The Study On Blood Pressure Circadian Rhythm And Standard Antihypertensive Treatment In Type 2 Diabetes Mellitus With Hypertension

Part1.Correlation analysis among blood pressure circadian rhythm,blood pressure variability and carotid atherosclerosis in type 2 diabetes mellitus with hypertensionBackgrounds and objective:Studies have showed that the change of blood pressure circadian rhythm is more frequent in type 2 diabetes mellitus(T2DM)because of insulin resistance,autonomic nerve dysfunction,impaired endothelial function and other factors.So non-dipper pattern is more common in T2 DM.The lack of nocturnal decrease in blood pressure is related with increased cardiovascular complications.At the same time,increased blood pressure variability is a risk factor for target organ damage.The prevalence of T2 DM with hypertension(HT)rises year by year.T2 DM and HT are independent risk factors for cardiovascular events.Cardiovascular disease is the main cause of death in T2 DM with HT.Carotid atherosclerosis can reflect the condition of the whole blood vessels.The clinician often evaluated the risk of cardiovascular disease through the degree of carotid atherosclerosis.Some studies about HT patients showed that blood pressure circadian rhythm,blood pressure variability are closely associated with carotid atherosclerosis,but hardly any studies about T2 DM patients.We will discuss the relationship of blood pressure circadian rhythm and blood pressure variability on carotid atherosclerosis in T2 DM with HT in this study through ambulatory blood pressure monitoring(ABPM)and carotid artery ultrasonography.Materials and methods:1.443 cases of inpatients with type 2 diabetes mellitus in Department of Endocrinology of Third Military Medical University Southwest Hospital from January 2014 to September were involved.They were 250 males and 193 females,at an average age of(60.36±12.11)years;2.Subjects were divided into the normal group(158 cases)and the hypertensive group(285 cases)according to hypertension diagnosis standard.Subjects in the hypertensive group were divided into the non-dipper group(226 cases)and the dipper group(59 cases)according to blood pressure falling rates(BPF);3.Recording the general information of patients.Recording systolic blood pressure(SBP),diastolic blood pressure(DBP),pulse pressure(PP)at all the time and their standard deviation after ambulatory blood pressure monitoring.Blood pressure variability was expressed as standard deviation of blood pressure.We measured carotid intima-media thickness(CIMT)through carotid artery ultrasonography.The differences of blood pressure,blood pressure variability and the degree of carotid atherosclerosis were compared among the groups,the effective factors of carotid atherosclerosis were analyzed at the same time;4.Statistical analysis: SPSS version 19.0 was used to analyze data.We compared the differences among the groups using the One-way analysis of variance.Logistic regression analysis was carried out to analyze the effective factors of carotid atherosclerosis.P<0.05 was statistically significant.Results:1.The incidence of the normal group was 35.67%.The incidence of the hypertensive group was 64.33%.79.29% patients are non-dipper pattern in hypertensive group.The incidence of carotid atherosclerosis in non-dipper group(60.6%)was significantly higher than in dipper group(42.4%)(P<0.01);2.24 h SBP,24 h PP,n SBP,n DBP and n PP in non-dipper group was significantly higher than in dipper group(P<0.01 or P<0.05);3.24 h SSD in non-dipper group was significantly higher than in dipper group(P<0.01);4.Logistic regression analysis showed that DBPF were independently related to carotid atherosclerosis(OR=0.952,95%CI:0.929~0.975;P<0.01).Conclusions:The non-dipper pattern was more common in T2 DM with HT.24 h systolic blood pressure variability was increased in non-dipper group.The change of blood pressure circadian rhythm and the increase of blood pressure variability promoted the formation of carotid atherosclerosis.Part2.Correlation analysis among non-dipper pattern,homocysteine and carotid atherosclerosis in type 2 diabetes mellitusBackgrounds and objective:With ambulatory blood pressure monitoring(ABPM)was widely applied in clinical practice and clinical research of hypertension,the researchers pay more attention to the blood pressure rhythm in type 2 diabetes mellitus(T2DM).The non-dipper pattern is closely related to the target organ damage,such as the damage of heart,brain,kidney,systemic blood vessels and so on.Studies have showed that non-dipper pattern could lead to early carotid artery plaque formation and increase the risk of cardiovascular events.Homocysteine(Hcy)is the intermediate product of methionine and cysteine in the process of metabolism.Some studies showed that Hcy might be associated with atherosclerosis.This study intends to observe the relationship of non-dipper pattern with homocysteine and carotid atherosclerosis in T2 DM,providing evidence for their prevention and treatment of vascular lesions.Materials and methods:1.240 cases of inpatients with T2 DM in Department of Endocrinology of Third Military Medical University Southwest Hospital from December 2013 to October 2014 were involved.They were 139 males and 101 females,at an average age of(60.77±11.44)years;2.Subjects were divided into the non-dipper group(160 cases)and the dipper group(80 cases)according to blood pressure falling rates(BPF).They were divided into the group with sclerosis(119 cases)and the group without sclerosis(121 cases)according to the carotid atherosclerosis;3.Recording the general information of patients.Measuring the concentration of Hcy and other biochemical indicators through fasting plasma.Recording systolic blood pressure(SBP),diastolic blood pressure(DBP),pulse pressure(PP)at all the time after ambulatory blood pressure monitoring.We measured carotid intima-media thickness(CIMT)through carotid artery ultrasonography.The differences of blood pressure,Hcy and the degree of carotid atherosclerosis were compared between the groups,.We analyzed the effective factors of