diabetes and high blood pressure
Introduction
Introduction to diabetes and high blood pressure Diabetes and hypertension are common diseases, and they are closely related. The prevalence of hypertension in diabetic patients is significantly higher, about twice that of non-diabetic patients, and increases with age, weight gain and prolonged disease duration. Women are higher than men, and foreign data show that the prevalence of hypertension among diabetic patients It is 40%-80%; the report in China is lower than that in foreign countries, which is 28.4%~48.1%. In addition, hypertension in the diabetic population occurs early, and the prevalence rate is 10 years earlier than non-diabetic people. basic knowledge The proportion of illness: 10% of the probability of being over 50 years old Susceptible people: no specific population Mode of infection: non-infectious Complications: arteriosclerosis Diabetic nephropathy Retinopathy
Cause
Diabetes and causes of hypertension
Hyperinsulinemia (20%)
Type 2 diabetes has hyperinsulinemia due to insulin resistance. Type 1 diabetes can also cause hyperinsulinemia due to long-term large amount of exogenous insulin. Hyperinsulinemia can lead to hypertension through the following factors: 1 increase renal sodium, water weight Absorption; 2 increase the sensitivity of blood pressure to salt intake; 3 increase the sensitivity of pressurized substances and aldosterone to angiotensin II; 4 change the transmembrane transport of electrolytes, showing increased intracellular sodium transport, Na-K-ATPase Reduced activity, increased Na-H-ATPase activity; 5 increased intracellular calcium; 6 stimulated growth factor (specific vascular smooth muscle growth factor) expression; 7 stimulated sympathetic nerve activity; 8 decreased vasodilator prostaglandin synthesis; Endothelin secretion; 10 damage to atrial natriuretic peptide sodium, the above results lead to sodium, water retention and increased vascular tone, eventually producing high blood pressure, in addition, it has been found that intracellular free magnesium levels are negatively correlated with plasma insulin levels That is, hyperinsulinemia with intracellular low magnesium, and intracellular magnesium levels are negatively correlated with blood pressure.
Sodium retention (20%)
Hyperinsulinemia, increased renin-angiotensin-aldosterone system activity, renal lesions, etc. can lead to sodium retention, and sodium retention can increase the sensitivity of blood vessels to catecholamines and sympathetic nerves. Studies have shown that even in Metabolically stable and azo-free diabetic patients with hypertension, whether type 1 or type 2 diabetes, with or without retinopathy or diabetic nephropathy, the average exchangeable sodium in the body increased by 10%, and was significantly positively correlated with blood pressure, After 6 weeks of diuretic administration to the patient, the exchange of sodium can be reduced to normal, and the cardiovascular system's pressor response to norepinephrine returns to normal from the enhanced state. The cause of sodium retention is also the increase of blood growth hormone, serum. Decreased albumin concentration causes a decrease in colloid osmotic pressure and a decrease in renal vasopressin factors such as prostaglandin E.
Catecholamine concentration increases (15%)
Hyperinsulinemia, poor glycemic control (especially when ketoacidosis occurs), the concentration of catecholamines in the body is significantly increased, sympathetic nerve activity is significantly increased, and hypertension is induced.
Vascular wall lesions (15%)
Diabetic patients often have disorders of lipid metabolism, and long-term poor glycemic control leads to increased glycosylated protein end products (AGEs), which can lead to atherosclerosis. In addition, diabetic patients are often accompanied by hyperinsulinemia, while some growth factors (such as transformation) Increased expression of growth factor 1, insulin-like growth factor, platelet-derived growth factor, etc., can lead to vascular smooth muscle hyperplasia, atherosclerosis and vascular smooth muscle cell proliferation lead to increased peripheral vascular resistance.
Increased free calcium (10%)
Hyperinsulinemia can lead to an increase in intracellular free calcium. On the other hand, it has been found that the level of free 1,25-(OH)2D3 in the blood circulation of diabetic patients is increased, which can cause an increase in intracellular free calcium, leading to arterial vascular resistance. Increase, causing high blood pressure.
Prevention
Diabetes and hypertension prevention
Diabetes hypertension is one of the common complications of multiple diabetes. First of all, special attention should be paid to the prevention of primary prevention in the population, especially for individuals with genetic predisposition, to eliminate and control the risk factors associated with this disease, and to develop a good diet and Hygienic habits, advocate "two high three low" diet, that is, low salt, low calorie, low fat and high potassium, high cellulose diet, for children with diabetes critical hypertension and family history of hypertension should take secondary precautions Close follow-up observation, control diet quality, avoid mental stimulation, strengthen physical exercise, and supplement clinical treatment if necessary.
