What are the screening guidelines and management strategies for Diabetes Mellitus (DM) and Hypertension (HTN)?

Screening Guidelines and Management Strategies for Diabetes Mellitus (DM) and Hypertension (HTN)

The 2024 European Society of Cardiology (ESC) guidelines recommend screening for hypertension in all adults and diabetes screening in those with hypertension, with pharmacological treatment initiated at ≥140/90 mmHg regardless of cardiovascular risk, and at ≥130/80 mmHg in high-risk individuals. 1

Hypertension (HTN) Screening

Who to Screen

• All adults should be screened for hypertension
• More frequent screening recommended for:
  • Individuals with high-normal BP (130-139/80-89 mmHg)
  • Those with family history of hypertension
  • Overweight/obese individuals
  • African ancestry individuals (higher risk)

Screening Methods

• Office BP measurement (at least two readings, 1-2 minutes apart)
• Home BP monitoring (HBPM) or ambulatory BP monitoring (ABPM) should be considered to exclude white-coat and masked hypertension 1
• 12-lead ECG recommended for all hypertensive patients 1

Diagnostic Criteria

• Hypertension defined as:
  • Office BP ≥140/90 mmHg
  • Home BP ≥135/85 mmHg
  • 24-hour ABPM ≥130/80 mmHg

Risk Assessment

• Calculate 10-year cardiovascular risk using SCORE2 or SCORE2-OP in patients without established CVD, CKD, diabetes, or hypertension-mediated organ damage (HMOD) 1
• Consider risk modifiers if 10-year risk is borderline (5-10%)

Diabetes Mellitus (DM) Screening

Who to Screen

• Adults aged ≥45 years (annually) 1
• Earlier and more frequent screening for those with:
  • BMI ≥25 kg/m² with additional risk factors
  • Hypertension (BP >135/80 mmHg) 1
  • Hyperlipidemia
  • Family history of diabetes
  • History of gestational diabetes or polycystic ovary syndrome 1
  • History of prediabetes

Screening Methods and Diagnostic Criteria

• Any of the following tests can be used 1:
  • Fasting plasma glucose (FPG) ≥126 mg/dL (7.0 mmol/L)
  • 2-hour plasma glucose ≥200 mg/dL (11.1 mmol/L) during OGTT
  • HbA1c ≥6.5%
  • Random plasma glucose ≥200 mg/dL with symptoms
• Abnormal results should be confirmed with repeat testing on a separate day

Management of Hypertension

Blood Pressure Targets

• General target: <140/90 mmHg for most patients 1
• Lower target (120-129/<80 mmHg) for:
  • High cardiovascular risk patients
  • Patients with diabetes
  • Patients with chronic kidney disease
• Higher targets may be appropriate for:
  • Age ≥85 years
  • Moderate-to-severe frailty
  • Limited life expectancy (<3 years)
  • Symptomatic orthostatic hypotension 1

Non-pharmacological Management

• Weight reduction to achieve normal BMI
• Regular physical activity (150 min/week)
• Sodium restriction (<5g salt/day)
• Moderation of alcohol consumption
• DASH-style diet (rich in fruits, vegetables, low-fat dairy)
• Smoking cessation

Pharmacological Management

• Initiate drug treatment promptly in:

  • Confirmed BP ≥140/90 mmHg regardless of CVD risk 1
  • BP ≥130/80 mmHg in high-risk patients after 3 months of lifestyle measures 1

• First-line medications:

  • ACE inhibitors or ARBs (especially for patients with diabetes, CKD, or albuminuria)
  • Calcium channel blockers
  • Thiazide or thiazide-like diuretics

• Combination therapy:

  • Most patients will require combination therapy
  • Consider single-pill combinations to improve adherence
  • Avoid ACE inhibitor + ARB combination 1

• Special considerations:

  • Young adults (<40 years): Screen for secondary hypertension 1, 2
  • Pregnant women: Avoid ACE inhibitors/ARBs; consider methyldopa, labetalol, or nifedipine 2
  • Resistant hypertension: Consider spironolactone addition and referral to specialist 1

Management of Diabetes Mellitus

Glycemic Targets

• General HbA1c target: <7.0%
• More stringent targets (<6.5%) for selected patients without hypoglycemia risk
• Less stringent targets (<8.0%) for elderly, frail patients, or those with limited life expectancy 1

Management Approach

1. Lifestyle modifications:

   • Medical nutrition therapy
   • Regular physical activity
   • Weight management
   • Smoking cessation

2. Pharmacological therapy:

   • Metformin as first-line therapy
   • Add second agent based on patient factors and comorbidities
   • Consider early combination therapy for HbA1c >9%

3. Cardiovascular risk reduction:

   • Blood pressure control (target <130/80 mmHg)
   • Lipid management (statin therapy)
   • Antiplatelet therapy for secondary prevention

Monitoring for Complications

• Annual comprehensive eye examination
• Annual screening for diabetic kidney disease (urine albumin-creatinine ratio and eGFR)
• Annual comprehensive foot examination
• Screening for cardiovascular disease

Management of Comorbid HTN and DM

• BP target: <130/80 mmHg 1, 3

• Preferred antihypertensive agents:

  • ACE inhibitors or ARBs as first-line therapy, especially with albuminuria 1, 3
  • Calcium channel blockers as second-line
  • Thiazide-like diuretics (chlorthalidone, indapamide)
  • Avoid beta-blockers as first-line unless compelling indications exist

• Comprehensive approach:

  • Aggressive lifestyle modifications
  • Multifactorial risk reduction (glycemia, BP, lipids)
  • Regular screening for microvascular complications
  • Consider aspirin for primary prevention in high-risk patients (10-year risk >10%) 1

Common Pitfalls and Caveats

• Single BP or glucose measurements are insufficient for diagnosis; confirmation is essential 4
• White-coat and masked hypertension may lead to misdiagnosis; consider ABPM or HBPM
• Overreliance on HbA1c alone for diabetes diagnosis (can be affected by hemoglobinopathies, anemia)
• Therapeutic inertia - failure to intensify treatment when targets are not met
• Inadequate attention to adherence issues
• Neglecting secondary causes of hypertension, especially in young adults (<40 years) 1
• Overlooking screening for primary aldosteronism in hypertensive patients 1