Sousa et al.

Diabetol Metab Syndr (2017) 9:98

https://doi.org/10.1186/s13098-017-0296-z Diabetology &
Metabolic Syndrome

RESEARCH Open Access

Hypertensive diabetic patients:

incidence of cardiovascular and renal outcomes
in a historical cohort over 11 years
Andréa Cristina Sousa2,3*, Thiago Veiga Jardim2,3, Thiago Olivera Costa2, Fabrício Galdino Magalhães2,3,
Marcos Paulo Marinho Montelo2, Weimar K. Barroso Souza2,3, Paulo César Brandão Veiga Jardim2,3
and Ana Luiza Lima Sousa1,2

Abstract 
Background:  Diabetics have increased risks for cardiovascular disease (CVD) and mortality, reducing their life
expectancy by up to 15 years. Type 2 diabetes mellitus specifically increases the risk for cardiovascular mortality nearly
fivefold. When hypertension is combined with diabetes, the risk of CVD is even greater.
Objective:  Identify non-fatal cardiovascular outcomes and renal function impairment in a cohort of hypertensive
patients in regular treatment in a reference treatment center, over 11 years of follow-up.
Methods:  Historical cohort of hypertensive patients in regular treatment for at least 11 years in a specialized service
for hypertension treatment. The exposed group was hypertensive diabetic patients at the beginning of the cohort,
and the non-exposed group had hypertension without diabetes. The cohort began in 2004, with follow-ups in 2009
and 2015. Variables used: gender, race, age, physical activity, alcohol consumption, smoking, blood pressure, body
mass index, glycated hemoglobin, diabetes and hypertension diagnosis times, treatment time in specialized service,
non-fatal cardiovascular outcomes, and renal impairment assessed by creatinine clearance.
Results:  139 patients participated in the study (55 diabetic hypertensive; 84 non-diabetic hypertensive), with an ini-
tial (2004) mean hypertension treatment time of 5.8 years. Females were the majority (75.5%) in both groups. Groups
were similar regarding socio-demographic variables, but the group of hypertensive diabetic patients had higher
frequency of obesity and uncontrolled BP, which persisted in all follow-ups. In 11 years of follow-up (2004–2015),
the diabetic group had more cardiovascular events, with increased risk of acute myocardial infarction (RR 95% CI 1.6
12.2–95.0), stroke (RR 95% CI 1.3–6.1 27.7) and complications requiring hospitalization (RR 95% CI 1.6 2.2–3.0). Wors-
ened renal function occurred more often in the non-exposed group, but in the end, the proportion of renal function
loss was similar between groups.
Conclusions:  Exposure to type 2 diabetes increased the risk of new cardiovascular outcomes over 11 years of follow-
up of hypertensive patients. Diabetes by itself increased the risk of cardiovascular outcomes, justifying more intensive
actions in this population.
Keywords:  Hypertension, Type 2 diabetes mellitus, Cardiovascular diseases, Diabetes complication

*Correspondence: andrea.c.sousa@hotmail.com
2
Hypertension League, Federal University of Goiás (Universidade
Federal de Goiás), 1ª Avenida, S/N‑Setor Leste Universitário, Goiânia, GO
74605‑020, Brazil
Full list of author information is available at the end of the article

© The Author(s) 2017. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,
provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license,
and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/
publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Sousa et al. Diabetol Metab Syndr (2017) 9:98 Page 2 of 9

Background
Medical records survey
Hypertension (HTN) is a well-established risk factor for in 2014

cardiovascular diseases in people with diabetes [1]. On N=425

the other hand, type 2 diabetes (T2DM) is an independ- 71 diabetic 270 non-diabetic 84 Diagnosed with DM in
ent risk factor for cardiovascular diseases such as athero- hypertensive hypertensive 10 years interval
*CKD was not identified at
sclerosis and heart failure [2]. T2DM increases the risk of the beginning of the cohort

cardiovascular mortality by 4.9 times, with a life expec-

tancy reduction ranging from 5 to 15 years, depending on 1 Refuse to participate Selected 84 Excluded for not fulfilling
the age at diagnosis [3, 4]. When T2DM is associated with 3 Deaths
12 Lost to follow-up
inclusion criteria

