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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EHypertension is present in more than two-thirds of patients with type 2 diabetes and its development can precede and predict the development of hyperglycemia, while impaired glucose tolerance can predict the development of hypertension. This article presents an overview of the comorbidity problems associated with hypertension and diabetes.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EHypertensive Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EHyperglycemia\/Hypoglycemia\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EDiabetes Mellitus\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EHypertension is present in more than two-thirds of patients with type 2 diabetes and its development can precede and predict the development of hyperglycemia, while impaired glucose tolerance can predict the development of hypertension. William C. Cushman, MD, Veterans Affairs Medical Center and University of Tennessee, Memphis, Tennessee, USA, presented an overview of the comorbidity problems associated with hypertension and diabetes.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003ETogether diabetes and hypertension increase the risk of cardiovascular (CV)-related death in men 4- to 6-fold [Stamler J et al. \u003Cem\u003EDiabetes Care\u003C\/em\u003E 1993] (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). Although it is generally agreed that reducing blood pressure (BP) is desirable, the exact target goal is in question. In one large study (n=4733), diabetic patients were randomized to intensive therapy (target systolic BP \u0026lt;120 mm Hg) or standard therapy (target systolic BP\u0026lt;140 mm Hg). Patients treated to the lower systolic BP goal did not experience a reduced rate of a composite outcome of fatal and nonfatal major CV events compared with the standard therapy [Cushman WC et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2010]. In Dr. Cushman\u0027s opinion a BP \u2264140\/85 mm Hg is a reasonable therapeutic goal in hypertensive patients with type 2 diabetes and can be achieved with number of BP-lowering regimens.\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/13\/30\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Elevated Systolic BP in Type 2 Diabetes Increases Cardiovascular Risk.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-532937099\u0022 data-figure-caption=\u0022Elevated Systolic BP in Type 2 Diabetes Increases Cardiovascular Risk.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/13\/30\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/13\/30\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/13\/30\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/14216\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-4\u0022 class=\u0022first-child\u0022\u003EElevated Systolic BP in Type 2 Diabetes Increases Cardiovascular Risk.\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EStamler J et al. Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial. \u003Cem\u003EDiabetes Care.\u003C\/em\u003E 1993;16(2):434\u201344.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-5\u0022\u003EHe recommends a renin-angiotensin system blocker combined with a thiazide-type diuretic as the most reasonable initial antihypertensive regimen for most people with diabetes, although calcium channel blockers (CCB) and a CCB\u2013angiotensin converting enzyme inhibitor (ACE) combination are also effective. Certain antihypertensive drugs can be associated with incident diabetes (the risk is lowest for angiotensin II receptor blockers and ACE inhibitors followed by CCBs and placebo, \u03b2-blockers, and highest for diuretics [Elliot WJ, Meyer PM. \u003Cem\u003ELancet\u003C\/em\u003E 2007]); however, Dr. Cushman advocated that the positive effects of antihypertensive drugs, especially thiazide-type diuretics, on CV outcomes outweigh their negative effects on glucose metabolism [Ferrannini E, Cushman WC. \u003Cem\u003ELancet\u003C\/em\u003E 2012].\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EBaroreflex stimulation and renal denervation are 2 new non-pharmacological treatments receiving attention for treating patients with drug-resistant hypertension (BP \u0026gt;140\/90 mm Hg on 3+ antihypertensive drugs in full- or highest-tolerated dose, 1 drug being a diuretic) that target the sympathetic nervous system. Murray Esler, MD, Baker IDI Heart and Diabetes Institute, Melbourne, Australia, presented data regarding the use of these new treatments.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EThe implantable baroreceptor stimulator is a device that delivers energy pulses targeting afferent nerve inputs to the carotid baroreceptors. These pulses are interpreted by the brain as a rise in BP, which then causes the brain to signal other parts of the body to reduce BP. In the largest clinical trial to-date using this device (n=265), 42% of patients receiving baroreflex activation therapy achieved systolic BP \u2264140 mm Hg at 6 months versus 24% not receiving the therapy (p=0.005; \u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E) [Bisognano JD et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2011].\u003C\/p\u003E\u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/13\/30\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Observed Mean Change in Systolic BP.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-532937099\u0022 data-figure-caption=\u0022Observed Mean Change in Systolic BP.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/13\/30\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/13\/30\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/13\/30\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/14218\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n            \u003Cp id=\u0022p-8\u0022 class=\u0022first-child\u0022\u003EObserved Mean Change in Systolic BP.\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EBAT=baroreflex activation therapy.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-3\u0022\u003EBisognano JD et al. Baroreflex activation therapy lowers blood pressure in patients with resistant hypertension. \u003Cem\u003EJ Am Coll Cardiol.\u003C\/em\u003E 2011;58(7):765\u201373.