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`American Diabetes Association
`Professional Practice Committee*
`
`31 May 2022. Sections 10 and 11
`have been updated to include
`evidence from trials of medication
`effects in patients with type 2
`diabetes on heart failure,
`cardiovascular, and chronic kidney
`disease outcomes, including
`EMPEROR-Preserved,
`PRESERVED-HF, FIDELIO-DKD,
`and FIGARO-DKD, and to remove
`information associated with the
`discontinued trial PROMINENT.
`
`The changes are described in detail
`in: Addendum. 10. Cardiovascular
`Disease and Risk Management:
`Standards of Medical Care in
`Diabetes—2022. Diabetes Care
`2022;45(Suppl. 1):S144–S174
`(https://doi.org/10.2337/dc22-
`ad08).
`And in: Addendum. 11. Chronic
`Kidney Disease and Risk
`Management: Standards of Medical
`Care in Diabetes—2022: Diabetes
`Care 2022;45(Suppl. 1):S175–S184
`(https://doi.org/10.2337/dc22-
`ad08a).
`
`*A complete list of members of the American
`Diabetes Association Professional Practice Com-
`mittee can be found at https://doi.org/10.2337/
`dc22-SPPC.
`
`This section has received endorsement from the
`American College of Cardiology.
`
`Suggested citation: American Diabetes Asso-
`ciation Professional Practice Committee. 10.
`Cardiovascular disease and risk management:
`Standards of Medical Care in Diabetes—2022.
`Diabetes Care 2022;45(Suppl. 1):S144–S175
`
`© 2021 by the American Diabetes Association.
`Readers may use this article as long as the
`work is properly cited, the use is educational
`and not for profit, and the work is not altered.
`More information is available at https://
`diabetesjournals.org/journals/pages/license.
`
`10. Cardiovascular Disease and
`Risk Management: Standardsof
`MedicalCareinDiabetes—2022
`
`Diabetes Care 2022;45(Suppl. 1):S144–S175 | https://doi.org/10.2337/dc22-S010
`
`The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes”
`includes the ADA’s current clinical practice recommendations and is intended to pro-
`vide the components of diabetes care, general treatment goals and guidelines, and
`tools to evaluate quality of care. Members of the ADA Professional Practice Commit-
`tee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are
`responsible for updating the Standards of Care annually, or more frequently as war-
`ranted. For a detailed description of ADA standards, statements, and reports, as well
`as the evidence-grading system for ADA’s clinical practice recommendations, please
`refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT).
`Readers who wish to comment on the Standards of Care are invited to do so at
`professional.diabetes.org/SOC.
`
`For prevention and management of diabetes complications in children and adoles-
`cents, please refer to Section 14, “Children and Adolescents” (https://doi.org/
`10.2337/dc22-S014).
`
`Atherosclerotic cardiovascular disease (ASCVD)—defined as coronary heart disease
`(CHD), cerebrovascular disease, or peripheral arterial disease presumed to be of
`atherosclerotic origin—is the leading cause of morbidity and mortality for individu-
`als with diabetes and results in an estimated $37.3 billion in cardiovascular-related
`spending per year associated with diabetes (1). Common conditions coexisting with
`type 2 diabetes (e.g., hypertension and dyslipidemia) are clear risk factors for
`ASCVD, and diabetes itself confers independent risk. Numerous studies have shown
`the efficacy of controlling individual cardiovascular risk factors in preventing or
`slowing ASCVD in people with diabetes. Furthermore, large benefits are seen when
`multiple cardiovascular risk factors are addressed simultaneously. Under the cur-
`rent paradigm of aggressive risk factor modification in patients with diabetes, there
`is evidence that measures of 10-year coronary heart disease (CHD) risk among U.S.
`adults with diabetes have improved significantly over the past decade (2) and that
`ASCVD morbidity and mortality have decreased (3,4).
