Letters to the Editor
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Diabetes, Hypertension, and Cardiovascular Ehud Grossman
Disease: An Update Internal Medicine D
The Chaim Sheba Medical Center
To the Editor:
Sackler School of Medicine
Sowers et al are to be commended for writing a thorough
Tel-Hashomer, Israel
review on the diabetic hypertensive patient.1 In doing so, they
came to the conclusion that, “Results of the SHEP [2] and the 1. Sowers JR, Epstein M, Frohlich ED. Diabetes, hypertension, and cardio-
UKPDS [3] trials suggest that diuretics and -blockers as well vascular disease: an update. Hypertension. 2001;37:1053–1059.
as ACE inhibitors are also useful therapeutic agents in 2. Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. Effects of
diabetic hypertensive patients who often require ⱖ2 drugs to an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular
control blood pressure adequately. [4]” Although we agree events in high-risk patients: the Heart Outcomes Prevention Evaluation
with this statement, it should be pointed out that -blockers Study Investigators. N Engl J Med. 2000;342:145–153.
seem to be far less efficacious than the other drug classes in 3. Tight blood pressure control and risk of macrovascular and microvascular
this subpopulation. The UKPDS (UK Prospective Diabetes complications in type 2 diabetes: UKPDS 38, UK Prospective Diabetes
Study Group. BMJ. 1998;317:703–713.
Study) has demonstrated that coronary heart disease is much
4. Sowers JR, Reed J. Clinical advisory treatment of hypotension in
more prevalent than cerebrovascular disease in the diabetic diabetes. J Clin Hypertens. 2000;2:132–133.
hypertensive patient. In fact, in the UKPDS, morbidity and 5. Messerli FH, Grossman E, Goldbourt U. Are -blockers efficacious as
mortality events from coronary heart disease were between 4 first-line therapy for hypertension in the elderly? JAMA. 1998;279:
to 6 times more common than events from cerebrovascular 1903–1907.
disease. Thus, any drug class used to treat the hypertensive 6. Gress TW, Nieto FJ, Shahar E, Wofford MR, Brancati FL. Hypertension
diabetic population should exert some primary cardioprotec- and antihypertensive therapy as risk factors for type 2 diabetes mellitus:
tive efficacy, ie, lower the risk of coronary heart disease. Atherosclerosis Risk in Communities Study. N Engl J Med. 2000;342:
Unfortunately, antihypertensive therapy in the UKPDS had no 905–912.
7. Sharma AM, Pischon T, Hardt S, Kunz I, Luft FC. -adrenergic receptor
effect on coronary artery disease (Figure). As Sowers et al
blockers and weight gain: a systematic analysis. Hypertension. 2001;37:
pointed out, half of these patients were treated with an ACE
250 –254.
inhibitor (captopril) and half with a -blocker (atenolol), but
there was no significant difference between the 2 treatment
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strategies. Similar to our previous findings in hypertension in Response
the elderly,5 -blockers failed to exert a primary cardiopro- I have reviewed the comments made by Drs Messerli and
tective effect in the diabetic patient in the UKPDS. Further, Grossman regarding our review on diabetes and hypertension
-blockers have well-documented detrimental effects on met- published recently in Hypertension.1 Although our review em-
abolic findings, increase the risk of diabetes in nondiabetic phasized rigorous treatment of hypertension and the importance
hypertensive patients,6 and cause weight gain,7 all of which of ACE inhibitor therapy as an important component, it did not
increase the risk of coronary heart disease and other cardio- focus on -blockers. Indeed, we emphasized that calcium antag-
vascular morbidity and mortality. Because coronary artery onists, low-dose diuretics, and -blockers were all appropriate
disease is the most prevalent cardiac complication in these medications for the diabetic population, who often need 2 to 3
patients, -blockers should be used with restraint only in classes of hypertensive medication. Given the high prevalence of
patients with specific indications. ischemic heart disease in the diabetic patient, -blockers were an
important component of the armatarium. Although they can
Franz H. Messerli cause a small weight gain, so does insulin, sulfonylurea, and
Ochsner Clinic and thiazolidinedione therapy for hyperglycemia, but that does not
Alton Ochsner Medical Foundation preclude their use. Also, prior concern regarding adverse effects
New Orleans, Louisiana of -blockers on hypoglycemia and masking of symptoms
increasingly appears to be important for only some type 1
diabetics. Accordingly, we do not believe the negative remarks
regarding use of -blockers in diabetics is warranted or sends the
correct message to practicing physicians.
James R. Sowers
Endocrinology, Diabetes, and Hypertension
SUNY Health Science Center at Brooklyn
New York
1. Sowers JR, Epstein M, Frohlich ED. Diabetes, hypertension, and cardio-
vascular disease: an update. Hypertension. 2001;37:1053–1059.
