Erfolge der Blutdrucksenkung bei Diabetes-Patienten

Zusammenfassung

Entscheidend für die Prognoseverbesserung bei Typ-2-Diabetes ist die breite Umsetzung der Studienergebnisse auf Populationsebene durch eine Verbesserung der Qualität des Blutdruck-Managements. Bei Typ-2-Diabetikern sollten Blutdruckzielwerte von unter 130/80 mmHg angestrebt werden, die allerdings trotz antihypertensiver Kombinationstherapien in den Interventionsstudien bisher zumeist nicht erreicht wurden. Aufgrund der bei Patienten mit Mikroalbuminurie oder manifester diabetischer Nephropathie beträchtlich erhöhten kardiovaskulären Mortalität werden hier noch niedrigere Blutdruckwerte (z. B. von 120/80 mmHg) empfohlen. Ob durch besonders niedrige Blutdruckwerte deren kardiovaskuläre Mortalität weiter gesenkt werden kann, ist bisher noch unsicher. Die Blutdrucksenkung bei Diabetespatienten ist bezüglich der Risikosenkung und Prognoseverbesserung besonders effektiv und möglicherweise erfolgreicher als bei Nicht-Diabetikern. Die Frage nach einer antihypertensiven Monotherapie stellt sich bei Diabetikern relativ selten, da die überwiegende Mehrheit aller Typ-2-Diabetiker zumindest zwei oder oft mehrere Antihypertensiva benötigt, um die angestrebten Zielwerte zu erreichen. Der Effekt der Blutdrucksenkung auf kardiovaskuläre Komplikationen dürfte bei Diabetikern im Vergleich zu Nicht-Diabetikern deutlich stärker ausgeprägt sein, wofür das weitaus höhere Risiko der hypertensiven Diabetespatienten verantwortlich sein dürfte.

Summary

Diabetes and hypertension frequently coexist, and their combination provides additive increases in the risk of life-threatening cardiovascular events. Recent guidelines agree (JN-VII) on the need for early, aggressive reduction of blood pressure, with a goal of < 130/80 mmHg, in patients with diabetes. The mechanism responsible for the increased sensitivity of diabetics to hypertension is not known, but may involve attenuated nocturnal decrease (non-dipping) of blood pressure. Treatment of hypertension in type 2 diabetes provides dramatic cardiovascular benefit. Aggressive blood pressure control may be the most important factor in preventing adverse outcomes in patients with type 2 diabetes. Target diastolic blood pressures of less than 80 mm Hg and systolic targets less than 135 mm Hg appear optimal. All classes of antihypertensive agents are effective in reducing blood pressure in patients with diabetes, and all show evidence of a concomitant reduction in cardiovascular risk. Although there is evidence that agents that interrupt the renin-angiotensin system system may be superior in both the nephroprotection and cardioprotection, however the data are not totally conclusive. However, most diabetics and especially diabetic patients with nephropathy will require combination therapy („antihypertensive cocktail”) to reach goal blood pressure. Hypertensive patients have a significantly increased risk for the development of type 2 diabetes, and antihypertensive drugs can also significantly influence the risk for that. While diuretics and ß-blockers have a prodiabetic effect, angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers may prevent diabetes more effectively than the metabolically neutral calcium channel blockers.

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