What are the new general‑medicine guideline recommendations for hypertension management, adult immunizations, NAFLD screening, cardiovascular risk assessment, tobacco‑cessation and psychosocial care, and antihypertensive treatment in patients with diabetes?

New General Medicine Guideline Updates

Hypertension Management

The most significant update in hypertension management is the 2025 European Society of Cardiology recommendation for an initial default systolic blood pressure target of 120-129 mmHg (if tolerated), representing a shift toward more intensive blood pressure control. 1

Blood Pressure Classification and Diagnosis

• New classification system: Non-hypertension is <120/70 mmHg, pre-hypertension is 120-139/70-89 mmHg, and hypertension is ≥140/90 mmHg 1
• Confirm diagnosis with multiple measurements on separate days using standardized technique 2
• Measure blood pressure at every routine clinical visit 3
• All hypertensive patients should monitor blood pressure at home 3

Treatment Targets by Risk Stratification

For high cardiovascular risk patients (existing ASCVD or 10-year risk ≥15%):

• Target systolic blood pressure <130/80 mmHg if safely attainable 3
• Optimal target within range is 120 mmHg 1

For lower cardiovascular risk patients (10-year ASCVD risk <15%):

• Target blood pressure <140/90 mmHg 3

For patients with diabetes:

• Blood pressure target <140/90 mmHg (updated from previous <130/80 mmHg recommendation) 3
• For diabetic patients with higher cardiovascular risk, consider <130/80 mmHg target 3

For elderly patients (>60 years):

• Target <150/90 mmHg per JNC-8 recommendations 3
• For those with low treatment tolerance, achieve blood pressure as low as reasonably achievable (ALARA principle) 1

Pharmacological Treatment Initiation

Initial therapy approach:

• For blood pressure ≥160/100 mmHg: Start two antihypertensive medications or single-pill combination immediately 3
• For blood pressure 140-159/90-99 mmHg: May begin with single agent 3
• For pre-hypertension (130-139/80-89 mmHg) with high cardiovascular risk (≥10% 10-year risk): Consider pharmacological treatment after 3 months of lifestyle intervention 1

Recommended drug classes:

• Initial combination therapy (preferred for most patients): RAS inhibitor (ACE inhibitor or ARB) plus dihydropyridine calcium channel blocker or thiazide-type diuretic 1
• For black patients: Thiazide-type diuretic or calcium channel blocker as initial therapy 3
• For patients with chronic kidney disease: Include ACE inhibitor or ARB in regimen 3
• Avoid: Combining ACE inhibitors with ARBs, or combining either with direct renin inhibitors 3

Resistant Hypertension Management

• Defined as blood pressure >140/90 mmHg despite three medications (including a diuretic) at optimal doses 2
• Add mineralocorticoid receptor antagonist (spironolactone) as fourth agent if potassium <4.5 mmol/L and eGFR >45 ml/min/1.73m² 3, 2
• Screen for secondary causes in patients <40 years old with new hypertension diagnosis 1

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Adult Immunizations in Diabetes

Annual influenza vaccination for all diabetic patients ≥6 months of age 3

Pneumococcal vaccination:

• Administer pneumococcal polysaccharide vaccine to all diabetic patients ≥2 years of age 3
• One-time revaccination for those <64 years at initial vaccination if ≥5 years have passed 3
• Additional indications for revaccination: nephrotic syndrome, chronic renal disease, immunocompromised states 3

Hepatitis B vaccination for adults with diabetes per CDC recommendations 3

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NAFLD Screening and Cardiovascular Risk

NAFLD is independently associated with increased cardiovascular disease risk in both type 1 and type 2 diabetes, with hazard ratios of 6.73-8.16 for incident cardiovascular events. 4

Screening Recommendations

• Screen for NAFLD in all patients with metabolic syndrome components (hypertension, type 2 diabetes, dyslipidemia, obesity) 5
• In NAFLD cohorts, prevalence of hypertension is 53.9% and type 2 diabetes is 57.5% 6
• Use ultrasonography for NAFLD diagnosis in clinical practice 4

Cardiovascular Risk Assessment

• NAFLD patients require comprehensive cardiovascular risk assessment regardless of traditional risk factors 5
• Use SCORE2 (ages 40-69) or SCORE2-OP (ages ≥70) for 10-year cardiovascular disease risk evaluation 1
• The ACC/AHA ASCVD risk calculator is useful but does not account for diabetes duration or complications like albuminuria 3

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Tobacco Cessation and Psychosocial Care

Psychosocial Assessment in Diabetes

• Include psychosocial assessment as ongoing part of diabetes medical management 3
• Screen for: depression, diabetes-related distress, anxiety, eating disorders, cognitive impairment when self-management is poor 3
• Assessment should cover: attitudes about illness, expectations for management, affect/mood, quality of life, financial/social/emotional resources, psychiatric history 3

Lifestyle Modifications for Hypertension

• Sodium restriction: Approximately 2g per day (equivalent to 5g of salt) 1
• Physical activity: At least 150 minutes of moderate-intensity aerobic exercise per week plus 2-3 sessions of resistance training 1
• DASH-style dietary pattern: 8-10 servings of fruits and vegetables per day 3
• Weight loss if overweight or obese 3
• Alcohol moderation: ≤1 drink/day for women, ≤2 drinks/day for men 3

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Antihypertensive Treatment in Diabetes

Drug Selection Algorithm

First-line therapy:

• ACE inhibitor, ARB, thiazide-type diuretic, or dihydropyridine calcium channel blocker 3
• All drug classes have demonstrated cardiovascular event reduction in diabetic patients 3

For diabetic patients with chronic kidney disease:

• Must include ACE inhibitor or ARB in regimen 3
• Does not need to be initial agent unless blood pressure controlled with single agent and proteinuria present 3

Multiple-drug therapy:

• Generally required to achieve blood pressure targets, particularly with diabetic kidney disease 3
• Use drugs from different classes demonstrated to reduce cardiovascular events 3

Treatment Intensity Based on Initial Blood Pressure

For systolic ≥140 or diastolic ≥90 mmHg:

• Initiate pharmacologic therapy immediately along with lifestyle modifications 3

For systolic 130-139 or diastolic 80-89 mmHg:

• May trial lifestyle therapy alone for maximum 3 months 3
• If targets not achieved, add pharmacological agents 3

Common Pitfalls to Avoid

• Do not discontinue medications if blood pressure falls below target without adverse effects—continue therapy 3
• Do not delay confirming diagnosis with multiple measurements 2
• Do not combine ACE inhibitors with ARBs due to increased risk of hyperkalemia, syncope, and acute kidney injury without added cardiovascular benefit 3