converting enzyme ( ACE ) inhibitor ( enalapril ) over a long-acting calcium antagonist ( nisoldipine ) with regard to the incidence of cardiovascular events over a 5-year follow-up period in hypertensive persons with type 2 diabetes . This trial was a prospect i ve , r and omized , blinded study comparing the effects of moderate blood pressure control ( target diastolic pressure 80 - 89 mm Hg ) with those of intensive control ( target diastolic pressure 75 mm Hg ) on the incidence and progression of diabetic vascular complications . The study also compared nisoldipine with enalapril as first-line antihypertensive therapy in terms of prevention and progression of complications of diabetes . In 470 hypertensive patients , the incidence of fatal and nonfatal myocardial infa rct ions was significantly ( p = 0.001 ) higher among those receiving nisoldipine ( n = 25 ) compared with those receiving enalapril ( n = 5 ) . Comparison with previous studies suggests that the difference observed between nisoldipine and enalapril result ed from a beneficial effect of enalapril rather than a deleterious effect from nisoldipine . Since these findings in the ABCD trial are based on a secondary endpoint , they require confirmation . Nevertheless , they suggest that ACE inhibitors should be the initial antihypertensive medication used in patients with type 2 diabetes and hypertension Objective To examine the effect on quality of life in hypertensive men of a multiple risk factor intervention programme  compared with that of usual care .  Design A prospect i ve , open , r and omized , parallel-group study with allocation either to a comprehensive multiple risk factor modification programme or to usual care . Setting An outpatient clinic in a city hospital . Patients : Five hundred and eight treated hypertensive men , aged 50–72 years , with at least one of the following : serum cholesterol ≥ 6.5 mmol/l , smoking habit or diabetes mellitus . Intervention Nutritional advice , behavioural treatment principles and drug therapy . Main outcome measures : Minor symptoms evaluation profile ( MSEP ) was used to measure change in quality of life . Results The intervention programme led to sustained effects on lifestyle-related variables such as hypercholesterolaemia , body mass index and smoking habits , whereas diastolic blood pressure and HbA1c remained unchanged . The change in the MSEP during follow-up did not differ between the intervention and the usual care groups . There was a close relationship between the measurements of the three MSEP dimensions at baseline and at follow-up ( P < 0.0001 ) . None of the potential risk factors measured at entry was significantly associated with change in the three MSEP dimensions during follow-up . Conclusion The multiple risk factor intervention programme directed towards smoking habits , hypercholesterolaemia and the metabolic control of diabetes mellitus in treated hypertensive men at high cardiovascular risk was not associated with an impaired quality of life compared with that in a control group . The method used , the MSEP , has previously been found to be a reliable method with good validity , and this study 's results provide further evidence of its validity Although the benefits of antihypertensive treatment in " young " elderly ( under 70 years ) hypertensive patients are well established , the value of treatment in older patients ( 70 - 84 years ) is less clear . The Swedish Trial in Old Patients with Hypertension ( STOP-Hypertension ) was a prospect i ve , r and omised , double-blind , intervention study set up to compare the effects of active antihypertensive therapy ( three beta-blockers and one diuretic ) and placebo on the frequency of fatal and non-fatal stroke and myocardial infa rct ion and other cardiovascular death in hypertensive Swedish men and women aged 70 - 84 years . We recruited 1627 patients at 116 health centres throughout Sweden , who were willing to participate , and who met the entry criteria of three separate recordings during a 1-month placebo run-in period of systolic blood pressure between 180 and 230 mm Hg with a diastolic pressure of at least 90 mm Hg , or a diastolic pressure between 105 and 120 mm Hg irrespective of the systolic pressure . The total duration of the study was 65 months and the average time in the study was 25 months . 812 patients were r and omly allocated active treatment and 815 placebo . The mean difference in supine blood pressure between the active treatment and placebo groups at the last follow-up before an endpoint , death , or study termination was 19.5/8.1 mm Hg . Compared with placebo , active treatment significantly reduced the number of primary endpoints ( 94 vs 58 ; p = 0.0031 ) and stroke morbidity and mortality ( 53 vs 29 ; p = 0.0081 ) . Although we did not set out to study an effect on total mortality , we also noted a significantly reduced number of deaths in the active treatment group ( 63 vs 36 ; p = 0.0079 ) . The benefits of treatment were discernible up to age 84 years . We conclude that antihypertensive treatment in hypertensive men and women aged 70 - 84 confers highly significant and clinical ly relevant reductions in cardiovascular morbidity and mortality as well as in total