Attention to Cardiovascular and Renal Complications in Diabetes – how to prevent them?

@#It is a well-established fact that patients with diabetes mellitus are at high risk of cardiovascular and renal complications in the course of their lifetime. Much effort has been invested in understanding the pathobiology of this as well as in developing an effective strategy to reduce the morbidity and mortality associated with it. Metabolic control together with mitigating other known risk factors for the cardiovascular and renal disease has been the basis of improving the outcomes of all patients with diabetes. Ongoing scientific discoveries continue to provide physicians and patients with better means of treatment over the years. Each is a step forward, and with the addition of new classes of therapeutics, we will need to reconstruct the management pathway that is best for each patient given their risk profiles and characteristics.

Ministry of Health Clinical Practice Guidelines: Hypertension

The Ministry of Health (MOH) has updated the clinical practice guidelines on hypertension to provide doctors and patients in Singapore with evidence-based treatment for hypertension. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH clinical practice guidelines on hypertension, for the information of SMJ readers. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical.html. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Updates in Hypertension Management - 2017

Management of hypertension will continue to evolve as new studies provide us more evidence on many relevant aspects of care for this very common condition. To define hypertension, we need to be able to measure blood pressure (BP) accurately and make it easily reproducible. The mercury sphygmomanometer has been a standard tool to measure BP, but it is evident that it will be phased out soon and replaced by electronic BP devices — both for clinic and home use. There is increasingly more awareness of the benefits of out-of-office (clinic) BP measurement to estimate extent of BP control and also prognosis. The goal for BP treatment has also evolved and, for the first time in decades, there has been a suggestion that a lower-than-140/90 mmHg target is associated with further reduction in adverse cardiovascular outcomes. There is, however, a need for more pills and an increased risk of treatment-related side effects. The choice of which anti-hypertensive to use, as well as the goal of treatment, should be individualised and discussed with the patient.

Blood pressure and antihypertensive medication profile in a multiethnic Asian population of stable chronic kidney disease patients

<p><b>INTRODUCTION</b>Clinical practice guidelines recommend different blood pressure (BP) goals for chronic kidney disease (CKD) patients. Usage of antihypertensive medication and attainment of BP targets in Asian CKD patients remain unclear. This study describes the profile of antihypertensive agents used and BP components in a multiethnic Asian population with stable CKD.</p><p><b>METHODS</b>Stable CKD outpatients with variability of serum creatinine levels < 20%, taken > 3 months apart, were recruited. Mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured using automated manometers, according to practice guidelines. Serum creatinine was assayed and the estimated glomerular filtration rate (GFR) calculated using the CKD Epidemiology Collaboration equation. BP and antihypertensive medication profile was examined using univariate analyses.</p><p><b>RESULTS</b>613 patients (55.1% male; 74.7% Chinese, 6.4% Indian, 11.4% Malay; 35.7% diabetes mellitus) with a mean age of 57.8 ± 14.5 years were recruited. Mean SBP was 139 ± 20 mmHg, DBP was 74 ± 11 mmHg, serum creatinine was 166 ± 115 µmol/L and GFR was 53 ± 32 mL/min/1.73 m(2). At a lower GFR, SBP increased (p < 0.001), whereas DBP decreased (p = 0.0052). Mean SBP increased in tandem with the number of antihypertensive agents used (p < 0.001), while mean DBP decreased when ≥ 3 antihypertensive agents were used (p = 0.0020).</p><p><b>CONCLUSION</b>Different targets are recommended for each BP component in CKD patients. A majority of patients cannot attain SBP targets and/or exceed DBP targets. Research into monitoring and treatment methods is required to better define BP targets in CKD patients.</p>

Statin-centric versus low-density lipoprotein-centric approach for atherosclerotic cardiovascular disease prevention: a Singapore perspective

The link between cholesterol levels and atherosclerotic cardiovascular disease (ASCVD) is well-established. In Singapore, there is an increasing prevalence of risk factors for ASCVD. Like many Asian countries, Singapore's population is rapidly ageing and increasingly sedentary, which predisposes individuals to chronic health problems. Current international and local guidelines recommend statin therapy for the primary and secondary prevention of ASCVD. However, despite the effectiveness of statin therapy, some studies have highlighted that Asian patients with cardiovascular disease are not achieving target lipid goals. Furthermore, it is widely believed that the responses of Asians (both patients and physicians) to statin therapy are different from those of their Western counterparts. Experts convened in 2014 to determine the impact of current guidelines on clinical practice in Singapore. This review summarises the key findings and recommendations of these guidelines, and presents key principles to aid clinicians to manage the cardiovascular risk of their patients more effectively.