HTN, the risk of developing CVD becomes even greater

[5]. Values of systolic blood pressure (SBP) ≥ 140 mmHg
in patients with T2DM increase the risks of coronary 55 Diabetic 84 Non-diabetic
hypertensive patients hypertensive patients
heart disease, stroke, cardiovascular events and mortality
Fig. 1  Cohort inclusion flow chart
from all causes [6].
Many studies on the cardiovascular risk factors asso-
ciated with T2DM have been conducted outside Brazil.
Studies to identify these associations require long-
term follow-up and are difficult to be held because of group was selected randomly to number 1.5 times the
its high costs. The possibility of retrospective analysis exposed group (Fig. 1).
imposes the need for records of data from the same The study protocol was submitted and approved by the
population over a long period of time. Information Ethics Committee of the institution (Protocol Number
about health conditions of the population and their 931.503). All subjects who agreed to participate signed a
demands for medical and social services are funda- consent form.
mental for health care planning and health promotion. The cohort had a duration of 11  years retrospectively
Health conditions and outcomes of the population are from 2015 and was assessed in three follow-ups: initial
of great relevance to identify better ways of approach- (2004), intermediate (2009) and final (2015). The data
ing their health issues. used were those from the first consultation held in the
This study evaluated whether hypertensive patients year of each evaluation.
exposed to T2DM had increased risk of new non-fatal Sociodemographic variables were evaluated along with
outcomes such as stroke, acute myocardial infarction, clinical data: HTN and T2DM diagnosis times, treatment
myocardial revascularization, acute coronary syndrome, time at the specialized service, blood pressure values,
renal impairment and hospitalizations, despite regular glycated hemoglobin (hemoglobin A1C—HbA1C), lipid
treatment in a specialized care unit, with a follow-up profile and body mass index (BMI), and use of lipid-low-
protocol implemented in 1989. ering and blood pressure control therapies.
The initial (2004) and intermediate follow-up (2009)
Methods BP values were those registered in medical records. For
This was a non-concurrent historical cohort study the final follow-up (2015), blood pressure was measured
that included hypertensive diabetic and non-diabetic by the leading researcher in the office using the OMRON
patients with regular outpatient follow-up (at least HEM-705CP semi-automatic device. At that time, the
11  years, counted retrospectively) in a clinic special- informed consent was signed. BP was considered con-
ized in hypertensive patients’ treatment in the midwest trolled in the non-exposed group (non-diabetic) at val-
region of Brazil. We excluded those diagnosed with ues  <  140/90  mmHg and the exposed group (diabetic)
chronic kidney disease and those who developed T2DM at values < 130/80 mmHg [7], according to the Brazilian
between 2004 and 2015, in order to avoid bias from dia- guidelines.
betes exposure. For the first and second laboratory evaluations, we
The exposed group was composed of hypertensive used the data of laboratory tests recorded in the medi-
patients who were diabetic in 2004, and the non-exposed cal record, and in the final follow-up, blood samples were
Sousa et al. Diabetol Metab Syndr (2017) 9:98 Page 3 of 9

