The Pressure to go Lower

English: Blood pressure measurement.

Blood pressure measurement.

Having high blood pressure or hypertension greatly increases the risk for onset and progression of morbidity in diabetics according to most clinical trials. However, no consensus yet exists for target goal blood pressures to maintain health in the diabetic population.

The diabetic with high blood pressure is at a heightened risk for heart disease and kidney damage. There is some evidence that the safety target for blood pressure should be much lower in diabetics than non-diabetics and yet most are not even reaching the targets of the normal population. So are the targets being set just unrealistic and is blood pressure just another symptom or a cause of kidney damage and heart disease?

Even in controlled trials only 10-30% of patients with diabetes and kidney disease achieve the recommended target blood pressure values. In real life with compliance and toxicity issues with antihypertensives, there is likely to be a much lower percentage success, as clinical trials are often designed and powered to get a maximum response. Therefore, it seems trite to set lower targets if normal targets are not even being hit in the first place.

Blood pressure is one of the oldest and most valued biometric measurements used in medicine. And yet in 25% of patients who get their blood pressure measured in the doctor’s surgery, the reading will be much higher than the actual blood pressure.

Blood pressure measurement in the surgery is completely unreliable as a medical measurement, but despite of this unreliability it is still used with such assurance and used for prescriptive purposes by many health professionals.

During a heartbeat, there are two blood pressure values that are of importance. The high value is called the systolic and the lower value is called diastolic.

High blood pressure is usually defined as a measurement that is above the value considered to be the normal 140/90mm Hg. This normal value is set in stone by our doctors, and yet there does not seem to be any viable explanation as to why it has been nominated as being normal. Normality may be variable from individual to individual and may also vary with age. So what is in fact a true normal and what does it mean?

For most medical professionals, systolic blood pressure is now thought to be the most important measure in terms of a marker of morbidity. Even relatively moderate levels of systolic blood pressure (SBP) are said to be predictive of an increased risk of cardiovascular events and stroke in some trials.

From some trials it is suggested that a difference of 20 mmHg systolic is associated with a significant doubling of risk at any age. The relationship for diastolic blood pressure tapers off at values below 80, so it is thought that only higher diastolic values are important in terms of health risk.

There is also evidence from some trials that lowering blood pressures, particularly in diabetic patients, will help protect their kidneys and hearts. Yet there is a range of blood pressure measurements and deciding which is the best predictor of renal damage is difficult to determine.

Again the timing of the measurement taken is suggested to be significant in trials. Night-time systolic blood pressure measurements seem to be the best predictor of risk. So measuring the blood pressure during the day may not be a true reflection of the average high blood pressure burden during the whole day at all.

There is also some evidence that intensified lowering blood pressures below the traditional target of 140/90 in patients with chronic kidney disease may be of clinical benefit. In diabetics patients, some studies have shown that possibly lowering the blood pressures by even only a small amount has a profound impact on the kidneys.

Similarly, trial evidence also suggests that non-diabetics with kidney disease tend to do better than diabetics with kidney disease.

Being a diabetic may have an impact on blood pressures. Also a different target blood pressure level may be required to protect the diabetic’s heart when compared with that required for protection of their kidneys.

If the diabetic patient has symptoms of cardiovascular disease, then lower blood pressures may be required to protect their kidneys. Similarly, it may be that lower blood pressures may be required to protect the heart of a diabetic who also has kidney disease and end organ damage.

However, according to some experts this does not necessarily mean that lower blood pressure is better for everyone. According to them it is important to tailor the blood pressure to fit each individual patient and for diabetics the most important thing seems to be to consider the presence or absence of cardiovascular problems that are already present.

Some studies have shown that even this is not without complexity. In particular, one study has shown that individuals with very low diastolic pressures (less than 70) may be at risk of a heart-attack and another study hinted at an increased risk of death in some patients with low systolic pressures (less than 120).

So it seems that it is important to select the candidates for more aggressive treatment and it is not a suit all. Selecting those at greatest risk of kidney damage and using this as a candidate criterion for intensive blood pressure lowering might be a good approach.

This includes patients with a family history of kidney disease, with metabolic syndrome or a family history of hypertension, patients with a history of gestational diabetes and/or a history of low birthweight or who have a heightened risk to kidney damage.

Reaching targets is the prime barrier to blood pressure management. Neglected aspects in patient management include high salt intake, underuse of diuretics, inappropriate timing of medications.

There is a need for alternative and safer antihypertensive agents, particularly for diabetics who may need to attain lower blood pressure targets because of heightened risks to their health.



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