`Heart failure is another major cause of morbidity and mortality from cardio-
`vascular disease. Recent studies have found that rates of incident heart failure
`hospitalization (adjusted for age and sex) were twofold higher in patients with
`diabetes compared with those without (5,6). People with diabetes may have
`heart failure with preserved ejection fraction (HFpEF) or with reduced ejection
`fraction (HFrEF). Hypertension is often a precursor of heart failure of either
`type, and ASCVD can coexist with either type (7), whereas prior myocardial
`infarction (MI) is often a major factor in HFrEF. Rates of heart failure hospitali-
`zation have been improved in recent trials including patients with type 2
`
`10.CARDIOVASCULARDISEASEANDRISKMANAGEMENT
`
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`
`ASCVD risk and help guide therapy, as
`described below.
`Recently, risk scores and other cardio-
`vascular biomarkers have been dev-
`eloped for risk stratification of secondary
`prevention patients (i.e., those who are
`already high risk because they have
`ASCVD) but are not yet in widespread
`use (15,16). With newer, more expensive
`lipid-lowering therapies now available,
`use of these risk assessments may help
`target these new therapies to “higher
`risk” ASCVD patients in the future.
`
`HYPERTENSION/BLOOD PRESSURE
`CONTROL
`Hypertension, defined as a sustained
`blood pressure $140/90 mmHg, is com-
`mon among patients with either type 1 or
`type 2 diabetes. Hypertension is a major
`risk factor for both ASCVD and microvas-
`cular complications. Moreover, numerous
`studies have shown that antihypertensive
`therapy reduces ASCVD events, heart fail-
`ure, and microvascular
`complications.
`Please refer to the American Diabetes
`Association (ADA) position statement
`“Diabetes
`and Hypertension”
`for
`a
`detailed review of the epidemiology, diag-
`nosis, and treatment of hypertension (17).
`
`Screening and Diagnosis
`
`Recommendations
`10.1 Blood pressure should be mea-
`sured at every routine clinical
`visit. When possible, patients
`found to have elevated blood
`($140/90 mmHg)
`pressure
`should have blood pressure
`confirmed using multiple read-
`ings,
`including measurements
`on a separate day, to diagnose
`hypertension. A Patients with
`blood pressure $180/110 mmHg
`and cardiovascular disease could
`be diagnosed with hypertension
`at a single visit. E
`10.2 All hypertensive patients with
`diabetes should monitor their
`blood pressure at home. A
`
`Blood pressure should be measured at
`every routine clinical visit by a trained
`individual and should follow the guide-
`lines established for the general popu-
`lation: measurement
`in the seated
`position, with feet on the floor and
`arm supported at heart level, after 5
`
`diabetes, most of whom also had
`ASCVD, with sodium–glucose cotrans-
`porter 2 (SGLT2) inhibitors (8–10).
`For prevention and management of
`both ASCVD and heart failure, cardiovas-
`cular risk factors should be systematically
`assessed at least annually in all patients
`with diabetes. These risk factors include
`duration of diabetes, obesity/overweight,
`hypertension, dyslipidemia, smoking, a
`family history of premature coronary dis-
`ease, chronic kidney disease, and the
`presence of
`albuminuria. Modifiable
`abnormal risk factors should be treated
`as described in these guidelines. Notably,
`the majority of evidence supporting inter-
`ventions to reduce cardiovascular risk in
`diabetes comes from trials of patients
`with type 2 diabetes. Few trials have
`been specifically designed to assess the
`impact of cardiovascular risk reduction
`strategies in patients with type 1 diabetes.
`As depicted in Fig. 10.1, a comprehen-
`sive approach to the reduction in risk of
`diabetes-related complications is recom-
`mended. Therapy that includes multiple,
`concurrent evidence-based approaches
`to care will provide complementary
`reduction in the risks of microvascular,
`kidney, neurologic, and cardiovascular
`complications. Management of glycemia,
`
`blood pressure, and lipids and the incor-
`poration of specific therapies with car-
`diovascular and kidney outcomes benefit
`(as individually appropriate) are consid-
`ered fundamental elements of global risk
`reduction in diabetes.