collected for biochemical analysis. The reference values square test or Fisher’s exact test, as needed. Quantita-
were creatinine  <  1.3  mg/dL, lipid profile (total choles- tive variables are presented with their means, stand-
terol  <  200  mg/dL; LDL cholesterol  <  100  mg/dL; HDL ard deviation, median and confidence interval. Means
cholesterol  >  60  mg/dL) [8], glucose (≤  130  mg/dL for were compared with Student’s T test only after analy-
diabetic hypertensives and  <  110  mg/dL for the general sis of data distribution with the Kolmogorov–Smirnov
population), and HbA1C (≤ 7%) [9]. test.
The classification used for the body mass index The relative risk of each outcome conferred by expo-
was (a) underweight (BMI  <  18.5  kg/m2); (b) nor- sure to T2DM was calculated in the form of a 95% con-
mal (BMI  =  18.5–25  kg/m2); (c) overweight fidence interval. Adjusted analysis was performed for all
(BMI  =  25–29.9  kg/m2); (d) obesity (BMI  ≥  30  kg/m2) predictors, with a significance level of  <  0.20 in bivari-
[10]. ate analysis, considering each outcome as dependent
Cardiovascular outcomes were defined as non-fatal variable.
myocardial infarction (MI), myocardial revasculariza- All tests were considered at a significance level of 5%
tion, stroke, acute coronary syndrome, hospitalizations and a confidence interval of 95%.
and blood pressure uncontrolled. Fatal events were not
considered outcomes because this was a non-concur- Results
rent cohort, whose composition was determined by We selected 71 diabetics (exposed group) and 84
whether patients were in regular treatment in the base non-diabetic hypertensive patients (non-exposed
year (2015). Medical records were analyzed to iden- group) for study participation. Among the diabetics,
tify cardiovascular outcomes that occurred between 12 were excluded due to follow-up loss, since they
the first and the second evaluation (2004–2009). In did not attend their appointments in the final follow-
the last evaluation (2015), the participants visited the up. Thus, in 2015, 139 patients agreed to participate
office and were asked about the occurrence of events. in the study. Among them, 55 were hypertensive dia-
At this time, the medical records were evaluated again betics, and 84 were hypertensive non-diabetics. At
to verify the reliability of the information provided by the beginning of the cohort, the mean age in both
patients. groups was similar (57.5  ±  9.3  years). The antihy-
For evaluation of renal impairment, we used the cre- pertensive treatment time in the service was also the
atinine clearance, determined by the Cockcroft–Gault same in the two groups (5.9  ±  3.9  years). However,
equation. For purposes of analysis, the estimation the average time from diagnosis of hypertension was
of glomerular filtration rate (GFR) was used con- significantly different (16.5  ±  9.5  years for the dia-
sidering the following categories: normal  ≥  90  mL/ betic group vs. 12.2  ±  7.32  years for non-diabetics;
min/1.73  m2, mild kidney failure 60–89  mL/ p  <  0.05). The average time from diagnosis of DM
min/1.73  m2, moderate kidney failure 30–59  mL/ was 4.0  ±  6.0  years. The groups at the beginning of
min/1.73  m2, severe kidney failure 15–29  mL/ the cohort (2004) were similar regarding socio-demo-
min/1.73  m2 and terminal renal insufficiency graphic variables, except the group of hypertensive
(CRI) < 15 mL/min/1.73 m2. In addition to that, these diabetic patients had higher frequencies of obesity
categories were dichotomized with a cutoff point (45.5%) and uncontrolled blood pressure (76.4%)
of  >  60  mL/min/1.73  m2 for normal kidney function (Table 1).
or mild damage, and below this value was considered In 11  years of follow-up, both groups decreased
moderate, severe or chronic renal failure [11]. diastolic blood pressure, total cholesterol, low-density
lipoproteins (LDL), triglycerides and creatinine clear-
Statistical analysis ance. Among the hypertensive diabetics in the same
The qualitative variables are presented with their period, there was a significant increase in high-density
absolute frequencies and proportions. The asso- lipoproteins (HDL) and a reduction in triglycerides
ciations between them were measured with the Chi (Table 2).
Sousa et al. Diabetol Metab Syndr (2017) 9:98 Page 4 of 9

Table 1 Composition of non-concurrent cohort regarding socio-demographic data, clinical data and lifestyle habits,

Goiânia, GO, Brazil, 2004
Diabetic hypertensive Non-diabetic hypertensive Total p*
(n = 55) (n = 84)
n % n % n %

