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Individualization of diabetes treatment for heart failure | Jay Shubrook & David Strain

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*Originally published January 31, 2018 on Medicine Matters diabetes*

Welcome to medicine matter diabetes i’m jay schubert leo professor and diabetologist at toro university california and i’m joined today by david strain md who’s a clinical senior lecturer in diabetes and vascular preventive medicine at the institute of biomedical and clinical sciences peninsula medical school in exeter uk he’s also the head of the academic

Department for health care in older adults and the author of the uk 2017 guidelines for the management of older adults with diabetes we’re going to continue our topic today talking about the american diabetes association’s uh update on the management of hypertension and adults with diabetes well so we live uh so david welcome and we’re so glad to have you here

Today thank you jay pleasure to be with you thank you so we have an aging population you know i think this is a global phenomenon we have more and more adults and we have older adults with chronic disease so you know what’s special about the elderly yeah it’s a really interesting point because when we’re talking about older adults with diabetes there are many

People who just talk about them as an extension of younger adults what we forget is the physiological changes that take place between the ages of 65 and 80 are actually greater than the physiological changes that children go through with puberty now none of us would consider treating a two-year-old in the same way we treat an 18 year old and yet when it comes to

Older adults we think nothing about implying the same treatment pathways and the same drugs and the same mechanisms for an eight-year-old that have only ever been tested and validated in our younger populations so as such we’ve got lots of special considerations that we need to think about the the underlying physiology is fundamentally changed the responsiveness

To external uh stimuli is also muted which means exactly the same thing that we do to a an eight-year-old could have profound effects than compared to what would have happened if we’d have used the same therapy for a 65 year old so that’s really important and do we have studies to support how we should treat the elderly differently well very very few studies

I mean in the whole of diabetes we know that two-thirds of clinical trials actually um routinely exclude older adults purely on the basis of their age if you think of a chord advance and vadt only a cord had no other age limits and therefore actually very often the older patients that we’re seeing don’t represent the typical manifestations that we see in

Our clinic there have been a few studies that have looked specifically at older adults but even in those settings they tend to use not particularly representative population an 80 year old that turns up to a typical clinic trial is completely different from the frail more mature elderly that we see in clinic and after the age of about 75 actually chronology

Nexus very very little two 80 year olds can be completely different one can be still very active dancing going to the football whereas another one may be in a nursing home with full dependency so we have to be very certain that the care that we’re offering these individuals will actually benefit them within their anticipated lifespan so the elderly are really

A diverse group they had very different presentations and there’s little information or imperfect information to advise us on the treatment absolutely i mean i think you’ve highlighted that we we don’t have very good accurate randomized control trials for to say what we should be doing for these people and therefore a lot of what we do is is opinion and so if

For example we take the sprint trial recently conducted with hypertension in older adults not specific to diabetes but it was a good study looking at hypertension in older animals across the board and suggested in that population that there is tremendous benefits that can be achieved from reducing blood pressure actually very similar benefits that we see in the

Younger adults it has to be uh the caveat in that has to be that they don’t hit the same targets in the study but the benefit did seem to be linear however if you go to um real world data sets so recently for example we’ve just published our uh an analysis of the cprd based on over a million patients and that suggests a different picture when you look at the

General all promise so including those frail elderly patients including the ones with multi-morbidities with heart failure or renal impairment or the other problems that are typical in a geriatrics service then those patients actually have do have a lower threshold and the threshold seems to be determined more about diastolic blood pressure which makes a lot

Of sense really just from a simple overview of it we spent two-thirds of our life in diastole these patients have had 80 years or so to build up the arterial and atherosclerosis and therefore reduce tissue perfusion and many of the drugs that reduce systolic blood pressure have an extreme effect on the diastolic blood pressure and we identified that if you get

Your diastolic blood pressure dropping below 75 millimeters of mercury the net result of that is an inadequate perfusion and so we start to see problems that are not typical blood pressure related problems but become very apparent and a highly significant non-less so for example we see rates of dementia will increase with lower diastolic blood pressure and we