`
`THE RISK CALCULATOR
`The American College of Cardiology/
`American Heart Association ASCVD risk
`calculator (Risk Estimator Plus) is gener-
`ally a useful tool to estimate 10-year risk
`of a first ASCVD event (available online
`at
`tools.acc.org/ASCVD-Risk-Estimator-
`Plus). The calculator includes diabetes
`as a risk factor, since diabetes itself
`confers
`increased risk
`for ASCVD,
`although it should be acknowledged
`that
`these risk calculators do not
`account for the duration of diabetes or
`the presence of diabetes complications,
`such as albuminuria. Although some
`variability in calibration exists in various
`subgroups, including by sex, race, and
`diabetes,
`the overall
`risk prediction
`does not differ in those with or without
`diabetes (11–14), validating the use of
`risk calculators in people with diabetes.
`The 10-year risk of a first ASCVD event
`should be assessed to better stratify
`
`REDUCTION IN DIABETES COMPLICATIONS
`
`Glycemic
`Management
`
`Blood Pressure
`Management
`
`Lipid
`Management
`
`Agents with
`cardiovascular
`and Kidney
`
`~ ~ ~ Benefit*
`/!J
`0 LIFESTYLE MODIFICATION AND DIABETES EDUCATION 0
`
`Figure 10.1—Multifactorial approach to reduction in risk of diabetes complications. *Risk reduc-
`tion interventions to be applied as individually appropriate.
`
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`min of rest. Cuff size should be appro-
`priate for
`the upper-arm circumfer-
`ence. Elevated values should preferably
`be confirmed on a separate day; how-
`ever,
`in patients with cardiovascular
`disease and blood pressure $180/110
`mmHg,
`it is reasonable to diagnose
`hypertension at a single visit (18). Pos-
`tural changes in blood pressure and
`pulse may be evidence of autonomic
`neuropathy
`and
`therefore
`require
`adjustment of blood pressure targets.
`Orthostatic blood pressure measure-
`ments should be checked on initial visit
`and as indicated.
`Home blood pressure self-monitoring
`and 24-h ambulatory blood pressure
`monitoring may provide evidence of
`white coat hypertension, masked hyper-
`tension, or other discrepancies between
`“true”
`office
`and
`blood
`pressure
`(17,18a,18b). In addition to confirming
`or refuting a diagnosis of hypertension,
`home blood pressure assessment may
`be useful to monitor antihypertensive
`treatment. Studies of individuals without
`diabetes found that home measure-
`ments may better correlate with ASCVD
`risk than office measurements (19,20).
`Moreover, home blood pressure moni-
`toring may improve patient medication
`adherence and thus help reduce cardio-
`vascular risk (21).
`
`Treatment Goals
`
`Recommendations
`10.3 For patients with diabetes and
`hypertension, blood pressure tar-
`gets
`should be individualized
`through a shared decision-making
`process that addresses cardiovas-
`cular
`risk, potential adverse
`effects
`of
`antihypertensive
`medications, and patient pref-
`erences. B
`10.4 For individuals with diabetes
`and hypertension at higher
`cardiovascular
`risk (existing
`atherosclerotic cardiovascular
`disease [ASCVD] or 10-year
`ASCVD risk $15%), a blood
`pressure target of <130/80
`mmHg may be appropriate, if
`it can be safely attained. B
`10.5 For individuals with diabetes
`and hypertension at lower risk
`for cardiovascular disease (10-
`year atherosclerotic cardiovas-
`cular disease risk <15%), treat
`
`to a blood pressure target of
`<140/90 mmHg. A
`10.6 In pregnant patients with dia-
`betes and preexisting hyper-
`tension,
`a blood pressure
`target of 110–135/85 mmHg is
`suggested in the interest of
`reducing the risk for acceler-
`ated maternal hypertension A
`and minimizing impaired fetal
`growth. E
`
`Randomized clinical trials have demon-
`strated unequivocally that treatment of
`hypertension to blood pressure <140/
`90 mmHg reduces cardiovascular events
`as well as microvascular complications
`(22–28). Therefore, patients with type 1
`or type 2 diabetes who have hyperten-
`sion should, at a minimum, be treated
`to blood pressure targets of <140/90
`mmHg. The benefits and risks of intensi-
`fying antihypertensive therapy to target
`blood pressures lower than <140/90
`mmHg (e.g., <130/80 or <120/80
`mmHg) have been evaluated in large
`randomized clinical trials and meta-anal-
`yses of clinical trials. Notably, there is
`an absence of high-quality data avail-
`able to guide blood pressure targets in
`type 1 diabetes.