Sex 0.420
 Male 11 20.0 23 27.4 34 24.5
 Female 44 80.0 61 72.6 105 75.5
Ethnicity 0.857
 White 30 57.7 42 54.5 72 55.8
 Non-white 22 42.3 35 45.5 57 44.2
 No record 3 5.5 7 8.3 10 7.2
Age (years) 0.804
 < 50 12 21.8 22 26.2 34 24.5
 50–60 22 40.0 30 35.7 52 37.4
 60–70 17 30.9 23 27.4 40 28.8
 > 70 4 7.3 9 10.7 13 9.4
Physical activity 0.488
 Regular 30 55.6 47 56.0 77 55.8
 Irregular 5 9.3 13 15.5 18 13.0
 Absent 19 35.2 24 28.6 43 31.2
 No record 1 1.8 0 0.0 1 0.7
Smoking 0.430
 Yes 1 1.8 5 6.0 7 4.5
 Former 21 38.2 27 32.1 48 34.5
 Never 33 60.0 52 61.9 85 61.2
Alcohol consumption 0.107
 Yes 1 1.8 7 8.3 8 5.8
 No 54 98.2 77 91.7 131 94.2
Number of antihypertensive drugs 0.811
 0–1 17 30.9 24 28.6 41 29.5
 2–3 37 67.3 57 67.9 94 67.6
 4+ 1 1.8 3 3.6 4 2.9
a
Blood pressure ­control < 0.001
 Yes 13 23.6 48 57.1 61 43.9
 No 42 76.4 36 42.9 78 56.1
Lipid-lowering agent use 0.302
 Yes 6 10.9 3 3.6 9 6.5
 No 49 89.1 81 96.4 130 93.5
Body mass index 0.003
 Normal 9 16.4 27 32.1 36 25.9
 Overweight 21 38.2 41 48.8 62 44.6
 Obese 25 45.5 16 19.0 41 29.5
Glycemic ­controlb –
 Yes 9 19.1 – – 9 19.1
 No 38 80.9 – – 38 80.9
* Pearson’s Chi square
a
  Blood pressure parameters: diabetic hypertensive < 130/80 mmHg and non-diabetic hypertensive < 140/90 mmHg
b
  HbA1C control ≤ 7%
Sousa et al. Diabetol Metab Syndr (2017) 9:98 Page 5 of 9

Table 2  Initial and final follow-up comparison of non-concurrent cohort according to groups (hypertensive diabetics
and non-diabetics) in laboratory and clinical parameters, Goiânia, GO, Brazil, 2004–2015
Diabetic hypertensive (n = 55) Non-diabetic hypertensive (n = 84)

2004 2015 p** 2004 2015 p**

Median Median Median Median

(95% CI) (95% CI) (95% CI) (95% CI)

SBP 139.0 (132.0–143.0) 134.0 (133.0–143.8) 0.586 130.7 (129.4–138.2) 131.0 (129.5–136.8) 0.742
DBP 85.0 (81.9–89.8) 73.0 (71.8–77.8) < 0.001 82.0 (81.7–87.4) 73.7 (71.8–76.3) < 0.001
BMI 29.3 (29.5–32.5) 29.3 (28.9–32.1) 0.080 26.3 (25.8–27.6) 27.1 (26.1–28.1) 0.081
GFR 139.0 (136.1–167.5) 139.0 (129.8–167.5) 0.891 96.0 (92.2–99.5) 93.0 (91.5–98.1) 0.655
TC 215.0 (200.9–229.8) 165.0 (157.2–184.8) < 0.001 201.5 (198.3–218.1) 181.6 (175.4–188.8) < 0.001
HDL 47.0 (43.6–51.5) 51.0 (49.2–56.2) 0.009 47.0 (45.0–50.3) 48.0 (45.7–51.2) 0.056
LDL 126.0 (111.5–197.3) 85.3 (80.4–95.3) < 0.001 129.5 (125.3–141.2) 112.0 (103.2–115.1) < 0.001
TG 179.0 (169.4–257.1) 134.0 (117.3–249.8) 0.024 110.5 (119.5–163.7) 114.0 (113.9–140.9) 0.825
CC 82.9 (76.7–87.7) 64.2 (62.2–79.1) < 0.001 70.2 (70.5–80.2) 61.9 (60.3–71.7) < 0.001
HbA1c 9.2 (5.0–15.0) 7.4 (5.5–13.3) 0.002 – – –
BMI body mass index, SBP systolic blood pressure, DBP diastolic blood pressure, GFR glomerular filtration rate, TC total cholesterol, HDL HDL cholesterol, LDL LDL
cholesterol, TG triglycerides, CC creatinine clearance, HbA1c hemoglobin, 95% CI 95% confidence interval
** Mann–Whitney U test

In the final evaluation of this cohort, 43.6% of hyper- renal impairment among the non-diabetic hypertensive
tensive diabetics showed renal impairment (creatinine group. This group initially showed 60.7% of participants
clearance < 60/min/1.73 m 2) and 45.2% of the non-dia- with mild renal lesion (60–89  mL/min/1.73  m2), and
betic group; in other words, between the initial and final 19.0% could be considered within the range of normal
follow-up, the proportion of renal impairment increased (≥  90  mL/min/1.73  m2); in the diabetic group, the mild
significantly in both groups, but they stayed similar to impairment was 52.7%, and 32.7% had rates within the
each other (Table 3). standards of normality. Both groups had increases in
Renal function, assessed by the proportion of patients the frequency of those with moderate renal impairment
in the different categories, suffered significant changes (30–59  mL/min/1.73  m2) over the 11  years of follow-up
over the follow-up course. There was a greater rate of (Fig. 2).