carotid atherosclerosis at the same time;4.Statistical analysis: SPSS version 19.0 was used to analyze data.We compared the differences between the groups using the Independent-Samples T Test.Multiple linear regression analysis(Enter method)was used to multiple factors analysis.Chi-square was used to screen the risks of carotid atherosclerosis.Unconditional logistic regression analysis(Forward: Conditional)was carried out to analyze the risk factors of carotid atherosclerosis.We used spearman rank correlation to do correlation analysis.P<0.05 was statistically significant.Results:1.The incidence of non-dipper pattern was 66.67%.Hcy,CIMT,24 h SBP,24 h PP,d SBP,d PP,n SBP,n DBP and n PP in non-dipper group were significantly higher than in dipper group(P<0.01);2.Multiple linear regression analysis showed that Hcy,n SBP,n DBP were the effective factors of the change of blood pressure circadian rhythm(P<0.01);3.CIMT,age,24 h SBP,d SBP,n SBP,n DBP in the group with sclerosis were significantly higher than in the group without sclerosis(P<0.01 or P<0.05).SBPF,DBPF in the group with sclerosis were significantly lower than in the group without sclerosis(P<0.01);4.Logistic regression analysis showed that age?70 years old(OR=2.204,95% CI:1.049~3.904;P < 0.05),n DBP?80mm Hg(OR=2.357,95%CI:1.177 ~ 4.719;P < 0.05),DBPF <10%(OR=2.562,95%CI:1.431~4.585;P<0.01)were the risk factors of carotid atherosclerosis.Spearman correlation analysis showed that CIMT was negatively associated with SBPF(r=-0.191,P<0.01)and positively associated with age(r=0.195,P<0.05).Conclusions: The non-dipper pattern was more common in T2 DM.Hcy in non-dipper group were significantly higher than in dipper group.Non-dipper pattern promoted the formation of carotid atherosclerosis.Part3.Chronotherapy of antihypertensive treatment in type 2 diabetes mellitus with hypertensionBackgrounds and objective:Nocturnal hypertension is more frequent and the non-dipper pattern is more common in type 2 diabetes meiilitus(T2DM).The continuously nocturnal hypertension(HT)will increase the risk of cardiovascular events.Studies have showed that bedtime administration(BA)of antihypertensive drugs could significantly reduce night blood pressure,so as to reduce the risk of cardiovascular events.Therefore,the American Diabetes Association suggests administration?1 antihypertensive drugs at bedtime for T2 DM.But no studies research the effect divided into different blood pressure rhythm.There is no study reported that administration?1 antihypertensive drugs at bedtime is the same with dipper pattern.This study researched the optimal antihypertensive strategy in T2 DM with HT through morning administration(MA)or BA for different blood pressure rhythm.Diabetic nephropathy is a chronic complication in T2 DM which is mainly performed as albuminuria at early stage.This study observed the influence of albuminuria for different treatment strategies.Materials and methods:1.128 cases with T2 DM and mild-to-moderate HT were involved.Subjects were divided into the non-dipper group(A)and the dipper group(B)according to blood pressure falling rates(BPF).A and B were randomly divided into A1(35 cases),A2(34 cases),B1(29 cases),B2(30 cases)through “random number table method”.A1 and B1 were treated in the morning.A2 and B2 were treated at nighttime;2.General information was recorded when patients were involved.Measuring the concentration of biochemical indicators through fasting plasma.We quantitatively analyzed 24 h urine protein by colorimetric method after subsistence of 24 h urine.Recording systolic blood pressure(SBP),diastolic blood pressure(DBP),mean arterial pressure(MAP)and pulse pressure(PP)and their standard deviation at all the time after ambulatory blood pressure monitoring.Then calculating smoothness index;3.Patients were measured the concentration of urine protein and monitored ambulatory blood pressure after following 24 weeks.We assessed the influence of BP,blood pressure rhythm,blood pressure variability and albuminuria of different blood pressure rhythm for different treatment strategies in T2DM;4.Statistical analysis: Statistical analysis was using SPSS version 19.0.One-way analysis of variance was used to compare the differences among the groups.Paired-Sample T Test was used to compare the differences between before and after treatment in the groups.Independent-Samples T Test was used to compare the differences in the groups after treatment.P<0.05 was statistically significant.Results:1.The enrollment situation: Creatinine,Cys-c and nighttime BP in A were significantly higher than in B(P<0.01 or P<0.05);2.24 h BP and their SD,daytime BP and their SD,night BP and n SSD,SISBP and SBPF significantly declined after treatment in A1(P<0.01 or P<0.05).24 h BP and their SD,daytime BP and their SD,night BP and their SD and the concentration of urine protein significantly declined after treatment in A2(P < 0.01).SBPF and DBPF significantly increased after treatment in A2(P<0.01).Non-dipper pattern was more obvious in A1 after treatment.Non-dipper pattern was tend to restore dipper pattern in A2;3.24 h BP and their SD,daytime BP and their SD,n SSD,SBPF and DBPF significantly declined after treatment in B1(P<0.01).24 h BP and their SD,daytime BP and their SD,and night BP and their SD significantly declined after treatment in B2(P<0.01).B1 and B2 maintained dipper pattern.The concentration of urine protein did not obviously change in B1 and B2 after treatment.4.n SBP,n PP and n DSD was significantly higher in A1 than in A2 after treatment.SBPF,DBPF and SISBP was significantly lower in A1 than in A2 after treatment(P<0.01 or P<0.05).n SBP,n MAP,d SSD,d PSD was significantly higher in B1 than in B2 after treatment.SBPF and DBPF was significantly lower in B1 than in B2 after treatment(P<0.01 or P<0.05).Conclusions:We suggest administration?1 antihypertensive drugs for patients with T2 DM and mild-to-moderate HT regardless of dipper pattern or non-dipper pattern.Bedtime administration of antihypertensive drugs could significantly reduce the concentration of urine protein in dipper pattern.