For patients with diabetes or diabetes hypertensive, it is advisable to take three levels of preventive measures for overall treatment. The treatment plan should be individualized, control blood sugar and blood pressure, and prevent the disease from repeating, so as not to cause repeated cumulative effects of the disease, affecting prognosis or outcome.
For young, middle-aged or diabetic patients, blood pressure should be reduced to an ideal or normal blood pressure range of <130/85 mmHg; for elderly patients, at least to a normal high blood pressure range of <140/90 mmHg.
The sixth report of the National Joint Commission for Prevention, Monitoring, Evaluation and Treatment of Hypertension (JNC IV) recommends that patients with diabetes mellitus, especially with proteinuria, should have blood pressure below 1300 mmHg. The optimal blood pressure should be controlled. 120/80mmHg, China's guidelines for the prevention and treatment of hypertension (1999) recommended: no kidney disease should be controlled at 130/85mmHg; patients with kidney disease should be controlled below 125/75mmHg, there are also data recommendations for diabetic nephropathy: urine protein In 0.25 ~ 1g / d, blood pressure is controlled below 130 / 80mmHg; standard protein > 1g / d, blood pressure should be controlled below 125 / 75mmHg, but should avoid blood pressure drop too fast.
Complication
Diabetes and hypertension complications Complications arteriosclerosis diabetic nephropathy retinopathy
Macrovascular disease
Hypertension and diabetes are independent risk factors for arteriosclerotic disease. A study from Framinghan reports that two or more risk factors present a simultaneous increase in the risk of an arteriosclerotic event rather than an additive form, regardless of systolic blood pressure. Increased diastolic blood pressure, affecting lifespan, the average arterial pressure increased by 10mmHg, the risk of cardiovascular disease increased by 40%, clinical meta-analysis suggests that if blood pressure starts from 115/75mmHg, systolic blood pressure increases by 20mmHg, diastolic blood pressure per With an increase of 10mmHg, cardiovascular events will multiply. 70% to 80% of untreated hypertensive patients in China die of cerebrovascular disease, 10% to 15% die of coronary heart disease, and 5% to 10% die of renal failure. Hypertension and diabetes can cause vascular endothelial damage, triggering a series of phenomena such as platelet adhesion, aggregation, release of platelet-derived growth factor (PDGF), smooth muscle cell proliferation, macrophage migration and lipid accumulation in the arterial wall. , finally fibrosis, necrosis, ulceration and thrombosis, normal arterial endothelial cells can produce prostacyclin, inhibit platelet adhesion, diabetic state endothelial cell prosthetic ring Reduced production of dyslipidemia, and common dyslipidemia and fibrinolysis disorders, further promote arteriosclerosis, the incidence and severity of coronary heart disease (including myocardial infarction) increased significantly in diabetic patients with hypertension, compared with non-diabetic hypertension patients, diabetes The incidence of left ventricular hypertrophy and congestive heart failure is significantly increased in patients with hypertension; the risk of cerebrovascular accidents and transient ischemic attacks is particularly high, and extensive clinical studies in non-diabetic populations have shown effective antihypertensive therapy. Can significantly reduce the occurrence of cerebrovascular accidents and congestive heart failure, the above results may be equally applicable to patients with diabetes, a recent study from the UKPDS (United Kingdom United Kingdom Prospective Diabetes Research Project), strict control of blood pressure (captopril or beauty) Torolol can significantly reduce the risk of diabetes-related death and the occurrence and progression of diabetes-related complications, including macrovascular disease. The presence of hypertension also increases the incidence of renal arteriosclerosis and peripheral vascular disease in diabetic patients.
2. Diabetic nephropathy
The presence of hypertension is an important factor in the acceleration of the occurrence and progression of diabetic nephropathy. Hypertension can further aggravate the existing glomerular hemodynamic abnormalities in diabetic patients (mainly increased renal plasma flow, glomerular hyperfiltration and Glomerular internal hypertension).
3. Retinopathy
Diabetes with hypertension also increases the incidence of retinopathy and promotes its progression. Prospective reports of diabetic patients with systolic blood pressure greater than 145 mmHg have a higher incidence of retinal exudation than those with blood pressure below 125 mmHg, and the severity of retinopathy is found. Significantly associated with blood pressure levels, retinopathy progresses faster in patients with diastolic blood pressure above 70 mmHg compared with patients with diastolic blood pressure below 70 mm Hg. Short-term clinical studies have also reported the use of angiotensin-converting enzyme inhibitor (ACEI). Blood pressure treatment can reduce the exudation of diabetic retina and delay the progression of background retinopathy.