Table 3 Outcomes of 11 years in a historical cohort between diabetic hypertensive and non-diabetic hypertensive

patients, Goiânia, GO, Brazil, 2015
Total outcomes 11 years

Diabetic hypertensive Non-diabetic hypertensive p* RR

n % n % IC 95%

Uncontrolled blood pressure 39 70.9 26 31.0 < 0.001 2.3 (1.6–3.3)

AMI 8 14.5 1 1.2 0.002 12.2 (1.6–95)
Stroke 8 14.5 2 3.7 0.007 6.1 (1.3–27.7)
Myocardial revascularization 20 36.4 25 29.7 0.417 1.2 (0.7–1.9)
Acute coronary syndrome 15 27.3 23 27.4 0.988 1.0 (0.6–1.7)
Hospital admissions 44 80.0 31 36.9 < 0.001 2.2 (1.6–3)
Renal impairment 23 43.4 38 45.2 0.692 0.9 (0.6–1.4)
AMI acute myocardial infarction
* Chi square test
Sousa et al. Diabetol Metab Syndr (2017) 9:98 Page 6 of 9

Fig. 2  Distribution of patients with different categories of renal function throughout the study period (2004–2015), Goiânia, GO, Brazil, 2004–2015.
McNemar–Browker test: *p < 0.05

Regarding cardiovascular outcomes, in the intermedi- risk of hypertensive diabetics raised in relation to the
ate evaluation, both groups showed similar occurrences non-diabetics.
of AMI, acute coronary syndrome, myocardial revascu-
larization and hospitalization. The proportion of hospi- Discussion
talizations in each group at the intermediate evaluation Our service is constituted in the Brazilian public health
surpassed 20%. However, the group of hypertensive dia- care system and is based on the attendance of a hyper-
betics had a higher incidence of stroke (exposed: n = 5, tensive population, aiming at pressure control and con-
9.1%; non-exposed: n  =  1, 1.2%), with a relative risk of sequently the prevention of cardiovascular outcomes,
7.6, counting the period of 5  years of follow-up from since diabetes mellitus and arterial hypertension cause
2004 (Table 3). diseases that entail high costs, both socially and econom-
Regarding blood pressure control, diabetics showed ically. A multiprofessional team (doctors of various spe-
lower rates of control throughout the entire cohort cialties, nurses and nutritionists) performs our services,
(23.6, 27.3, and 29.1%, respectively) when compared but even so, this study showed a higher incidence and
to the unexposed group (57.1, 67.9, and 69.0%) in the risk of AMI, stroke, hospitalization and uncontrolled BP
three follow-ups (p < 0.05). The additional risk presented among hypertensive diabetics. Type 1 or 2 DM patients
by the diabetic group was 2.3 times higher than in the have CVD rates 4–10 times higher than non-diabetic
other group on the intermediate and final follow-ups individuals [12]. The occurrence of these outcomes is
(p < 0.001). likely related to the interaction between the side effects of
Overall, in 11  years of follow-up, the group of hyper- hyperglycemia in association with other risk factors, such
tensive diabetic patients presented more cardiovascular as hypertension, dyslipidemia and obesity [13].
events and a higher risk of cardiovascular events: the risk Diabetics who are even being treated for HAS and dys-
of AMI was 12.2 times greater, the risk of stroke was 6.1 lipidemia still have an increased risk of CVD, showing
times greater, and the risk of hospital admissions was at least twice the risk of stroke and a death risk approxi-
2.2 times higher compared to non-diabetics (Table 3). In mately 20% higher compared to non-diabetic individu-
the adjusted analysis, no predictive variable was associ- als [14]. The relative risk for stroke in this study was six
ated with the outcomes analyzed. The diagnosis time of times higher among diabetic individuals. A cohort study
T2DM and treatment in the service were not associated in England, with duration of 5.5  years in 1,900,000 peo-
with the frequency of events. ple, showed that diabetics had a higher risk of ischemic
Diabetic hypertensive patients had more cardiovas- stroke [15]. The same situation was identified in a cohort
cular complications and hospitalizations compared to study (17  years) of 10,582 Japanese, where the risk of
non-diabetic hypertensive patients. The main non-fatal non-embolic ischemic stroke was approximately two
outcomes found in our study were stroke, AMI, hospi- times higher in individuals with type 2 DM than in non-
talizations and uncontrolled blood pressure, with the diabetic individuals [16]. A meta-analysis involving 102
Sousa et al. Diabetol Metab Syndr (2017) 9:98 Page 7 of 9

prospective studies demonstrated that the adjusted risk European patients had a rate of 8.4%, patients in South
rate for ischemic stroke was two times higher in diabetic Asia had 6.0% and Chinese patients had 3.8% [22].
individuals [17]. We must consider that the study sample DM is in itself an independent risk factor for coronary
consisted of hypertensive patients with an average age artery disease, and the risk is dramatically higher when
above 60 years in the final analysis. hypertension is a comorbidity [23]. In this study, the dia-
The time of DM exposure is also considered a risk fac- betic patients had their best BP pressure control rate of
tor for stroke, indicating that each year of disease diag- 29.1% in the last follow-up. HTN affects approximately
nosis increases the outcome risk by up to 3% [18]. In this 70% of patients with diabetes and is approximately twice
study, there was no association between duration of DM as common in people with diabetes [24]; it significantly
diagnosis and any outcome. We should emphasize that increases the risk of vascular complications, predisposing
our patients were under treatment in a specialized ser- these patients to chronic kidney disease (CKD) [25] and
vice, and the study sample was homogeneous. substantially increasing the risk of ischemic stroke [26].
In 11 years of follow-up, the exposed group presented There are still some uncertainties and controversies
12.2-fold higher risk to be affected by AMI. In the Eng- over the BP reduction target in hypertensive patients,
lish cohort study mentioned above, non-fatal AMI risk especially those above 60  years, who typically feature
was 1.5 times greater for the hypertensive diabetics [15]. higher levels of systolic blood pressure [27]. Recently,
Again our study found rates higher than those reported the SPRINT study concluded that among hypertensive
in the literature and that may be related to the socio- patients at high cardiovascular risk, but without dia-
demographic specificities of the study population from betes, treatment aiming for a systolic blood pressure of
which the sample was selected. Clinical trials have shown less than 120 mmHg, compared with blood pressure less
that simply improving glycemic control is unlikely to pre- than 140 mmHg, resulted in lower rates of cardiovascular
vent the increased mortality after AMI in patients with events and death [28], i.e., the lower the goals for blood
DM, because intensive glucose control cannot reduce pressure control, the greater the benefits to be achieved
cardiovascular events, as well as the mortality rate in in a population of non-diabetics hypertensive.
patients with DM [19]. The control of other risk factors, Regarding diabetic hypertensive, BP goals have been
such as dyslipidemias, is considered more effective than widely discussed, since there is no consensus if the same
glucose-lowering therapy to reduce the incidence of car- goal of BP  <  140/90  mmHg should be applied. In the
diovascular events. ACCORD study, with a population of hypertensive dia-
Diabetics in this study showed bad glycemic control, betics, intensive BP and glucose control was tested, and
although it improved over the follow-up time (16.4% it demonstrated a reduction in the number of isolated
controlled initially vs 41.8% at the end of follow-up). On strokes compared with controlling BP to a lower value
the other hand, they showed worse BP control rates. It (120 mmHg). On the other hand, the number of serious
should be noted that stricter parameters were considered adverse events increased as a result of the intensive treat-
for BP control among diabetics [20]. T2DM patient care ment of hypertension and glycemia [29].
should be the result of integral management of cardio- After the publication of the SPRINT study, in 2015, the
vascular risk, which includes other factors than glucose, researchers of the ACCORD study supported the posi-
such as dyslipidemias, obesity and hypertension [3]. tion of the benefits of intensive reduction of systolic BP
We observed a higher rate of hospitalization among to < 120 mmHg in patients with high cardiovascular risk
hypertensive diabetics. A study evaluating the independ- and that these goals should also be extended to hyperten-
ent contributions of HbA1c, systolic blood pressure and sive diabetics, though they acknowledged some limita-
LDL cholesterol control to hospitalizations in patients tions in their study of intensive control of blood glucose
with T2DM demonstrated that patients without control and BP [30].
of these risk factors or with just the HbA1c controlled In the present study, the hypertensive patients with-
showed the highest rates of cardiovascular hospitali- out a diabetes diagnosis showed a worse evolution of
zation, while those with all risk factors controlled had renal function. HTN is the most important independ-
the lowest rates. This same study showed that to keep ent risk factor for renal involvement that is associated
SBP  <  130  mmHg or LDL-C  <  100  mg/dL was signifi- with increased cardiovascular morbidity and mortality
cantly associated with reducing the risk of cardiovas- [31]. Chronic kidney disease is the 18th cause of overall
cular hospitalization, but keeping HbA1c  <  7% did not mortality [32]. In hypertensives, chronic kidney disease
translate to a reduction in CVD hospitalization risk [21]. (CKD) is less frequent than among diabetic patients [33],
Another study comparing rates of cardiovascular com- but it is also considered harmful to the prognosis of the
plications that required hospital admission among dia- disease [34]. Treating hypertension improves prognosis,
betic individuals from various countries revealed that as it slows the progression of kidney disease [35]. Among
Sousa et al. Diabetol Metab Syndr (2017) 9:98 Page 8 of 9