`
`Randomized Controlled Trials of Intensive
`Versus Standard Blood Pressure Control
`The Action to Control Cardiovascular
`Risk in Diabetes Blood Pressure (ACCORD
`BP) trial provides the strongest direct
`assessment of the benefits and risks of
`intensive blood pressure control among
`people with type 2 diabetes (29).
`In
`ACCORD BP, compared with standard
`blood pressure control
`(target
`systolic
`blood pressure <140 mmHg), intensive
`blood pressure control (target systolic
`blood pressure <120 mmHg) did not
`reduce
`total major
`atherosclerotic
`cardiovascular events but did reduce
`the risk of stroke, at the expense of inc-
`reased adverse events (Table 10.1). The
`ACCORD BP results suggest that blood
`pressure targets more intensive than
`<140/90 mmHg are not likely to imp-
`rove cardiovascular outcomes among
`most people with type 2 diabetes but
`may be reasonable for patients who may
`derive the most benefit and have been
`educated about added treatment bur-
`den, side effects, and costs, as discussed
`below.
`
`Additional studies, such as the Sys-
`tolic Blood Pressure Intervention Trial
`(SPRINT) and the Hypertension Optimal
`Treatment (HOT) trial, also examined
`effects of
`intensive versus standard
`control (Table 10.1), though the rele-
`vance of their results to people with
`diabetes is less clear. The Action in
`Diabetes and Vascular Disease: Pre-
`terax and Diamicron MR Controlled
`Evaluation–Blood Pressure (ADVANCE
`BP) trial did not explicitly test blood
`pressure targets (30);
`the achieved
`blood pressure in the intervention
`group was higher than that achieved
`in the ACCORD BP intensive arm and
`would be consistent with a target
`blood pressure of <140/90 mmHg.
`Notably, ACCORD BP and SPRINT mea-
`sured blood pressure using automated
`office blood pressure measurement,
`which yields values that are generally
`lower than typical office blood pres-
`sure readings by approximately 5–10
`mmHg (31), suggesting that
`imple-
`menting the ACCORD BP or SPRINT
`protocols in an outpatient clinic might
`require a systolic blood pressure tar-
`get higher than <120 mmHg, such as
`<130 mmHg.
`A number of post hoc analyses have
`attempted to explain the apparently
`divergent results of ACCORD BP and
`SPRINT. Some investigators have argued
`that the divergent results are not due
`to differences between people with and
`without diabetes but rather are due to
`differences in study design or to charac-
`teristics other than diabetes (32–34).
`Others have opined that the divergent
`results are most readily explained by
`the lack of benefit of intensive blood
`pressure control on cardiovascular mor-
`tality in ACCORD BP, which may be due
`to differential mechanisms underlying
`cardiovascular disease in type 2 diabe-
`tes, to chance, or both (35). Interest-
`ingly, a post hoc analysis has found that
`intensive
`blood
`pressure
`lowering
`increased the risk of incident chronic
`kidney disease in both ACCORD BP and
`SPRINT, with the absolute risk of inci-
`dent
`chronic
`kidney disease being
`higher in individuals with type 2 diabe-
`tes (36).
