Question: L.N. is a 49-year-old white woman with a history of type 2 diabetes, obesity, hypertension, and migraine headaches

L.N. is a 49-year-old white woman with a history of type 2 diabetes, obesity, hypertension, and migraine headaches. The patient was diagnosed with type 2 diabetes 9 years ago when she presented with mild polyuria and polydipsia. L.N. is 5'4" and has always been on the large side, with her weight fluctuating between 165 and 185 lb. Initial treatment for her diabetes consisted of an oral sulfonylurea with the rapid addition of metformin. Her diabetes has been under fair control with a most recent hemoglobin A1c of 7.4%.
Hypertension was diagnosed 5 years ago when blood pressure (BP) measured in the office was noted to be consistently elevated in the range of 160/90 mmHg on three occasions. L.N. was initially treated with Lisinopril, starting at 10 mg daily and increasing to 20 mg daily, yet her BP control has fluctuated. One year ago, microalbuminuria was detected on an annual urine screen, with 1,943 mg/dl of micro-albumin identified on a spot urine sample. L.N. comes into the office today for her usual follow-up visit for diabetes and HTN.
Subjective data reveals that she is experiencing increased exertional SOB. She expresses concern because when this happens it takes her awhile to get her breath back to normal. Denies any pain or dizziness with these episodes.
Physical examination reveals an obese woman with a BP of 154/86 mmHg and a pulse of 78 bpm. Otherwise exam is unremarkable.
CC: “I am more short of breath when walking up stairs than I used to be”.
Questions:
1. What are the effects of controlling BP in people with diabetes?
2. What is the target BP for patients with diabetes and hypertension?
3. Which antihypertensive agents are recommended for patients with diabetes?
4 What testing does this woman need ordered due to her change in status both SOB and BP?
5. What is the significance of microalbuminuria in this woman? How does this affect her cardiovascular risk?

DRAFT / STUDY TIPS

1. Controlling blood pressure in people with diabetes is crucial for reducing the risk of complications such as diabetic nephropathy (kidney disease), retinopathy (eye disease), cardiovascular disease, and stroke. High blood pressure can exacerbate existing diabetes-related complications and increase the risk of developing new ones.

2. The target blood pressure for patients with diabetes and hypertension is generally <130/80 mmHg according to most guidelines. However, individualized targets may vary based on factors such as age, comorbidities, and patient tolerance.

3. Antihypertensive agents recommended for patients with diabetes include angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), calcium channel blockers (CCBs), and thiazide diuretics. These medications have been shown to have renoprotective effects and are often preferred in patients with diabetes due to their ability to reduce the risk of diabetic nephropathy.

4. Given the patient's symptoms of increased exertional shortness of breath (SOB) and elevated blood pressure, further testing may include:

   • Echocardiogram to assess for cardiac function and potential heart failure.
   • Pulmonary function tests to evaluate lung function and rule out respiratory causes of SOB.
   • Exercise stress test to assess cardiovascular fitness and detect any ischemic heart disease.
   • