The influence of
hypertension on the
clinical course and complications of
type 2 diabetes is well established. With a special focus on
angiotensin-converting enzyme inhibitors, this paper will review recently published results of prospective studies addressing two important aspects: the degree of blood pressure control, and the choice of
antihypertensive regimen, in the prevention of complications in hypertensive type 2 diabetic patients. None of the recent studies have shown worse outcomes in patients treated with
angiotensin-converting enzyme inhibitor-based regimens compared with alternative treatments. Some studies have suggested that
angiotensin-converting enzyme inhibitor-based
antihypertensive regimens may be superior to alternative treatments in reducing the risk of micro- and macrovascular complications, whereas other studies found similar effects for beta-blockers or
calcium antagonists. Several trials showed beneficial effects of
angiotensin-converting enzyme inhibitors over
calcium antagonists, and have raised concerns about the use of
dihydropyridine calcium antagonists in these patients. However, it remains to be determined whether there should be more reserved use of
calcium antagonists in such patients, in the light of more major trials showing the safety and efficacy of
calcium antagonists in preventing cardiovascular and renal endpoints. The degree of reduction of blood pressure rather than the choice of a particular
drug may be the most important factor. Studies focusing on renal endpoints suggest that
angiotensin-converting enzyme inhibitors have a better antiproteinuric effect than other agents, but this phenomenon is not always reflected by a more beneficial effect of
angiotensin-converting enzyme inhibitors on the decline in glomerular filtration rate. In many ways, the question of whether
angiotensin-converting enzyme inhibitors are the best class of agent in these patients is academic.
Angiotensin-converting enzyme inhibitors are sufficiently safe, and, according to recent evidence, equally or more effective than other classes of agents. Tight blood pressure control is usually achievable only with a combination of agents. On the basis of available evidence, it appears that
angiotensin-converting enzyme inhibitors, together with a low-dose cardioselective beta-blocker and a
diuretic, should be used in most hypertensive
type 2 diabetes patients, with
calcium antagonists serving as reserve drugs in case of insufficient blood pressure control.