4. Diabetic neuropathy is now
There are no reports on the relationship between hypertension and diabetic neuropathy. Individual reports of sensory neuropathy are associated with renal damage and blood pressure levels. Animal experiments have shown that the use of ACEI such as lisinopril can improve sciatic nerve movement and sensory conduction velocity, resulting in hypoxia. The nerve block is restored to normal and the capillary density is increased.
Symptom
Diabetes and Hypertension Symptoms Common Symptoms Weight loss, polydipsia, polydipsia, fatigue, tiredness, high blood pressure, high blood viscosity, visual acuity, haze-like haze, heatstroke, high fever, blood pressure, zero
1. Clinical manifestations of diabetes itself: symptoms are atypical or have characteristic changes such as polydipsia, polyuria, polyphagia, fatigue, drowsiness, weight loss, and the corresponding manifestations of diabetes with other complications.
2. Clinical manifestations of hypertension: early symptoms can be asymptomatic or have headache, dizziness, blurred vision, vertigo, loss of appetite, tinnitus, insomnia, etc., symptoms and blood pressure levels can be inconsistent, physical examination can have aortic valve second heart sound hyperthyroidism, Long-term hypertension can have signs of left ventricular hypertrophy.
3. The unique manifestations of diabetes complicated with hypertension: 1 case of hypertension with orthostatic hypotension: Diabetic patients with autonomic neuropathy are prone to normal blood pressure or elevated blood pressure with straight steric position, maintaining erect blood pressure requires cardiac discharge Quantity, effective circulation capacity, baroreceptor reflex activation of various vasoactive hormones, etc., any abnormality in this mechanism will occur the possibility of orthostatic hypotension, one or more of the above-mentioned disorders may occur in diabetes , can not effectively compensate for the occurrence of orthostatic hypotension; 2 low renin or renin normal hypertension: diabetic nephropathy patients with more normal plasma renin activity or a small part of the low renin activity, combined with more serious kidney disease Low renin, low angiotensin, and low aldosterone change.
Examine
Examination of diabetes and high blood pressure
Consider the following checks depending on the situation:
1. Determination of fasting blood glucose: oral glucose tolerance test.
2. Glycosylated hemoglobin assay: Glycosylated erythrocyte membrane assay.
3. Diabetes blood rheology determination.
4. Liver and kidney function tests.
5. Determination of total cholesterol, blood lipids, and determination of serum creatinine.
6. Urine routine examination.
7. Dynamic blood pressure level check to observe changes in blood pressure.
8. Chest X-ray examination, electrocardiogram, echocardiography to understand changes in ventricular structure.
9. Fundus examination of fundus arterial stenosis.
10. Diabetes microcirculation observation.
Diagnosis
Diagnosis of diabetes and hypertension
diagnosis
1. Diagnosis of hypertension
In 1999, WHO made a new definition and classification of hypertension diagnosis, but the American Diabetes and Hypertension Research Group advocated blood pressure above 140/90mmHg (18.6/12kPa) because of the high risk of cardiovascular disease in diabetic patients. That is, treatment should begin.
2. Diabetes combined with hypertension classification
(1) Essential hypertension without diabetic nephropathy: Primary hypertension is more common in middle-aged and elderly patients with type 2 diabetes. The incidence of essential hypertension is more likely to be associated with insulin resistance; systolic hypertension More common in the elderly, is generally believed to be caused by decreased compliance with blood vessels.
Systolic hypertension: when the diastolic blood pressure <90mmHg (12kPa), systolic blood pressure <140mmHg (18.7kPa) normal blood pressure 140mmHg (18.7kPa) simple contractile hypertension 140 ~ 149mmHg (18.7 ~ 21.2kPa) critical simple contraction High blood pressure.
(2) Hypertension caused by diabetic nephropathy: It is generally believed that in the early stage of diabetes, patients have a tendency to increase their blood pressure when they have microalbuminuria. Once they progress to the stage of clinical diabetic nephropathy and renal insufficiency, 2/ 3 to 3/4 patients with hypertension; in addition, diabetes often associated with renal arteriosclerosis and chronic pyelonephritis, can also increase blood pressure.
(3) Hypertension with standing hypotension: supine hypertension, orthostatic hypotension (or normal blood pressure) in standing position, mostly thought to be caused by diabetic autonomic dysfunction.
