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Old 10-20-2011
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Default Cardiology

A 55-year-old man with diabetes comes to the office for an annual visit. He denies any chest pain, palpitations, headache, dyspnea or lightheadedness. He is currently taking insulin for the diabetes. He has no other medical issues. He is fairly active and is able to perform all activities of daily living. He has no medical allergies. His blood pressure is 135/85 mm Hg and pulse is 80/min. His lungs are clear and heart rate is regular. He has no pedal edema. Chemistry panel is unremarkable. An electrocardiogram shows normal sinus rhythm. Urine studies reveal normal albumin in the urine. Which of the following is the appropriate management at this time?
A. Encourage lifestyle modification
B. Prescribe hydrochlorothiazide 12.5 mg daily
C. Prescribe hydrochlorothiazide 12.5 mg daily and metoprolol 25 mg twice daily
D. Prescribe lisinopril 10 mg daily
E. Prescribe metoprolol 25 mg twice daily
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D. Prescribe lisinopril 10 mg daily
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D. Prescribe lisinopril 10 mg daily
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D. Prescribe lisinopril 10 mg daily
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D. Prescribe lisinopril 10 mg daily
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Default Answer

The correct answer is B. The new national guidelines, known as the Seventh Report of the Joint National Committee (JNC) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), recommend a more aggressive approach to detecting and treating hypertension. The new classification introduces a new "prehypertension" classification. In patients older than 50, systolic blood pressure should be the focus of treatment. Individuals with a systolic BP of 120 to 139 mm Hg or a diastolic BP of 80 to 89 mm Hg should be considered as "prehypertensive." This reflects an increased risk of future hypertension and requiring health-promoting lifestyle modifications to prevent cardiovascular disease. Those with BPs in the 130/80-to-139/89-mm-Hg range have twice the risk of hypertension as those with lower values. Thiazide-type diuretics should be used in drug treatment for most patients with uncomplicated hypertension, either alone or in combination with drugs from other classes.

In the absence of a compelling reason such as kidney disease or diabetes, prehypertension can be treated by encouraging lifestyle modification (choice A).

Two or more antihypertensive drugs may be required to control hypertension to goal in most patients. However, this is true if the patient has stage 2 hypertension (SBP ≥160 or diastolic blood pressure ≥100 (choice C).

If this patient had microalbuminuria, an ACE-inhibitor could be considered (choice D).

JNC recommends thiazides as a first line treatment of pre-hypertension (choice E).
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