Department of Cardiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China.
Institute of Cardiovascular Disease, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China.
Cardiovasc Diabetol. 2019 Nov 16;18(1):160. doi: 10.1186/s12933-019-0959-1.
Controversies exist regarding the optimal blood pressure (BP) level that is safe and provides cardiovascular protection in patients with type 2 diabetes mellitus (T2DM) and coexistent coronary artery disease. Several new glucose-lowering agents have been found to lower BP as well, making the interaction between BP and T2DM even more complex.
With the reference to recent literature, this review article describes the potential mechanisms of increased risk of hypertension in T2DM and outlines the possible optimal BP levels based upon recommendations on the management of hypertension by the current guidelines, in combination with our research findings, for type 2 diabetic patients with coronary artery disease.
The development of hypertension in T2DM involves multiple processes, including enhanced sympathetic output, inappropriate activation of renin-angiotensin- aldosterone system, endothelial dysfunction induced through insulin resistance, and abnormal sodium handling by the kidney. Both AGE-RAGE axis and adipokine dysregulation activate intracellular signaling pathways, increase oxidative stress, and aggravate vascular inflammation. Pancreatic β-cell specific microRNAs are implicated in gene expression and diabetic complications. Non-pharmacological intervention with lifestyle changes improves BP control, and anti-hypertensive medications with ACEI/ARB, calcium antagonists, β-blockers, diuretics and new hypoglycemic agent SGLT2 inhibitors are effective to decrease mortality and prevent major adverse cardiovascular events. For hypertensive patients with T2DM and stable coronary artery disease, control of BP < 130/80 mmHg but not < 120/70 mmHg is reasonable, whereas for those with chronic total occlusion or acute coronary syndromes, an ideal BP target may be somewhat higher (< 140/90 mmHg). Caution is advised with aggressive lowering of diastolic BP to a critical threshold (< 60 mmHg).
Hypertension and T2DM share certain similar aspects of pathophysiology, and BP control should be individualized to minimize adverse events and maximize benefits especially for patients with T2DM and coronary artery disease.
在伴有冠状动脉疾病的 2 型糖尿病（T2DM）患者中，血压（BP）的安全水平和心血管保护作用存在争议。几种新的降糖药物也被发现具有降低 BP 的作用，这使得 BP 和 T2DM 之间的相互作用更加复杂。
本文参考了最新文献，描述了 T2DM 患者高血压风险增加的潜在机制，并根据当前指南对高血压管理的建议，结合我们的研究结果，为伴有冠状动脉疾病的 2 型糖尿病患者概述了可能的最佳 BP 水平。
T2DM 中高血压的发展涉及多个过程，包括增强的交感神经输出、肾素-血管紧张素-醛固酮系统的不当激活、胰岛素抵抗引起的内皮功能障碍以及肾脏对钠的异常处理。AGE-RAGE 轴和脂肪因子失调激活细胞内信号通路，增加氧化应激，加重血管炎症。胰腺β细胞特异性 microRNAs 参与基因表达和糖尿病并发症。生活方式改变的非药物干预可改善 BP 控制，ACEI/ARB、钙拮抗剂、β 受体阻滞剂、利尿剂和新型降糖药 SGLT2 抑制剂等抗高血压药物可有效降低死亡率并预防主要不良心血管事件。对于伴有 T2DM 和稳定冠状动脉疾病的高血压患者，将 BP 控制在 <130/80mmHg 但不低于 <120/70mmHg 是合理的，而对于伴有慢性完全闭塞或急性冠状动脉综合征的患者，理想的 BP 目标可能略高（< 140/90mmHg）。应谨慎将舒张压低至临界阈值（< 60mmHg）以下。
高血压和 T2DM 在病理生理学方面具有某些相似之处，BP 控制应个体化，以最大限度地减少不良反应并使患者获益，尤其是伴有 T2DM 和冠状动脉疾病的患者。
