The AHA Guidelines and Scientifi c Statements Handbook
used, however, if the serum creatinine level is
≥2.5 mg/dL in men or ≥2.0 mg/dL in women, or if
the serum potassium level is ≥5.0 mEq/L. Spirono-
lactone or eplerenone may be used together with a
thiazide diuretic, particularly in patients with refrac-
tory hypertension (Class I; Level of Evidence A).
Consider the addition of hydralazine/isosorbide
dinitrate to the regimen of diuretic, ACE inhibitor
or ARB, and β-blocker in black patients with NYHA
class III or IV heart failure (Class I; Level of Evidence
B). Others may benefi t similarly, but this has not yet
been tested.
Drugs to avoid in patients with HF and hyperten-
sion are nondihydropyridine CCBs (such as vera-
pamil and diltiazem), clonidine, and moxonidine
(Class III; Level of Evidence B). α-Adrenergic block-
ers, such as doxazosin, should be used only if other
drugs for the management of hypertension and HF
are inadequate to achieve BP control at maximum
tolerated doses (Class IIa; Level of Evidence B).
The target BP is <130/80 mm Hg, but consider-
ation should be given to lowering the BP even
further, to <120/80 mm Hg. The same caveats apply
as in “CAD and stable angina” above. (Class IIa;
Level of Evidence B).
Diabetes
American Diabetes Association published “Guide-
lines for the Treatment of Hypertension in Adults
with Diabetes” in 2003 [6]. These are the main
recommendations:
Blood pressure should be measured at every
routine diabetes visit. Patients found to have a BP of
≥130 mm Hg (systolic) or ≥80 mm Hg (diastolic)
should have blood pressure confi rmed on a separate
day. Orthostatic measurement of blood pressure
should be performed to assess for the presence of
autonomic neuropathy.
Tr e a t m e n t
Patients with diabetes should be treated to a
blood pressure <130/80 mm Hg. Patients with a
systolic blood pressure of 130–139 mm Hg or a
diastolic blood pressure of 80–89 mm Hg should
be given lifestyle/behavioral therapy alone for a
maximum of 3 months and then, if targets are
not achieved, should also be treated pharmacologi-
cally. Patients with hypertension (systolic blood
pressure ≥140 mm Hg or diastolic blood pressure
≥90 mm Hg) should receive drug therapy in addi-
tion to lifestyle/behavioral therapy.
The 2003 American Diabetes Association guide-
lines suggest that initial drug therapy may be with
any drug class currently indicated for the treatment
of hypertension, and state, further, that some drug
classes (ACE inhibitors, β-blockers, and diuretics)
have been repeatedly shown to be particularly ben-
efi cial in reducing CVD events during the treatment
of uncomplicated hypertension and are therefore
preferred agents for initial therapy. However more
recent meta-analyses have shown poorer outcomes
with β-blockers as initial therapy for patients without
coronary artery disease [25]. If ACE inhibitors are
not tolerated, ARBs may be used. Additional drugs
may be chosen from these classes or another drug
class. If ACE inhibitors or ARBs are used, monitor
renal function and serum potassium levels.
In patients with type 1 diabetes, with or without
hypertension, with any degree of albuminuria, ACE
inhibitors have been shown to delay the progression
of nephropathy. In patients with type 2 diabetes,
hypertension and microalbuminuria, ACE inhibi-
tors and ARBs have been shown to delay the pro-
gression to macroalbuminuria. In patients with
overt diabetic nephropathy, ARB slow the decline in
GFR and delay the development of end-stage renal
disease. In those with type 2 diabetes, hypertension,
macroalbuminuria (>300 mg/day), nephropathy, or
renal insuffi ciency, an ARB should be strongly con-
sidered. If one class is not tolerated, the other should
be substituted.
In patients over age 55 years, with hypertension
or without hypertension but with another cardio-
vascular risk factor (history of cardiovascular disease,
dyslipidemia, microalbuminuria, smoking), an ACE
inhibitor (if not contraindicated) should be consid-
ered to reduce the risk of cardiovascular events. In
patients with a recent myocardial infarction, β-
blockers, in addition, should be considered to reduce
mortality.Chronic kidney disease (CKD)
The National Kidney Foundation developed com-
prehensive guidelines “Kidney Disease Outcome
Quality Initiative (K/DOQI) Clinical Practice Guide-
lines on Hypertension and Antihypertensive Agents
in Chronic Kidney Disease” in 2004 [7]. The follow-
ing are extracts.