Tracked back a long way before the the blood pressure to the incident so we’re not suggesting here that this person has a low blood pressure and they have dementia and those two are interrelated we track back the diastolic blood pressure over a 10-year period and they’re the prognosis for the dementia for falls for fractured neck of fema and all of these plays

A big impact in the the outcomes in our older adults and of course that the first rule of managing people is first do no harm so we have to be very careful where we’re going with our patients and make sure that we end up not over treating them for problems that may not arise those are very important points and i think that that’s one of the concerns is how much

Treatment do we actually provide in the elderly what is too much what is too little so with that in mind what should i expect the blood pressure to do as my patient ages what is there any generalities well in general systolic blood pressure rises and diastolic blood pressure falls and this is all caused by the arterial sclerosis the the rebound within the aorta

And which is the the main call the main way of maintaining your diastolic blood pressure our older adults have got stiffer arteries and therefore they can no longer maintain that diastolic contraction now your body’s compensating mechanism therefore is to put the systolic blood pressure up in order to get the same expansion the same um the same storage of

Energy and then you will then get a diastolic push to maintain the diastolic blood pressure at a level that’s perfusing the heart and the brain during that vital period when we are treating therefore this isolated systolic hypertension becomes a condition in its own right and therefore we are looking at a different treatment protocol that we see in our younger

Adults those under the age of 65 who don’t suffer from this isolated systemic hypertension which has been triggered by the poor compliance as you develop arterial sclerosis so i should expect more uh isolated systolic hypertension what is the role of the pulse pressure is that something i should be looking at in my overlay dots well pull with pulse pressure and

Um isolated high potential two things that go hide in your hand i mean your pulse pressure the difference between systolic and diastole is basically driven by rising systole and falling diastolic blood pressure and many people will consider that pulse pressure is an alternative way of assessing um the blood pressure and we see that actually coming from some of the

The recent glycemic studies that if you take for example in the leader trial where systolic blood pressure fell and diastolic blood pressure rose we actually have a reduction in blood pressure presumably caused by an improvement in arterial compliance which was in some way a driver towards those beneficial results we’ve seen the converse is true in our elderly

Patients systolic blood pressure gut rises diastolic blood pressure falls and we see the huge wave patterns that are causing some of the end organ damage down in the small blood vessels so if i hear you correctly knowing the challenges of aging in the aging blood vessels we really should be focusing on making sure we lower the systolic blood pressure but don’t

Drop the diastolic too low certainly not below 75. absolutely and therein lies that the real difficulty because many of the therapies that we use for our younger adults that the main role is to actually reduce the systolic blood pressure and the diastolic blood pressure falls with them and there are very few strategies that have got a good evidence base for

Improving arterial compliance which is really what we are aiming to do for our older adults i think one of the best assessments of that was the sub-study of the the ascot blood pressure arm where they compared the calcium channel blockers and the ace inhibitors with the beta blocker and thiazide diuretic components and it demonstrated not only for similar blood

Pressure results if we get better improvements with the the newer agents the calcium channel operation of this combination but also on a separate the cafe study they measured central blood pressure which is another measure of the arterial compliance and this central blood pressure also improved far more so in the newer strategies and this has left a lot of us to

Think that maybe we should be approaching the hypertension in those with poorer arterial compliance with the the newer strategy on calcium channel blockers and the um ace inhibitors or angiotensin receptor antagonists wow so a really important point today we talked about the challenges of hypertension in the elderly the normal physiologic changes the separation

And the systolic and diastolic pressure all things that we need to be cognizant about when we’re treating the person with diabetes and hypertension in a future session we’re going to get to talk about the nitty-gritty of some of the treatment recommendations that you think are best for this population so i want to thank you for your time today and thank you for

Joining medicine matters diabetes you’re welcome jay i look forward to speaking to you again

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Individualization of diabetes treatment for heart failure | Jay Shubrook & David Strain By Medicine Matters diabetes