ADVANCE in the Prevention of Cardiovascular Diseas

Authors: Mancia Giuseppe

Publish Date: 2007/07/01

Volume: 20, Issue: S1, Pages: 1S-2S

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Abstract

This supplement of the American Journal of Hypertension focuses on the problem of the association of diabetes and hypertension in the same patient and is based on data presented at a satellite symposium during the annual meeting of the European Society of Hypertension held in Milan Italy June 15 to 18 2007 There is probably no need to emphasize the importance of this topic for cardiovascular prevention and treatment It should suffice to say the following 1 Hypertension is a highly prevalent condition in Type 2 diabetes by far the most common form of diabetes In diabetes of several years duration 70 to 80 of individuals have this condition 2 The concomitance of these two conditions will be even more common in the future because the prevalence of diabetes shows a marked increase worldwide which is also true of hypertension 3 Both diabetes and hypertension are major cardiovascular risk factors and the risk is additive when the two conditions are present in the same patient The overall chance of having a cardiovascular event within 10 years is two to three times higher than that for either condition alone 4 Finally the cardiovascular risk for the diabetic patient with hypertension is not irreversible because either glucose control or blood pressurelowering interventions can to variable extents reduce diabetesrelated complications with a substantial advantage for the quality of life and life expectancy of the individual patient as well as for publichealth aims and costsThe following aspects deserve to be highlighted First bloodpressure reduction is highly protective in patients with Type 2 diabetes Both microvascular and macrovascular complications are clearly lessened when patients are on treatment that reduces their blood pressure to 140/90 mm Hg compared with values above that threshold More aggressive bloodpressure reduction and bloodpressure targets of 130/80 mm Hg are even more protective and the effects are similar with different types of treatment suggesting that the protection is due to blood pressurelowering per se Second to achieve the desired bloodpressure targets the administration of more than one antihypertensive drug is usually needed Indeed in diabetic patients included in intervention trials combination treatment was by far the most commonly used strategy The present consensus also maintains that a combination of two drugs is needed for the initiation of treatment because in highrisk individuals such as those with diabetes the rapid achievement of bloodpressure control is of clinical relevance a substantial increase in cardiovascular events caused by ineffective bloodpressure control may already be apparent within weeks or months Third there is also evidence that not all antihypertensive drugs are the same in terms of patient protection An important part of this supplement review is the finding that drugs such as inhibitors of the reninangiotensinaldosterone system are more effective in preventing the appearance and progression of diabetic nephropathy and that for a similar bloodpressure reduction their antiproteinuric effect ie their effect on an important marker of cardiovascular risk is more pronounced than that of other drug classes This is more extensively addressed with regard to the association of the angiotensinconverting enzyme inhibitor perindopril and the diuretic indapamide which combines the ability to effectively reduce blood pressure with evidence of protection against renal damage and other diabetesrelated complications perhaps because of a favorable effect on an emerging determinant of damage and cardiovascular risk ie central blood pressure Finally this supplement includes information on an important ongoing largescale study on treatment strategies in diabetes ADVANCE Trial Action in Diabetes and Vascular disease PreterAx and DiamicroN MR Controlled Evaluation This study was designed to determine whether bloodpressure lowering obtained with the fixed combination of perindopril plus indapamide reduces macrovascular and microvascular complications in patients with diabetes both hypertensive and normotensive who are already receiving optimal background treatment The study was also designed to investigate whether the reduction in macrovascular and microvascular events is observed when intensive bloodglucose control with gliclazide modified release MR is implemented This question was not resolved in previous studies Finally the ADVANCE Trial was designed to assess the benefits of either intervention alone and to determine whether the combined effects of the two treatment strategies can be additive and if they can substantially improve patient protection when used together All of this research will provide information of crucial importance that may substantially modify current treatment strategies in patients with diabetes who have variable degrees of bloodpressure abnormality

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