`
`Meta-analyses of Trials
`To clarify optimal blood pressure targets
`in patients with diabetes, meta-analyses
`have stratified clinical
`trials by mean
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`
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`Table 10.1—Randomized controlled trials of intensive versus standard hypertension treatment strategies
`
`Clinical trial
`
`ACCORD BP (29)
`
`Population
`
`Intensive
`
`Standard
`
`4,733 participants with T2D
`aged 40–79 years with
`prior evidence of CVD or
`multiple cardiovascular
`risk factors
`
`SBP target:
`<120 mmHg
`Achieved (mean)
`SBP/DBP:
`119.3/64.4 mmHg
`
`SBP target:
`130–140 mmHg
`Achieved (mean)
`SBP/DBP:
`135/70.5 mmHg
`
`ADVANCE BP (30)
`
`11,140 participants with
`T2D aged 55 years and
`older with prior
`evidence of CVD or
`multiple cardiovascular
`risk factors
`
`Intervention: a single-pill,
`fixed-dose combination
`of perindopril and
`indapamide
`Achieved (mean)
`SBP/DBP:
`136/73 mmHg
`
`Control: placebo
`Achieved (mean)
`SBP/DBP:
`141.6/75.2 mmHg
`
`HOT (220)
`
`18,790 participants,
`including 1,501
`with diabetes
`
`DBP target:
`#90 mmHg
`
`DBP target:
`#80 mmHg
`Achieved (mean):
`81.1 mmHg, #80
`group; 85.2 mmHg,
`#90 group
`
`SPRINT (41)
`
`9,361 participants
`without diabetes
`
`SBP target:
`<120 mmHg
`Achieved (mean):
`121.4 mmHg
`
`SBP target:
`<140 mmHg
`Achieved (mean):
`136.2 mmHg
`
`Outcomes
` No benefit in primary end point:
`composite of nonfatal MI,
`nonfatal stroke, and CVD death
` Stroke risk reduced 41% with
`intensive control, not sustained
`through follow-up beyond the
`period of active treatment
` Adverse events more common
`in intensive group, particularly
`elevated serum creatinine and
`electrolyte abnormalities
` Intervention reduced risk of
`primary composite end point of
`major macrovascular and
`microvascular events (9%),
`death from any cause (14%),
`and death from CVD (18%)
` 6-year observational follow-up
`found reduction in risk of death
`in intervention group attenuated
`but still significant (198)
` In the overall trial, there was no
`cardiovascular benefit with
`more intensive targets
` In the subpopulation with
`diabetes, an intensive DBP
`target was associated with a
`significantly reduced risk (51%)
`of CVD events
` Intensive SBP target lowered
`risk of the primary composite
`outcome 25% (MI, ACS, stroke,
`heart failure, and death due to
`CVD)
` Intensive target reduced risk of
`death 27%
` Intensive therapy increased risks
`of electrolyte abnormalities and
`AKI
`
`ACCORD BP, Action to Control Cardiovascular Risk in Diabetes Blood Pressure trial; ACS, acute coronary syndrome; ADVANCE BP, Action in Diabetes and
`Vascular Disease: Preterax and Diamicron MR Controlled Evaluation–Blood Pressure trial; AKI, acute kidney injury; CVD, cardiovascular disease; DBP, dia-
`stolic blood pressure; HOT, Hypertension Optimal Treatment trial; MI, myocardial infarction; SBP, systolic blood pressure; SPRINT, Systolic Blood Pressure
`Intervention Trial; T2D, type 2 diabetes. Data from this table can also be found in the ADA position statement “Diabetes and Hypertension” (17).
`
`baseline blood pressure or mean blood
`pressure attained in the intervention (or
`intensive treatment) arm. Based on these
`analyses, antihypertensive treatment appears
`to be beneficial when mean baseline blood
`pressure is $140/90 mmHg or mean
`attained intensive blood pressure is $130/
`80 mmHg (17,22,23,25–27). Among trials
`with lower baseline or attained blood pres-
`sure, antihypertensive treatment reduced
`the risk of stroke, retinopathy, and albumin-
`uria, but effects on other ASCVD outcomes
`and heart failure were not evident. Taken
`together, these meta-analyses consistently
`show that treating patients with baseline
`
`pressure $140 mmHg
`to
`blood
`targets <140 mmHg is beneficial, while
`more intensive targets may offer additional
`(though probably less robust) benefits.
`
`Individualization of Treatment Targets
`Patients and clinicians should engage in a
`shared decision-making process to deter-
`mine individual blood pressure targets
`(17). This approach acknowledges that
`the benefits and risks of intensive blood
`pressure targets are uncertain and may
`vary across patients and is consistent
`with a patient-focused approach to care
`that values patient priorities and provider
`
`judgment (37). Secondary analyses of
`ACCORD BP and SPRINT suggest that clin-
`ical factors can help determine individu-
`als more likely to benefit and less likely
`to be harmed by intensive blood pres-
`sure control (38,39).
