What is the appropriate SOAP note for a 55-year-old male with a history of hypertension (high blood pressure) and hyperlipidemia (elevated lipids) presenting with fatigue and shortness of breath upon exertion?

SOAP Note: 55-Year-Old Male with Hypertension, Hyperlipidemia, Fatigue, and Dyspnea on Exertion

SUBJECTIVE

Chief Complaint: "I've been feeling tired and short of breath when I walk up stairs or do yard work."

History of Present Illness:

• 55-year-old male presents for annual wellness visit with new complaints of progressive fatigue and dyspnea on exertion over the past 3 months 1
• Reports shortness of breath when climbing one flight of stairs or walking more than 2 blocks 1
• Denies chest pain, palpitations, orthopnea, paroxysmal nocturnal dyspnea, or lower extremity edema 1
• Fatigue described as persistent throughout the day, not relieved by rest 1
• Denies syncope, presyncope, or irregular heartbeat 1
• Reports snoring at night per wife; daytime sleepiness despite 7-8 hours of sleep 1, 2

Past Medical History:

• Hypertension diagnosed 5 years ago, currently on amlodipine 10 mg daily and metoprolol succinate 50 mg daily 3
• Hyperlipidemia diagnosed 3 years ago, on atorvastatin 40 mg daily 1
• No history of diabetes, coronary artery disease, stroke, or chronic kidney disease 1

Medications:

• Amlodipine 10 mg daily 3
• Metoprolol succinate 50 mg daily 3
• Atorvastatin 40 mg daily 1

Allergies: No known drug allergies 1

Social History:

• Former smoker, quit 10 years ago (15 pack-year history) 1
• Alcohol: 2-3 beers on weekends 1
• Sedentary lifestyle, no regular exercise 1
• Works as accountant (desk job) 1

Family History:

• Father: myocardial infarction at age 58, hypertension 1
• Mother: stroke at age 65, diabetes 1
• Brother: hypertension 1

Review of Systems:

• Constitutional: Fatigue, no fever, no weight loss 1
• Cardiovascular: Dyspnea on exertion, no chest pain, no palpitations 1
• Respiratory: No cough, no wheezing, snoring 1, 2
• Neurological: No headaches, no focal weakness 1
• Musculoskeletal: No joint pain 1

OBJECTIVE

Vital Signs:

• Blood Pressure: 152/94 mmHg (right arm, seated, repeated: 148/92 mmHg) 1, 3
• Heart Rate: 78 bpm, regular 1
• Respiratory Rate: 16 breaths/min 1
• Temperature: 98.4°F 1
• Weight: 235 lbs (106.8 kg) 1
• Height: 5'10" (178 cm) 1
• BMI: 33.7 kg/m² 1, 2
• Waist Circumference: 108 cm 1
• Oxygen Saturation: 97% on room air 1
• Neck Circumference: 42 cm 2

Physical Examination:

• General: Alert, oriented, obese male in no acute distress 1
• HEENT: Normocephalic, atraumatic; oropharynx with Mallampati class III; no thyromegaly 1, 2
• Cardiovascular: Regular rate and rhythm, normal S1 and S2, no S3 or S4 gallop, no murmurs, rubs, or clicks; point of maximal impulse at 5th intercostal space midclavicular line, non-displaced 1
• Pulmonary: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi 1
• Abdomen: Soft, obese, non-tender, no hepatosplenomegaly, no abdominal bruits 1
• Extremities: No peripheral edema, peripheral pulses 2+ and symmetric bilaterally (radial, femoral, dorsalis pedis, posterior tibial); no femoral bruits 1
• Neurological: Cranial nerves II-XII intact, strength 5/5 in all extremities, sensation intact 1

Laboratory Results (fasting):

• Fasting Plasma Glucose: 104 mg/dL 1
• Hemoglobin A1C: 5.9% 1
• Total Cholesterol: 215 mg/dL 1
• LDL Cholesterol: 138 mg/dL 1
• HDL Cholesterol: 38 mg/dL 1
• Triglycerides: 195 mg/dL 1
• Serum Creatinine: 1.0 mg/dL 1
• Estimated GFR: 88 mL/min/1.73 m² 1
• Serum Potassium: 4.2 mEq/L 1
• Serum Sodium: 140 mEq/L 1
• Serum Uric Acid: 7.2 mg/dL 1
• TSH: 2.1 mIU/L 1
• Hemoglobin: 14.5 g/dL 1
• Urinalysis: No protein, no blood, no glucose 1
• Urine Albumin-to-Creatinine Ratio: 18 mg/g 1

12-Lead ECG:

• Normal sinus rhythm, heart rate 76 bpm 1
• No left ventricular hypertrophy by voltage criteria (Sokolow-Lyon index: 2.8 mV; Cornell voltage: 1.9 mV) 1
• No ST-T wave abnormalities 1
• No evidence of prior myocardial infarction 1

ASSESSMENT

Primary Diagnoses:

1. Uncontrolled Stage 2 Hypertension (ICD-10: I10)

• Blood pressure 148-152/92-94 mmHg on two-drug regimen (calcium channel blocker and beta-blocker) 3
• Target BP <130/80 mmHg not achieved 1, 3
• Patient is 55 years old with multiple cardiovascular risk factors including male sex, obesity (BMI 33.7), hyperlipidemia, prediabetes, family history of premature CVD, and low HDL 1
• Cardiovascular risk stratification: High risk based on presence of ≥3 additional risk factors 1
• No evidence of target organ damage (no LVH on ECG, normal renal function, no microalbuminuria) 1

2. Dyslipidemia, Uncontrolled (ICD-10: E78.5)

• LDL cholesterol 138 mg/dL (goal <100 mg/dL for high-risk patient, ideally <70 mg/dL) 1
• HDL cholesterol 38 mg/dL (goal >40 mg/dL in men) 1
• Triglycerides 195 mg/dL (goal <150 mg/dL) 1
• Total cholesterol 215 mg/dL (goal <200 mg/dL) 1
• Currently on atorvastatin 40 mg daily with suboptimal response 1

3. Suspected Obstructive Sleep Apnea (ICD-10: G47.33)

• Clinical presentation: snoring, daytime sleepiness, obesity (BMI 33.7), large neck circumference (42 cm), Mallampati class III 1, 2
• Sleep apnea is a common secondary cause of resistant hypertension and is present in approximately 20% of patients with uncontrolled hypertension 1, 2
• Likely contributing to fatigue and potentially to hypertension 1, 2

4. Dyspnea on Exertion, Etiology Undetermined (ICD-10: R06.02)

• New onset progressive dyspnea with exertion over 3 months 1
• No evidence of heart failure on physical exam (no S3, no peripheral edema, no pulmonary rales) 1
• Normal oxygen saturation 1
• Requires further evaluation to rule out cardiac vs. pulmonary etiology vs. deconditioning 1

5. Obesity (ICD-10: E66.9)

• BMI 33.7 kg/m² (Class I obesity) 1
• Waist circumference 108 cm (goal <102 cm for men) 1
• Contributing to hypertension, dyslipidemia, and likely sleep apnea 1

6. Prediabetes (ICD-10: R73.03)

• Fasting plasma glucose 104 mg/dL (100-125 mg/dL range) 1
• Hemoglobin A1C 5.9% (5.7-6.4% range) 1
• Increased risk for progression to type 2 diabetes 1

7. Sedentary Lifestyle (ICD-10: Z72.3)

• No regular physical activity 1
• Contributing to obesity, hypertension, and dyslipidemia 1

Differential Diagnoses:

Differential Diagnosis #1: Heart Failure with Preserved Ejection Fraction (HFpEF)

• Rationale for consideration: Patient presents with dyspnea on exertion and fatigue in the setting of longstanding hypertension, obesity, and multiple cardiovascular risk factors 1. HFpEF is common in hypertensive patients and can present with exertional dyspnea without overt signs of volume overload 1.
• Supporting data: Dyspnea on exertion, fatigue, hypertension, obesity, age >55 years 1.
• Distinguishing features: Physical exam shows no S3 gallop, no peripheral edema, no jugular venous distension, and no pulmonary rales 1. ECG shows no left ventricular hypertrophy 1. NT-proBNP would be elevated in HFpEF (>100 pg/mL), and echocardiography would show preserved ejection fraction (≥50%) with evidence of diastolic dysfunction 1.
• Diagnostic test needed: Echocardiogram to assess left ventricular systolic and diastolic function, and NT-proBNP or BNP level 1.

Differential Diagnosis #2: Coronary Artery Disease with Exertional Angina Equivalent

• Rationale for consideration: Patient has multiple cardiovascular risk factors (male sex, age 55, hypertension, hyperlipidemia, obesity, family history of premature MI, former smoker, prediabetes, low HDL) placing him at high risk for atherosclerotic cardiovascular disease 1. Dyspnea on exertion can be an angina equivalent, particularly in patients with diabetes or prediabetes 1.
• Supporting data: Dyspnea with exertion, fatigue, multiple cardiovascular risk factors, family history of MI at age 58 1.
• Distinguishing features: Patient denies chest pain, pressure, or discomfort 1. ECG shows no evidence of ischemia or prior infarction 1. Symptoms are not associated with diaphoresis, nausea, or radiation 1.
• Diagnostic test needed: Exercise stress test (or pharmacologic stress test if unable to exercise adequately) with imaging (echocardiography or nuclear) to assess for inducible ischemia 1.

Differential Diagnosis #3: Deconditioning Secondary to Sedentary Lifestyle and Obesity

• Rationale for consideration: Patient has BMI 33.7 kg/m², sedentary lifestyle with no regular exercise, and desk job 1. Deconditioning is a common cause of exertional dyspnea and fatigue in obese, sedentary individuals 1.
• Supporting data: Obesity (BMI 33.7), sedentary lifestyle, desk job, gradual onset of symptoms over 3 months 1.
• Distinguishing features: Deconditioning would not typically cause progressive worsening over only 3 months unless there has been significant weight gain or further reduction in activity 1. Physical exam and vital signs are otherwise reassuring with normal oxygen saturation and no tachycardia at rest 1.
• Diagnostic test needed: If cardiac and pulmonary workup is negative, a structured exercise program would be both diagnostic and therapeutic, with expected improvement in symptoms over 6-8 weeks 1.

PLAN

1. Uncontrolled Stage 2 Hypertension

Pharmacologic Management:

• Add chlorthalidone 12.5 mg daily (thiazide-like diuretic) to current regimen of amlodipine 10 mg and metoprolol succinate 50 mg 1, 3. This follows the ACC/AHA guideline-recommended stepwise approach for non-Black patients requiring three-drug therapy 1, 3.
• Continue amlodipine 10 mg daily and metoprolol succinate 50 mg daily 3.
• Target blood pressure <130/80 mmHg per ACC/AHA 2017 guidelines 1, 3.
• If BP remains uncontrolled after 4 weeks on three-drug therapy, consider adding spironolactone 25 mg daily for resistant hypertension 3.

Non-Pharmacologic Management:

• Dietary sodium restriction to <1,500 mg/day (or at minimum, reduce current intake by 1,000 mg/day) 1.
• Increase dietary potassium intake to 3,500-5,000 mg/day through diet (bananas, oranges, potatoes, spinach, beans) unless contraindicated 1.
• Weight loss goal: lose at least 1 kg initially, with ultimate goal of achieving BMI <25 kg/m² (approximately 60 lbs total weight loss) 1.
• Structured aerobic exercise program: 90-150 minutes per week of moderate-intensity activity (brisk walking, cycling, swimming) 1.
• Limit alcohol consumption to ≤2 standard drinks per day (currently consuming 2-3 beers on weekends) 1.
• DASH diet (Dietary Approaches to Stop Hypertension): emphasize fruits, vegetables, whole grains, lean proteins, low-fat dairy, and limit saturated fats 1.

Monitoring:

• Recheck blood pressure in office in 4 weeks after adding chlorthalidone 3.
• Recheck serum potassium, sodium, and creatinine in 2 weeks after starting thiazide diuretic to monitor for hypokalemia and renal function 1.
• Home blood pressure monitoring: instruct patient to check BP twice daily (morning and evening) and maintain log 1, 3.
• Goal: achieve target BP <130/80 mmHg within 3 months 3.
• If BP remains ≥160/100 mmHg or uncontrolled on 4 medications including a diuretic, refer to hypertension specialist 1, 3.

2. Dyslipidemia, Uncontrolled

Pharmacologic Management:

• Increase atorvastatin from 40 mg to 80 mg daily to achieve LDL goal <100 mg/dL (ideally <70 mg/dL for high-risk patient) 1.
• Alternative: Consider switching to rosuvastatin 20-40 mg daily if patient experiences statin-related side effects or inadequate response 1.

Non-Pharmacologic Management:

• Therapeutic Lifestyle Changes (TLC) diet: reduce saturated fat to <7% of total calories, reduce cholesterol intake to <200 mg/day, increase soluble fiber to 10-25 g/day, and consider plant stanols/sterols 2 g/day 1.
• Weight loss: as above, targeting BMI <25 kg/m² 1.
• Increase physical activity: as above, 90-150 minutes per week of aerobic exercise 1.
• Limit alcohol: as above, ≤2 drinks per day 1.

Monitoring:

• Recheck fasting lipid panel in 6-8 weeks after increasing atorvastatin dose 1.
• Monitor liver function tests (ALT, AST) and creatine kinase if patient develops muscle symptoms 1.
• Goal: LDL <100 mg/dL, HDL >40 mg/dL, triglycerides <150 mg/dL, total cholesterol <200 mg/dL 1.

3. Suspected Obstructive Sleep Apnea

Diagnostic Workup:

• Order home sleep apnea test (HSAT) or refer to sleep medicine for polysomnography to confirm diagnosis of obstructive sleep apnea 1, 2.
• Use validated screening tool: STOP-BANG score (Snoring, Tiredness, Observed apnea, high BP, BMI >35, Age >50, Neck circumference >40 cm, male Gender) = 6/8, indicating high risk for OSA 2.

Management (pending sleep study results):

• If OSA confirmed, initiate continuous positive airway pressure (CPAP) therapy, which can modestly lower BP and reduce cardiovascular risk 1, 2.
• Weight loss (as above) can reduce severity of sleep apnea 1.
• Counsel on sleep hygiene: maintain regular sleep schedule, avoid alcohol before bedtime, sleep on side rather than back 1.

Monitoring:

• Follow up after sleep study results available to discuss CPAP initiation and titration 1.
• Reassess daytime sleepiness and snoring after 3 months of CPAP therapy 1.

4. Dyspnea on Exertion, Etiology Undetermined

Diagnostic Workup:

• Order transthoracic echocardiogram to assess left ventricular systolic function (ejection fraction), diastolic function, left ventricular hypertrophy, valvular abnormalities, and pulmonary artery pressure 1.
• Order NT-proBNP or BNP level to assess for heart failure (NT-proBNP >100 pg/mL or BNP >35 pg/mL suggests heart failure) 1.
• Order exercise stress test with imaging (echocardiography or nuclear) if echocardiogram and BNP are normal, to evaluate for inducible ischemia given high cardiovascular risk 1.
• Consider chest X-ray to rule out pulmonary pathology if cardiac workup is unrevealing 1.
• Consider pulmonary function tests if chest X-ray abnormal or if clinical suspicion for obstructive or restrictive lung disease 1.

Management:

• Pending workup results, continue current management of hypertension, hyperlipidemia, and obesity 1, 3.
• If heart failure confirmed, initiate guideline-directed medical therapy (GDMT) based on ejection fraction 1.
• If coronary artery disease confirmed, consider antiplatelet therapy (aspirin 81 mg daily) and optimize medical management 1.

Monitoring:

• Follow up in 2 weeks to review echocardiogram, BNP, and stress test results 1.
• Reassess symptoms at each visit 1.

5. Obesity

Non-Pharmacologic Management:

• Caloric restriction: reduce daily caloric intake by 500-750 kcal/day to achieve weight loss of 1-2 lbs per week 1.
• Structured exercise program: 90-150 minutes per week of moderate-intensity aerobic activity (as above) 1.
• Behavioral modification: refer to registered dietitian for medical nutrition therapy and behavioral counseling 1.
• DASH diet (as above) 1.

Pharmacologic Management:

• Consider weight loss medication (e.g., semaglutide, liraglutide, phentermine/topiramate) if patient fails to achieve ≥5% weight loss after 6 months of lifestyle modification 1.

Monitoring:

• Weigh patient at each visit and track progress toward weight loss goal 1.
• Goal: initial weight loss of at least 1 kg, with ultimate goal of BMI <25 kg/m² 1.

6. Prediabetes

Non-Pharmacologic Management:

• Weight loss: goal of 7% body weight reduction (approximately 16 lbs for this patient) to reduce risk of progression to type 2 diabetes 1.
• Structured exercise program: 150 minutes per week of moderate-intensity aerobic activity 1.
• Dietary modification: reduce refined carbohydrates and added sugars, increase fiber intake, follow DASH or Mediterranean diet 1.

Pharmacologic Management:

• Consider metformin 500-850 mg daily if patient has additional risk factors for diabetes (BMI ≥35, age <60, history of gestational diabetes, or A1C >6.0%) and fails lifestyle modification after 6 months 1.

Monitoring:

• Recheck hemoglobin A1C in 6 months 1.
• Annual screening for progression to diabetes with fasting glucose and/or A1C 1.

7. Sedentary Lifestyle

Non-Pharmacologic Management:

• Prescribe structured aerobic exercise program: 90-150 minutes per week of moderate-intensity activity (brisk walking, cycling, swimming) 1.
• Encourage daily physical activity: take stairs instead of elevator, park farther away, walk during lunch breaks 1.
• Consider referral to cardiac rehabilitation program or exercise physiologist for supervised exercise program 1.

Monitoring:

• Assess exercise adherence at each visit 1.
• Encourage patient to track physical activity using pedometer or smartphone app (goal: 10,000 steps per day) 1.

Health Promotion and Disease Prevention Screening

Age-Appropriate Preventive Services (55-year-old male):

• Colorectal cancer screening: Order colonoscopy (if not done within past 10 years) or fecal immunochemical test (FIT) annually or stool DNA test every 3 years 1.
• Lung cancer screening: Order low-dose CT chest annually given 15 pack-year smoking history and quit within past 15 years (age 50-80 with ≥20 pack-year history qualifies, but consider for this patient given high cardiovascular risk) 1.
• Abdominal aortic aneurysm screening: Order one-time abdominal ultrasound for men age 65-75 who have ever smoked (not yet indicated for this patient, but will be in 10 years) 1.
• Aspirin for primary prevention: Consider low-dose aspirin 81 mg daily for primary prevention of cardiovascular disease in adults age 50-59 with ≥10% 10-year ASCVD risk and low bleeding risk (will calculate ASCVD risk score at next visit) 1.
• Immunizations: Ensure up-to-date on influenza vaccine (annually), Tdap (every 10 years), and COVID-19 vaccine (per current CDC recommendations) 1.
• Depression screening: Administer PHQ-2 or PHQ-9 at today's visit 1.
• Alcohol use screening: Administer AUDIT-C at today's visit 1.

Cardiovascular Risk Assessment:

• Calculate 10-year ASCVD risk using Pooled Cohort Equations at next visit (requires fasting lipid panel, which was done today) 1.
• Based on risk factors present (male, age 55, hypertension, hyperlipidemia, obesity, prediabetes, family history of premature CVD, former smoker, low HDL), estimated 10-year ASCVD risk is likely >10%, placing patient in high-risk category 1.

Patient Education

Hypertension:

• Explain that blood pressure is not adequately controlled and requires addition of third medication (chlorthalidone) 3.
• Discuss importance of medication adherence, home blood pressure monitoring, and lifestyle modifications 1, 3.
• Counsel on dietary sodium restriction, DASH diet, weight loss, and exercise 1.
• Provide written educational materials on hypertension management 1.

Hyperlipidemia:

• Explain that cholesterol levels are not at goal and require increase in statin dose 1.
• Discuss importance of dietary modification (TLC diet), weight loss, and exercise 1.
• Counsel on statin side effects (muscle aches, liver enzyme elevation) and when to report symptoms 1.

Obstructive Sleep Apnea:

• Explain that symptoms (snoring, daytime sleepiness) and physical exam findings (obesity, large neck circumference) are concerning for sleep apnea 1, 2.
• Discuss that untreated sleep apnea increases risk of hypertension, heart disease, stroke, and motor vehicle accidents 1, 2.
• Explain sleep study process and potential need for CPAP therapy 1.

Dyspnea on Exertion:

• Explain that shortness of breath with exertion requires further evaluation to rule out heart or lung problems 1.
• Discuss planned diagnostic tests (echocardiogram, BNP, stress test) and rationale 1.
• Counsel to seek emergency care if develops chest pain, severe shortness of breath at rest, or syncope 1.

Obesity and Prediabetes:

• Explain that weight loss is critical for improving blood pressure, cholesterol, blood sugar, and sleep apnea 1.
• Discuss realistic weight loss goals (1-2 lbs per week) and strategies (caloric restriction, exercise, behavioral modification) 1.
• Counsel that prediabetes can be reversed with weight loss and lifestyle changes 1.
• Provide referral to registered dietitian for medical nutrition therapy 1.

