Diabetes and Hypertension: A Position Statement by the American Diabetes Association
Authors: Ian H. de Boer, Sripal Bangalore, Athanase Benetos, Andrew M. Davis, Erin D. Michos, Paul Muntner, Peter Rossing, Sophia Zoungas, George Bakris
Journal: Diabetes Care (2017)

Hypertension is common among patients with diabetes, with the prevalence depending on type and duration of diabetes, age, sex, race/ethnicity, BMI, history of glycemic control, and the presence of kidney disease, among other factors (1-3).Furthermore, hypertension is a strong risk factor for atherosclerotic cardiovascular disease (ASCVD), heart failure, and microvascular complications.ASCVDddefined as acute coronary syndrome, myocardial infarction (MI), angina, coronary or other arterial revascularization, stroke, transient ischemic attack, or peripheral arterial disease presumed to be of atherosclerotic origindis the leading cause of morbidity and mortality for individuals with diabetes and is the largest contributor to the direct and indirect costs of diabetes.Numerous studies have shown that antihypertensive therapy reduces ASCVD events, heart failure, and microvascular complications in people with diabetes (4-8).Large benefits are seen when multiple risk factors are addressed simultaneously (9).There is evidence that ASCVD morbidity and mortality have decreased for people with diabetes since 1990 (10,11) likely due in large part to improvements in blood pressure control (12)(13)(14).This Position Statement is intended to update the assessment and treatment of hypertension among people with diabetes, including advances in care since the American Diabetes Association (ADA) last published a Position Statement on this topic in 2003 (3). DEFINITIONS, SCREENING, AND DIAGNOSISRecommendations c Blood pressure should be measured at every routine clinical care visit.Patients found to have an elevated blood pressure ($140/90 mmHg) should have blood pressure confirmed using multiple readings, including measurements on a separate day, to diagnose hypertension.B c All hypertensive patients with diabetes should have home blood pressure monitored to identify white-coat hypertension.B c Orthostatic measurement of blood pressure should be performed during initial evaluation of hypertension and periodically at follow-up, or when symptoms of orthostatic hypotension are present, and regularly if orthostatic hypotension has been diagnosed.E Blood pressure should be measured at every routine clinical care visit (15).At the initial visit, blood pressure should be measured in both arms to detect and account for abnormalities that may lead to spurious blood pressures, such as arterial stenosis.Patients with elevated blood pressure ($140/90 mmHg) who are not known to have hypertension should have elevated blood pressure confirmed on a separate day, within 1 month, to confirm the diagnosis of hypertension.Office-based semiautomated oscillometric blood pressure (conventional or office blood pressure) is the conventional method used to diagnose hypertension and monitor treatment response.Blood pressure should be measured by a trained individual (15) in the seated position, with feet on the floor and arm supported at heart level.Cuff size should be appropriate for the upper-arm circumference (Table 1).To reduce withinpatient variability, blood pressure should be measured after 5 min of rest, 2-3 readings should be taken 1-2 min apart, and blood pressure measurements should be averaged (16).It is particularly important to make and average repeated measurements of blood pressure for the diagnosis of hypertension and titration of antihypertensive treatment.