`Absolute benefit from blood pressure
`reduction correlated with absolute
`baseline cardiovascular risk in SPRINT
`and in earlier clinical trials conducted at
`higher baseline blood pressure levels
`(11,39). Extrapolation of these studies
`suggests that patients with diabetes
`may also be more likely to benefit from
`intensive blood pressure control when
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`they have high absolute cardiovascular
`risk. Therefore, it may be reasonable to
`target blood pressure <130/80 mmHg
`among patients with diabetes and
`either clinically diagnosed cardiovascu-
`lar disease (particularly stroke, which
`was significantly reduced in ACCORD
`BP) or 10-year ASCVD risk $15%, if it
`can be attained safely. This approach is
`consistent with guidelines
`from the
`American College of Cardiology/Ameri-
`can Heart Association, which advocate a
`blood pressure target <130/80 mmHg
`for all patients, with or without diabetes
`(40).
`Potential adverse effects of antihy-
`pertensive therapy (e.g., hypotension,
`syncope, falls, acute kidney injury, and
`electrolyte abnormalities) should also
`be taken into account
`(29,36,41,42).
`Patients with older age, chronic kidney
`disease, and frailty have been shown to
`be at higher risk of adverse effects of
`intensive blood pressure control (42). In
`addition, patients with orthostatic hypo-
`tension, substantial comorbidity, func-
`tional limitations, or polypharmacy may
`be at high risk of adverse effects, and
`some patients may prefer higher blood
`pressure targets to enhance quality of
`life. However,
`in ACCORD BP,
`it was
`found that
`intensive blood pressure
`lowering
`decreased
`the
`risk
`of
`cardiovascular events
`irrespective of
`baseline diastolic blood pressure in
`patients who also received standard gly-
`cemic control (43). Therefore, the pres-
`ence of low diastolic blood pressure is
`not
`necessarily
`a
`contraindication
`to more intensive blood pressure man-
`agement in the context of otherwise
`standard care.
`Patients with low absolute cardiovas-
`cular risk (10-year ASCVD risk <15%) or
`with a history of adverse effects of
`intensive blood pressure control or at
`high risk of adverse effects should have
`a higher blood pressure target. In such
`patients, a blood pressure target of
`<140/90 mmHg is recommended, if it
`can be safely attained.
`
`Pregnancy and Antihypertensive Medications
`There are few randomized controlled tri-
`als of antihypertensive therapy in preg-
`nant women with diabetes. A 2014
`Cochrane systematic review of antihyper-
`tensive therapy for mild to moderate
`chronic hypertension that included 49 tri-
`als and over 4,700 women did not find
`
`any conclusive evidence for or against
`blood pressure treatment to reduce the
`risk of preeclampsia for the mother or
`effects on perinatal outcomes such as
`preterm birth, small-for-gestational-age
`infants, or fetal death (44). The more
`recent Control of Hypertension in Preg-
`nancy Study (CHIPS) (45) enrolled mostly
`women with chronic hypertension.
`In
`CHIPS, targeting a diastolic blood pres-
`sure of 85 mmHg during pregnancy was
`associated with reduced likelihood of
`developing accelerated maternal hyper-
`tension and no demonstrable adverse
`outcome for infants compared with tar-
`geting a higher diastolic blood pressure.
