Review on Coexistence of Hypertension with Diabetes Mellitus

The coexistence of both diabetes mellitus and hypertension affect the some major target organs. Their common target organ is heart and kidney. The primary goal in the management of the hypertensive diabetic patients is lowering blood pressure to less than 130/80mm Hg Betablockers have been reported to adversely affect the overall risk factor profile in the diabetic patient. Initially ACE inhibitors and ARB are initially can be given to diabetic hypertensive. Beta blockers also show great effects in preventing further cardiovascular diseases in diabetic hypertensive. Although combined drug therapy is usually required to achieve goal but in addition to drug therapy some other precautions should also plays effective role like exercise ،low sodium chloride intake, lower lipids in diet, maintaining glucose level, stress less patients environment. Calcium channels blockers and diuretics in combination with ACE inhibitors and antidiabetic drugs will also exerts beneficial effects.


INTRODUCTION
Hypertension elevated Blood pressure and diabetes elevated blood glucose level both frequently coexists. By occurring individually they both lead to several cardiac diseases but when they coexist may increase the risk for cardiovascular and renal diseases [1,2]. Diabetes and hypertension coexist in approximately 40 to 60% of patients with type 2 diabetes. Diabetics subjects have a 1.5 -3 times increased prevalence of hypertension compared to nondiabetics Hypertension itself is a strong threat for other cardiovascular disease such as stroke, myocardial infarction, angina, peripheral arterial diseases [3]. The coexistence of hypertension and diabetes is due to a reason Epidemiology that Patients with Type2 Diabete Mellitus have metabolic derangements termed the cardio metabolic or cardio renal metabolic syndrome [4,5]. This syndrome comprises a many of CVD risk factors including hypertension, dyslipidemia, central obesity, and chronic kidney disease. The coexistence of hypertension and diabetes increases the risk for cardiovascular disease (CVD), cerebrovascular accident (CVA), retinopathy, and nephropathy Hypertension during diabetes can increase progression of microvascular and macrovascular complications.

EPIDEMIOLOGY
In Between 1976 -1987, the occurence of diabetes, arise from 11.4 to 14.3% in the USA It is estimated that globally, the number of people with diabetes will rise from 151 million in the year 2000 to 221 million by the year 2010 and to 300 million by 2025!more than 5% of the world population. (According to WHO) [6]. Rising of Diabetic patients in the United States and all over the globe, thereby becoming an increasingly powerful threat to global health.

RISK FACTORS
Hypertension and diabetes have almost similar risk factors, which includes obesity, which is most common cause because in obesity the extra fat can cause release of different mediators which results in sensitivity to insulin and constriction of blood vessels ,lipid profile ,stress which results in more release of epinephrine which results in increase in blood pressure and release of glucocorticoids which results in more gluconeogenesis and results in increase blood pressure and blood glucose level genetic factors also contribute for both of these conditions in addition with all of these environmental factors also plays role in development of diabetes and hypertension moreover, as both are factors of metabolic syndrome, they commonly occur together in individuals [7]. Some studies indicated that high BP is a significant predictor of type 2 Diabetes [8,9] In the results 47.6% of patients are found to have Hypertension with diabetes.

PATHOPHYSIOLOGY OF HYPERTENSION IN DIABETES MELLITUS
Hypertension occurs because of increased body fluid. Patients with diabetes mellitus experience increased peripheral artery resistance due to vascular remodeling and increased body fluid volume associated with insulin resistanceinduced hyperinsulinemia and hyperglycemia. Other factors include maladaptive changes in the autonomic nervous system, vascular endothelial dysfunction, enhanced activation of the reninangiotensin-aldosterone system, immune function alterations, and harmful environmental factors. In diabetes there is higher risk of increase production of thromboxane A2, which is produced by platelets and cause vasoconstriction [10,11]. In diabetes there is low concentration of Nitric Oxide which act as vasodilator In first 2 weeks of diabetes, Nitric Oxide is blocked by the products of glycosylation. In this way glycosylated hemoglobin reduces the endothelium dependent relaxation mediated by Nitric Oxide.
The activation of the renin-angiotensinaldosterone system also plays an important role in endothelial dysfunction. Levels angiotensin II & bradykinin inside the endothelial wall are controlled by the angiotensin-converting-enzyme (ACE).
ACE breaks down bradykinin to produce angiotensin II. Bradykinin stimulates the endothelial cell to release vasodilating substances. The action of kinese is maintained in spite of endothelial dysfunction except in very severe arterial injuries. Angiotensin II could be partly responsible for endothelial dysfunction because it induces resistance to the vasodilatory effect of the Nitric Oxide.

TREATMENT
In addition with antidiabetic medicines to control blood glucose levels Angiotensin-converting enzymes Inhibitors (ACE inhibitors) and angiotensin receptor blockers (ARB) are considered as 1st line therapy to treat Hypertension in diabetic patients, but they can't be given together. The Target goal is to maintain BP is 130/80mmhg,if the goal is not achieved with these class of anti hypertensives then beta blockers, and diuretics are given as 2 nd line of therapy [9]. Calcium channel blockers are used in very last when Hypertension is refractory and cannot be maintaine with other drugs. Multiple drug therapy should also give to maintain target blood pressure.
• Daily monitoring of Blood pressure and glucose level.
• Low glucose in diet.
• Multiple medicines should be used to maintain targeted Blood pressure [12].
• Avoiding excessive alcohol and engaging in stress free activities.
Avoid smoking and doing regular exercise.

CONCLUSION
Mostly patients who are suffering from hyperglycemia are very likely to be more prone to have developed with hypertension. Diabetes and hypertension both disease alone itself causes the high risk of morbidity and mortality [13]. HTN affects the majority of individuals with diabetes mellitus. A combination therapy of drugs can frequently required to control blood pressure with other precaution and life style modification and may be more beneficial in patients with hypertension and diabetes mellitus.

CONSENT
It is not applicable.

ETHICAL APPROVAL
It is not applicable.