T2DM patients, CKD occurs in 25–40% of patients [36], lipoproteins; GFR: glomerular filtration rate; TC: total cholesterol; TG: triglycer-
ides; CC: creatinine clearance; HbA1c: hemoglobin A1C; CHD: coronary heart
representing great morbidity and mortality, and is con- disease.
sidered one of the criteria that defines a patient at greater
risk of suffering future coronary events [37]. Hyperten- Authors’ contributions
All authors gathered data, reviewed and edited the manuscript and contrib-
sion, diabetes and dyslipidemia control are decisive in uted to discussions. All authors read and approved the final manuscript.
renal disease of diabetic and non-diabetic patients, aim-
ing to reduce cardiovascular events as well [38]. Author details
1
 Nursing School, Federal University of Goiás (Universidade Federal de Goiás),
Goiânia, Brazil. 2 Hypertension League, Federal University of Goiás (Universi-
Limitations dade Federal de Goiás), 1ª Avenida, S/N‑Setor Leste Universitário, Goiânia, GO
Because this is a retrospective study and the criteria for 74605‑020, Brazil. 3 Medical School, Federal University of Goiás (Universidade
Federal de Goiás), Goiânia, Brazil.
inclusion were to be in regular treatment in our service
with an active chart, it was not possible to identify the Acknowledgements
casualties that may have occurred between the years of We thank the entire team of the Arterial Hypertension League HC/UFG.
2004–2015. However, that does not minimize the results Competing interests
of the study, since the objective was to compare the The authors declare that they have no competing interests.
occurrence of nonfatal outcomes in hypertensive diabetic
Availability of data and materials
patients to those who were hypertensive but without the The authors do not wish to share their data.
development of other morbidity.
Another point to consider is that it has not been pos- Consent for publication
“Not applicable” in this section.
sible to analyze the correlations between the values of
blood pressure and the incidence of outcomes, because Ethics approval and consent to participate
we used chart registry data that did not allow the iden- All of the participants were voluntary recruits who freely agreed to participate
in the study. All participating patients signed a free and informed consent
tification of the BP values at the outcome time. This is form. The study conformed to the Declaration of Helsinki and was approved
an intrinsic limitation to non-concurrent cohort studies, by the Research Ethics Committee of the Clinical Hospital of the Federal
and only prospective studies would permit this assess- University of Goiás (Ruling No. 931,503).
ment. The cohort of participants in this study should Funding
remain under evaluation, with regular follow-ups that The present study had no funding from any research support agency.
will allow for assessing such results in the future.
Publisher’s Note
Conclusions Springer Nature remains neutral with regard to jurisdictional claims in pub-
lished maps and institutional affiliations.
Both groups showed cardiovascular outcomes, as well
as hospitalizations and renal impairment. However, an Received: 22 August 2017 Accepted: 24 November 2017
increased frequency of these outcomes was found among
the diabetic patients. Hypertensive diabetics, as a result
of metabolic and vascular damage, are more prone to car-
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