What is the diagnosis and treatment plan for a patient with symptoms of hypertension or diabetes?

Diagnosis and Management of Hypertension in Patients with Diabetes

For a patient with diabetes and hypertension, initiate pharmacologic therapy immediately if blood pressure is ≥140/90 mmHg, or after 3 months of lifestyle modification if blood pressure is 130-139/80-89 mmHg, with ACE inhibitors or ARBs as first-line agents. 1

Blood Pressure Screening and Diagnosis

• Measure blood pressure at every routine diabetes visit 1
• Confirm elevated readings (systolic ≥130 mmHg or diastolic ≥80 mmHg) on a separate day before diagnosing hypertension 1
• The diagnosis is confirmed when repeat measurements show systolic ≥130 mmHg or diastolic ≥80 mmHg 1

Blood Pressure Goals

Target blood pressure is <130/80 mmHg for all patients with diabetes. 1

• This target reduces risk of stroke, coronary heart disease events, and nephropathy 1
• The 2023 American Diabetes Association guidelines represent the most current evidence, superseding older targets of <140/90 mmHg 1

Treatment Algorithm Based on Blood Pressure Severity

Blood Pressure 120-129/80-89 mmHg

• Initiate lifestyle modifications only 1
• Reassess in 3 months 1

Blood Pressure 130-139/80-89 mmHg

• Begin lifestyle modifications immediately 1
• If target not achieved after 3 months, add pharmacologic therapy 1
• For blood pressure ≥130/80 mmHg confirmed on separate occasions, initiate pharmacologic therapy promptly 1

Blood Pressure 140-159/90-99 mmHg

• Start lifestyle modifications plus single pharmacologic agent immediately 1
• Do not delay medication initiation 1

Blood Pressure ≥160/100 mmHg

• Initiate lifestyle modifications plus two antihypertensive drugs immediately 1
• Consider single-pill combination therapy to improve adherence 1

Lifestyle Modifications (All Patients)

• Weight loss if overweight or obese through caloric restriction 1
• DASH-style eating pattern: 8-10 servings of fruits/vegetables daily, 2-3 servings of low-fat dairy products daily 1
• Sodium restriction to <2,300 mg/day 1
• Increase potassium intake through dietary sources 1
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 1
• Physical activity: at least 150 minutes of moderate-intensity aerobic activity per week 1

First-Line Pharmacologic Therapy

ACE inhibitors or ARBs are the preferred initial agents for most patients with diabetes and hypertension. 1

Specific Indications for ACE Inhibitors or ARBs:

• Mandatory first-line for patients with albuminuria (UACR ≥30 mg/g) to reduce progressive kidney disease 1
• Strongly recommended for patients with coronary artery disease 1
• Use maximum tolerated dose indicated for blood pressure treatment 1

Alternative First-Line Agents (if ACE inhibitor/ARB not tolerated or insufficient):

• Thiazide-like diuretics (chlorthalidone or indapamide preferred over hydrochlorothiazide) 1
• Dihydropyridine calcium channel blockers 1

Additional Agents:

• Beta-blockers: indicated for patients with prior myocardial infarction, active angina, or heart failure with reduced ejection fraction 1
• Beta-blockers have not shown mortality benefit as blood pressure-lowering agents alone without these specific indications 1

Multiple-Drug Therapy

Most patients require 2-3 antihypertensive medications to achieve blood pressure goal of <130/80 mmHg. 1

• Combine drugs from different classes with complementary mechanisms 1
• Never combine ACE inhibitors with ARBs—this increases risk of hyperkalemia, syncope, and acute kidney injury without added cardiovascular benefit 1
• Never combine ACE inhibitors or ARBs with direct renin inhibitors 1

Resistant Hypertension

Defined as blood pressure ≥140/90 mmHg despite appropriate lifestyle management plus a diuretic and two other antihypertensive drugs at adequate doses 1

Before diagnosing resistant hypertension, exclude:

• Medication nonadherence (address cost and side effect barriers) 1
• White coat hypertension 1
• Secondary hypertension 1

Management:

• Add mineralocorticoid receptor antagonist (spironolactone) for patients not meeting targets on three drug classes including a diuretic 1
• Refer to specialist with expertise in blood pressure management 1

Monitoring Requirements

• Monitor serum creatinine/eGFR and potassium at least annually in patients taking ACE inhibitors, ARBs, or diuretics 1
• Continue ACE inhibitor or ARB therapy even as eGFR declines to <30 mL/min/1.73 m² for cardiovascular benefit, unless contraindicated 1

Critical Clinical Pitfalls

• Do not delay pharmacologic therapy in patients with blood pressure ≥140/90 mmHg—immediate initiation reduces cardiovascular events 1
• Do not use bedtime dosing preferentially—recent trials show no benefit over morning dosing 1
• Do not withhold ACE inhibitors/ARBs in patients with declining kidney function unless hyperkalemia or acute kidney injury develops 1
• In patients without albuminuria, ACE inhibitors and ARBs offer no superior cardioprotection compared to thiazide-like diuretics or dihydropyridine calcium channel blockers 1

Special Considerations for Diabetes

• Hypertension is twice as frequent in patients with diabetes compared to the general population 2
• The combination of diabetes and hypertension dramatically accelerates both microvascular (retinopathy, nephropathy, neuropathy) and macrovascular (coronary artery disease, stroke, heart failure) complications 3, 2, 4
• Insulin resistance appears to play a pivotal role in the pathogenesis of hypertension in type 2 diabetes 3, 5, 4