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-9\u0022\u003ERenal denervation has been shown to delay\/prevent the development of preclinical experimental forms of hypertension. The Renal Denervation in Patients With Uncontrolled Hypertension [Symplicity HTN-2] trial was a prospective, randomized trial in 106 treatment-resistant hypertensive patients with a baseline systolic BP \u2265160 mm Hg (\u2265150 mm Hg for type diabetics) in which catheter-based renal denervation using radio frequency was shown to reduce BP by 32\/12 mm Hg at 6 months [Symplicity HTN-2 Investigators et al. \u003Cem\u003ELancet\u003C\/em\u003E 2010] (\u003Ca id=\u0022xref-fig-3-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F3\u0022\u003EFigure 3\u003C\/a\u003E). Prof. Esler shared new data showing that the effect was still durable after 3 years, with no evidence of atherogenesis, fibrotic stenosis, renal artery aneurysm, deterioration in renal function, or orthostatic or electrolyte disturbances [Lenski M et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2012].\u003C\/p\u003E\u003Cdiv id=\u0022F3\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/13\/30\/F3.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Primary Endpoint: 6-Month Office BP.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-532937099\u0022 data-figure-caption=\u0022Primary Endpoint: 6-Month Office BP.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 3.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/13\/30\/F3.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/13\/30\/F3.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 3.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/13\/30\/F3.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/14221\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 3.\u003C\/span\u003E \n            \u003Cp id=\u0022p-10\u0022 class=\u0022first-child\u0022\u003EPrimary Endpoint: 6-Month Office BP.\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-4\u0022\u003EReproduced with permission from The \u003Cem\u003ELancet\u003C\/em\u003E; Symplicity HTN-2 Investigators. Renal sympathetic denervation in patients with treatment-resistant hypertension (The Symplicity HTN-2 Trial): A randomised controlled trial. 2010;376(9756):1903\u20139.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-11\u0022\u003EIn addition to significantly reducing BP, a small study suggests denervation may also improve glucose metabolism and insulin sensitivity [Mahfoud F et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2011]. Left ventricular (LV) hypertrophy and diastolic dysfunction are associated with elevated sympathetic activity and increased morbidity and mortality [Redfield MM et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2003; Bombeli M et al. \u003Cem\u003EJ Hypertens\u003C\/em\u003E 2009]. New evidence suggests renal denervation may improve LV and diastolic function. Six months after 46 resistant hypertensive patients underwent bilateral renal denervation, the patients experienced a significant reduction in LV mass and improved diastolic function in addition to significant BP reduction [Brandt MC et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2012].\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EThere is also evidence that renal denervation improves cardiorespiratory response to exercise. In a small study with 37 patients, renal denervation reduced BP during exercise without compromising chronotropic competence. Resting heart rate decreased and heart rate recovery improved after the procedure [Ukena C et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2011]. In another recent study, renal denervation safely reduced BP, renal resistive index, and the incidence of albuminuria without adversely affecting glomerular filtration rate (GFR) or renal artery structure within 6 months [Mahfoud F et al. \u003Cem\u003EHypertension\u003C\/em\u003E 2012] and may be equally effective in resistant hypertensive patients with Stage 3\/4 chronic kidney disease (mean estimated GFR 31 mL\/min\/1.73 m\u003Csup\u003E2\u003C\/sup\u003E) [Hering D et al. \u003Cem\u003EJ Am Soc Nephrol\u003C\/em\u003E 2012].\u003C\/p\u003E\u003Cp id=\u0022p-13\u0022\u003EKeys to good outcomes with renal denervation include good patient selection and a thorough preprocedural work-up. Alberto Cremonesi, MD, Villa Maria Cecilia Hospital, Cotignola, Italy, provided his insight regarding appropriate patient selection for renal denervation. It is important to establish that the patient is truly drug-resistant and is not undertreated, non-compliant, or taking other medications\/therapies that interfere with BP control. Contributing lifestyle factors (eg, obesity, physical inactivity, excessive alcohol ingestion, high salt intake) should be identified and treated, substances that interfere with BP should be addressed, and patients should also be screened for secondary causes of hypertension. The best treatment modality should maximize pharmacological treatment, which may include maximizing diuretic therapy, combining agents with different mechanisms of action, and using aldosterone antagonists such as spironalactone.\u003C\/p\u003E\u003Cp id=\u0022p-14\u0022\u003EFelix Mahfoud, MD, Universit\u00e4tsklinikum des Saarlandes, Homburg\/Saar, Germany, described his catheter-based approach to renal denervation. The renal nerves should receive \u22655 ablations (120 seconds each) separated both longitudinally and rotationally (spacing \u0026gt;5 mm) with ablation occurring distal to proximal. Prof. Mahfoud noted that a secondary rise in BP should not be expected after renal denervation and that the amount of BP reduction correlates to baseline systolic BP. It is best to use office BP to monitor BP changes, confirmed by ambulatory BP, he added. New treatment catheters using radiofrequency energy, new approaches using ultrasound, and chemical denervation are on the horizon. Although renal denervation shows promise as treatment for a variety of conditions, there remain unanswered questions such as its clinical durability, how to explain non-responders, whether its clinical indication can be expanded beyond hypertension, and whether new ablation systems will address anatomical limitations. These questions are likely to be answered by the Symplicity-HTN-3 trial, an ongoing randomized study in \u0026gt;500 hypertensive resistant patients.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2012 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/12\/13\/30.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nznbs1\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nznbs1\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}