Cardiovascular Risk Reduction:

• Explain that patient has multiple risk factors for heart attack and stroke (hypertension, high cholesterol, obesity, prediabetes, family history, former smoking) 1.
• Emphasize importance of controlling all risk factors through medication adherence and lifestyle changes 1.
• Discuss smoking cessation maintenance and avoiding relapse 1.

Follow-Up

• Return to clinic in 2 weeks to review echocardiogram, BNP, and stress test results, and to check serum potassium, sodium, and creatinine after starting chlorthalidone 1, 3.
• Return to clinic in 4 weeks to recheck blood pressure after adding chlorthalidone 3.
• Return to clinic in 6-8 weeks to recheck fasting lipid panel after increasing atorvastatin dose 1.
• Follow up after sleep study results available to discuss CPAP initiation 1.
• Return to clinic in 3 months for comprehensive follow-up to assess blood pressure control, lipid control, weight loss progress, exercise adherence, and symptom improvement 1, 3.
• Refer to registered dietitian for medical nutrition therapy and weight management counseling 1.
• Refer to sleep medicine for polysomnography if home sleep apnea test is inconclusive or if patient prefers in-lab study 1.
• Refer to hypertension specialist if blood pressure remains uncontrolled on 4 medications including a diuretic 1, 3.
• Refer to cardiology if echocardiogram shows significant abnormalities (reduced ejection fraction, severe valvular disease, significant LVH) or if stress test is positive for inducible ischemia 1.

Prescriptions

1. Chlorthalidone 12.5 mg tablet: Take 1 tablet by mouth once daily in the morning. Dispense: 30 tablets. Refills: 3. 1, 3
2. Atorvastatin 80 mg tablet: Take 1 tablet by mouth once daily at bedtime. Dispense: 30 tablets. Refills: 3. 1
3. Amlodipine 10 mg tablet: Continue taking 1 tablet by mouth once daily. Dispense: 30 tablets. Refills: 3. 3
4. Metoprolol succinate 50 mg tablet: Continue taking 1 tablet by mouth once daily. Dispense: 30 tablets. Refills: 3. 3

Orders

1. Transthoracic echocardiogram with Doppler 1
2. NT-proBNP or BNP level 1
3. Exercise stress test with echocardiography or nuclear imaging (pending echocardiogram and BNP results) 1
4. Home sleep apnea test or referral to sleep medicine for polysomnography 1, 2
5. Recheck serum potassium, sodium, and creatinine in 2 weeks 1
6. Recheck fasting lipid panel in 6-8 weeks 1
7. Colonoscopy (if not done within past 10 years) 1
8. Referral to registered dietitian for medical nutrition therapy 1

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Clinical Guideline Rationale:

This plan is based on the 2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults 1, 3, which recommends a target BP <130/80 mmHg for all adults and stepwise addition of antihypertensive medications from four preferred drug classes (thiazide diuretics, calcium channel blockers, ACE inhibitors, ARBs). For this patient on a calcium channel blocker and beta-blocker, the next step is to add a thiazide-like diuretic (chlorthalidone preferred over hydrochlorothiazide due to longer duration of action and superior cardiovascular outcomes) 1, 3.

The 2013 ESH/ESC Guidelines for the Management of Arterial Hypertension 1 emphasize comprehensive cardiovascular risk assessment, including evaluation for target organ damage (ECG, echocardiogram, renal function, urinalysis) and secondary causes of hypertension (sleep apnea, primary aldosteronism, renovascular disease). This patient's clinical presentation (obesity, large neck circumference, snoring, daytime sleepiness) is highly suggestive of obstructive sleep apnea, which is a common and treatable secondary cause of resistant hypertension 1, 2.

The 2020 ACC/AHA Guideline on Blood Pressure Management in the Elderly 4 does not apply to this 55-year-old patient, but will be relevant in future years. For now, the standard adult target of <130/80 mmHg is appropriate 1, 3.

The dyspnea on exertion requires systematic evaluation to rule out heart failure and coronary artery disease, given the patient's high cardiovascular risk profile 1. The 2019 ACC/AHA Guideline on Incorporation of Biomarkers into Risk Assessment 1 supports the use of NT-proBNP or BNP to identify patients at higher risk for heart failure, and echocardiography to assess for structural heart disease and diastolic dysfunction 1.