`The mean
`systolic
`blood
`pressure
`achieved in the more intensively treated
`group was 133.1 ± 0.5 mmHg, and the
`mean diastolic blood pressure achieved
`in that group was 85.3 ± 0.3 mmHg. A
`similar approach is supported by the
`International Society for the Study of
`Hypertension in Pregnancy, which specifi-
`cally recommends use of antihyperten-
`sive therapy to maintain systolic blood
`pressure between 110 and 140 mmHg
`and diastolic blood pressure between 80
`and 85 mmHg (46). Current evidence
`supports controlling blood pressure to
`110–135/85 mmHg to reduce the risk of
`accelerated maternal hypertension but
`also to minimize impairment of
`fetal
`growth. During pregnancy,
`treatment
`with ACE inhibitors, angiotensin receptor
`blockers, and spironolactone are contra-
`indicated as they may cause fetal dam-
`age. Antihypertensive drugs known to be
`effective and safe in pregnancy include
`methyldopa,
`labetalol, and long-acting
`nifedipine, while hydralzine may be con-
`sidered in the acute management of
`hypertension in pregnancy or severe
`preeclampsia (47). Diuretics are not rec-
`ommended for blood pressure control in
`pregnancy but may be used during late-
`stage pregnancy if needed for volume
`control (47,48). The American College of
`Obstetricians and Gynecologists also rec-
`ommends that postpartum patients with
`gestational hypertension, preeclampsia,
`and superimposed preeclampsia have
`their blood pressures observed for 72 h
`in the hospital and for 7–10 days post-
`partum. Long-term follow-up is recom-
`mended for these women as they have
`increased lifetime cardiovascular
`risk
`(49). See Section 15, “Management
`of Diabetes in Pregnancy” (https://
`
`doi.org/10.2337/dc22-S015), for add-
`itional information.
`
`Treatment Strategies
`Lifestyle Intervention
`
`Recommendation
`10.7 For patients with blood pres-
`sure >120/80 mmHg,
`life-
`style intervention consists of
`weight loss when indicated, a
`Dietary Approaches to Stop
`Hypertension (DASH)-style eating
`pattern including reducing sodium
`and increasing potassium intake,
`moderation of alcohol
`intake,
`and increased physical activity. A
`
`Lifestyle management is an important
`component of hypertension treatment
`because it lowers blood pressure, enhan-
`ces the effectiveness of some antihyper-
`tensive medications, promotes other
`aspects of metabolic and vascular health,
`and generally leads
`to few adverse
`effects.
`Lifestyle therapy consists of
`reducing excess body weight
`through
`caloric restriction (see Section 8, “Obesity
`and Weight Management for the Preven-
`tion and Treatment of Type 2 Diabetes,”
`https://doi.org/10.2337/dc22-S008),
`restricting sodium intake (<2,300 mg/
`day), increasing consumption of fruits
`and vegetables (8–10 servings per
`day) and low-fat dairy products (2–3
`servings per day), avoiding excessive
`alcohol consumption (no more than 2
`servings per day in men and no more
`than 1 serving per day in women)
`(50), and increasing activity levels
`(51).
`These lifestyle interventions are rea-
`sonable for individuals with diabetes and
`mildly elevated blood pressure (systolic
`>120 mmHg or diastolic >80 mmHg)
`and should be initiated along with phar-
`macologic therapy when hypertension is
`diagnosed (Fig. 10.2) (51). A lifestyle ther-
`apy plan should be developed in collabo-
`ration with the patient and discussed as
`part of diabetes management. Use of
`internet or mobile-based digital platforms
`to reinforce healthy behaviors may be
`considered as a component of care, as
`these interventions have been found to
`enhance the efficacy of medical therapy
`for hypertension (52,53).