(4) Hypertension caused by other causes: Like non-diabetic hypertensive patients, diabetic hypertensive patients also need to find other secondary hypertension that causes elevated blood pressure: 1 Endocrine hypertension: Cushing syndrome or Cushing Disease, pheochromocytoma (or pheochromocytoma), primary aldosteronism, acromegaly and hyperthyroidism can cause secondary hypertension, often with diabetes; 2 renal hypertension : including renal parenchymal diseases (various acute and chronic glomerulonephritis, chronic pyelonephritis, hydronephrosis, polycystic kidney disease, etc.), renal vascular disease (renal artery fibromuscular dysplasia, renal atherosclerosis, renal artery Embolism, renal artery stenosis caused by multiple arteritis, and renal traumatic diseases (peri-renal hematoma, renal artery thrombosis and renal artery dissection hematoma, etc.); 3 cardiovascular diseases: mainly arteriovenous fistula, aortic valve closure Incompleteness and aortic coarctation, etc.; 4 neurological diseases: high blood pressure, diencephalic syndrome can occur due to increased intracranial pressure caused by intracranial tumors, inflammation, cerebrovascular disease or brain trauma Vasomotor central dysfunction in the diencephalon can cause elevated blood pressure; 5 other causes: pregnancy toxemia, hematoporphyria, polycythemia vera, menopausal syndrome and drugs (such as glucocorticoids and birth control pills) And other adverse reactions.
3. Head performance
Headache, head swelling, dizziness, tinnitus, insomnia, neck stiffness, dim vision, retinal arteriosclerosis, thinning, arteriovenous cross-pressure, exudation, hemorrhage, optic disc edema, sometimes coexisting with diabetic retinopathy, leading to blindness .
4. Cardiac performance
Long-term hypertension with cardiac hypertrophy, heart enlargement, formation of hypertensive heart disease, patients will have chest tightness, palpitations, shortness of breath, fatigue, physical examination of the apex beat strong and powerful, lifting, heart expansion to the left, aortic valve auscultation District, the second heart sounds hyperthyroidism, the apex can be heard and systolic murmur, severe heart failure occurs.
5. Edema
Finally, renal failure, uremia, clinically diabetic glomerulosclerosis, and renal atherosclerosis caused by hypertension are difficult to identify.
Differential diagnosis
Some endocrine diseases can cause high blood pressure, such as pheochromocytoma, Cushing's syndrome and primary aldosteronism. The main points of identification are:
1. History of diabetes.
2. Pheochromocytoma has its specific clinical symptoms, urinary catecholamines, norepinephrine increased, can be identified by phentolamine inhibition test and challenge test.
Cushing's syndrome has characteristic clinical symptoms such as central obesity, moon face or full moon face, increased hair, flushing, thin skin with purple lines, elevated cortisol in the blood, 17 hydroxy in the urine, 17 ketone cortex Increased steroid excretion.
Primary aldosteronism is adrenal hyperplasia or adenoma. The basic pathophysiological changes are sodium and potassium excretion, hypertension caused by increased blood volume, elevated aldosterone levels in the blood, high sodium, low potassium, and electrocardiogram. Low potassium changes.
3. Autonomic neuropathy: Because diabetes damages autonomic nerve-induced hypertension, its blood pressure is often characterized by orthostatic changes, ie, lying hypertension and orthostatic hypotension, so its differential diagnosis is not difficult.
In patients with type 1 diabetes and kidney disease, the cause of hypertension is usually renal, so most patients do not have to be identified in detail if there are no other clinical abnormalities.
In patients with type 2 diabetes mellitus with proteinuria, hypertension can be renal, or hypertension occurs in most patients before kidney disease. Kidney disease is the cause of further deterioration of hypertension. According to clinical symptoms, hypertension caused by other causes Should be further identified.
"White big sputum hypertension" is more common in diabetic patients. "White sputum hypertension" refers to patients who repeatedly measure blood pressure in the doctor's office over 140/90mmHg, and the fluctuation blood pressure monitoring is less than 135/80mmHg. The survey found that type 1 diabetes is not high. The incidence of "white sputum hypertension" in patients with a history of blood pressure is 74%, which generally reaches the standard of first-grade hypertension. In patients with type 2 diabetes, the incidence rate is 23% to 62%. In a survey of hypertensive people, Verdecchia et al found that the incidence was 19%, and 33% of patients with primary hypertension also found that the measured blood pressure was high. These phenomena suggest that white sputum hypertension is more common in patients with mild hypertension.
