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A 55-year-old man with a history of diabetes mellitus type 2 comes to your clinic for a 1-month follow-up visit. His blood pressures in the last 2 visits have been 145/90, 140/85, 140/90, and 135/90 mm Hg. Today his blood pressure shows similar numbers. You explain to the patient that he likely has hypertension and appropriate management is important to prevent complications.

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Important considerations include blood pressure target lifestyle modifications, medical therapy and additional testing.

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Given his history of diabetes, his blood pressure target is <130/80 mm Hg. The BP goal for the general population is <140/90 mm Hg.

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You should recommend dietary changes including decrease of sodium intake to less than 2400 mg per day and adoption of the DASH (Dietary Approaches to Stop Hypertension) diet, which is rich in fruits, vegetables, and potassium and low in saturated fats. Weight loss for those who are overweight and aerobic exercise most days of the week for 20 to 30 minutes are also recommended.

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Patients with diabetes and hypertension should be treated with ACE inhibitors or angiotensin receptor blockers (ARBs) as they help delay the onset and progression of diabetic nephropathy.

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All patients with a new diagnosis of HTN should be assessed for organ damage and the presence of other cardiovascular risk factors. Complete blood count (CBC), basic metabolic profile (BMP), urinalysis (for microalbuminuria), EKG, lipid profile, and fasting blood sugar (or HbA1C) should be obtained at the time of diagnosis.

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The Seventh Report of the JNC-7 defines hypertension as systolic pressure ≥140 mm Hg or diastolic pressure ≥90 mm Hg for the general population, and ≥130 or ≥80 mm Hg for certain groups including patients with diabetes and chronic kidney disease.

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Epidemiology

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Hypertension affects about 30% of the adult population in the United States and is one of the leading causes of cardiovascular disease including coronary artery disease, stroke, and congestive heart failure. Along with diabetes, it is also responsible for many cases of end-stage renal disease, retinopathy, and peripheral arterial disease (PAD). Approximately 30% of adults in the United States who have hypertension are unaware, and only about 50% of those diagnosed are adequately controlled. The prevalence continues to increase as our population ages and obesity worsens. Hypertension affects all races but African Americans in general have an earlier onset, are more difficult to control, and have a higher rate of complications than Caucasian Americans.

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Classification

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According to the JNC-7 report, blood pressure is classified as normal, prehypertension, stage 1 hypertension, and stage 2 hypertension. See Table 56-1.

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Table Graphic Jump Location
Table 56-1. Classification and Management of Blood Pressure for Adults Aged 18 Years or Older

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