mortality Objective To compare the effects of two antihypertensive treatment strategies for the prevention of coronary heart disease and other cardiovascular events in the large sub population ( n = 5137 ) with diabetes mellitus in the blood pressure-lowering arm of the Anglo-Sc and inavian Cardiac Outcomes Trial . Methods Patients had either untreated hypertension or treated hypertension . For those with type II diabetes mellitus , inclusion criteria required at least two additional risk factors . Patients were r and omized to amlodipine with addition of perindopril as required ( amlodipine-based ) or atenolol with addition of thiazide as required ( atenolol-based ) . Therapy was titrated to achieve a target blood pressure of less than 130/80 mmHg . Results The trial was terminated early due to significant benefits on mortality and stroke associated with the amlodipine-based regimen . In patients with diabetes mellitus , the amlodipine-based treatment reduced the incidence of the composite endpoint – total cardiovascular events and procedures – compared with the atenolol-based regimen ( hazard ratio 0.86 , confidence interval 0.76–0.98 , P = 0.026 ) . Fatal and nonfatal strokes were reduced by 25 % ( P = 0.017 ) , peripheral arterial disease by 48 % ( P = 0.004 ) and noncoronary revascularization procedures by 57 % ( P < 0.001 ) . For the other endpoints included in the composite , the endpoint differences were less clear including coronary heart disease deaths and nonfatal myocardial infa rct ions ( the primary endpoint ) , which were reduced nonsignificantly by 8 % ( hazard ratio 0.92 , confidence interval 0.74–1.15 ) . Conclusion In the large diabetic subgroup in the blood pressure-lowering arm of the Anglo-Sc and inavian Cardiac Outcomes Trial , the benefits of amlodipine-based treatment , compared with atenolol-based treatment , on the incidence of total cardiovascular events and procedures was significant ( 14 % reduction ) and similar to that observed in the total trial population ( 16 % reduction ) BACKGROUND In 1989 , the European Working Party on High Blood Pressure in the Elderly started the double-blind , placebo-controlled , Systolic Hypertension in Europe Trial to test the hypothesis that antihypertensive drug treatment would reduce the incidence of fatal and nonfatal stroke in older patients with isolated systolic hypertension . This report addresses whether the benefit of antihypertensive treatment varied according to sex , previous cardiovascular complications , age , initial blood pressure ( BP ) , and smoking or drinking habits in an intention-to-treat analysis and explores whether the morbidity and mortality results were consistent in a per- protocol analysis . METHODS After stratification for center , sex , and cardiovascular complications , 4695 patients 60 years of age or older with a systolic BP of 160 to 219 mm Hg and diastolic BP less than 95 mm Hg were r and omized . Active treatment consisted of nitrendipine ( 10 - 40 mg/d ) , with the possible addition of enalapril maleate ( 5 - 20 mg/d ) and /or hydrochlorothiazide ( 12.5 - 25 mg/d ) , titrated or combined to reduce the sitting systolic BP by at least 20 mm Hg , to below 150 mm Hg . In the control group , matching placebo tablets were employed similarly . RESULTS In the intention-to-treat analysis , male sex , previous cardiovascular complications , older age , higher systolic BP , and smoking at r and omization were positively and independently correlated with cardiovascular risk . Furthermore , for total ( P = .009 ) and cardiovascular ( P = .09 ) mortality , the benefit of antihypertensive drug treatment weakened with advancing age ; for total mortality ( P = .05 ) , the benefit increased with higher systolic BP at entry , while for fatal and nonfatal stroke ( P = .01 ) , it was most evident in nonsmokers ( 92.5 % of all patients ) . In the per protocol analysis , active treatment reduced total mortality by 24 % ( P = .05 ) , reduced all fatal and nonfatal cardiovascular end points by 32 % ( P<.001 ) , reduced all strokes by 44 % ( P = .004 ) , reduced nonfatal strokes by 48 % ( P = .005 ) , and reduced all cardiac end points , including sudden death , by 26 % ( P = .05 ) . CONCLUSIONS In elderly patients with isolated systolic hypertension , stepwise antihypertensive drug treatment , starting with the dihydropyridine calcium channel blocker nitrendipine , improves prognosis . The per- protocol analysis suggested that treating 1000 patients for 5 years would prevent 24 deaths , 54 major cardiovascular end points , 29 strokes , or 25 cardiac end points . The effects of antihypertensive drug treatment on total and cardiovascular mortality may be attenuated in very old patients
CONCLUSIONS Antihypertensive treatment reduces the risk of mortality and cardiovascular morbidity in people with diabetes mellitus and a systolic blood pressure more than 140 mm Hg .
If systolic blood pressure is less than 140 mm Hg , however , further treatment is associated with an increased risk of cardiovascular death , with no observed benefit
OBJECTIVE To assess the effect of antihypertensive treatment on mortality and cardiovascular morbidity in people with diabetes mellitus , at different blood pressure levels .