`
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`
`Cardiovascular Disease and Risk Management
`
`S149
`
`Pharmacologic Interventions
`
`Recommendations
`10.8 Patients with confirmed office-
`based blood pressure $140/
`90 mmHg should, in addition
`to lifestyle therapy, have prompt
`initiation and timely titration
`of
`pharmacologic
`therapy
`
`to achieve blood pressure
`goals. A
`10.9 Patients with confirmed office-
`based blood pressure $160/
`100 mmHg should, in addition
`to
`lifestyle
`therapy,
`have
`prompt
`initiation and timely
`titration of two drugs or a sin-
`gle-pill combination of drugs
`
`demonstrated to reduce car-
`diovascular events in patients
`with diabetes. A
`10.10 Treatment
`for hypertension
`should include drug classes
`demonstrated to reduce car-
`diovascular events in patients
`with diabetes. A ACE inhibitors
`or
`angiotensin
`receptor
`
`Recommendations for the Treatment of
`
`Confirmed Hypertension in People With Diabetes ,g,_,
`
`~~
`
`Initial BP >140/90 and
`<160/100 mmHg
`
`Initial BP 2:160/100 mmHg
`
`Start one agent
`
`Lifestyle management
`
`Start two agents
`
`Albuminuria or CAD*
`
`Albuminuria or CAD*
`
`No
`
`Yes
`
`No
`
`Yes
`
`Start one drug:
`■ ACEi or ARB
`• CCB***
`■ Diuretic**
`
`Start:
`■ ACEi or ARB
`
`Start drug from
`2 of 3 options:
`■ ACEi or ARB
`
`Start:
`■ ACEi or ARB
`and
`■ CCB*** or Diuretic**
`
`Treatment tolerated
`and target achieved
`
`Continue therapy
`
`Not meeting target
`on two agents
`
`Not meeting target
`
`Adverse effects
`
`Add agent from
`complementary drug class:
`■ ACEi or ARB
`■ CCB***
`■ Diuretic**
`
`Consider change to
`alternative medication:
`• ACEi or ARB
`• CCB***
`• Diuretic**
`
`Treatment tolerated
`and target achieved
`
`Not meeting target or
`adverse effects using a drug
`from each of three classes
`
`Continue therapy
`
`Consider Addition of Mineralocorticoid Receptor Antagonist;
`Refer to Specialist With Expertise in BP Management
`
`Figure 10.2—Recommendations for the treatment of confirmed hypertension in people with diabetes. *An ACE inhibitor (ACEi) or angiotensin
`receptor blocker (ARB) is suggested to treat hypertension for patients with coronary artery disease (CAD) or urine albumin-to-creatinine ratio
`30–299 mg/g creatinine and strongly recommended for patients with urine albumin-to-creatinine ratio $300 mg/g creatinine. **Thiazide-like
`diuretic; long-acting agents shown to reduce cardiovascular events, such as chlorthalidone and indapamide, are preferred. ***Dihydropyridine cal-
`cium channel blocker (CCB). BP, blood pressure. Adapted from de Boer et al. (17).
`
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`
`recommended
`are
`blockers
`first-line therapy for hyperten-
`sion in people with diabetes
`and coronary artery disease. A
`10.11 Multiple-drug therapy is gener-
`ally required to achieve blood
`pressure targets. However, com-
`binations of ACE inhibitors and
`angiotensin receptor blockers
`and combinations of ACE inhibi-
`tors or angiotensin receptor
`blockers with direct renin inhibi-
`tors should not be used. A
`10.12 An ACE inhibitor or angiotensin
`receptor blocker, at the maxi-
`mum tolerated dose indicated
`for blood pressure treatment,
`is the recommended first-line
`treatment for hypertension in
`patients with diabetes and uri-
`nary albumin-to-creatinine ratio
`$300 mg/g creatinine A or
`30–299 mg/g creatinine. B If
`one class is not tolerated, the
`other should be substituted. B
`10.13 For patients treated with an
`ACE inhibitor, angiotensin recep-
`tor blocker, or diuretic, serum
`creatinine/estimated glomerular
`filtration rate and serum potas-
`sium levels should be moni-
`tored at least annually. B
`
`Initial Number of Antihypertensive Medi-
`cations. Initial treatment for people with
`diabetes depends on the severity of
`hypertension (Fig. 10.2). Those with
`blood pressure between 140/90 mmHg
`and 159/99 mmHg may begin with a sin-
`gle drug. For patients with blood pressure
`$160/100 mmHg,
`initial pharmacologic
`treatment with two antihypertensive
`medications is recommended in order to
`more effectively achieve adequate blood
`pressure control (54–56). Single-pill anti-
`hypertensive combinations may improve
`medication adherence in some patients
`(57).
`
`Classes of Antihypertensive Medications.
`Initial
`treatment
`for
`hypertension
`should include any of the drug classes
`demonstrated to reduce cardiovascular
`events in patients with diabetes: ACE
`inhibitors (58,59), angiotensin receptor
`blockers
`(ARBs)
`(58,59),
`thiazide-like
`diuretics (60), or dihydropyridine cal-
`cium channel blockers (61). In patients
`with diabetes and established coronary
`
`artery disease, ACE inhibitors or ARBs
`are recommended first-line therapy for
`hypertension (62–64). For patients with
`albumi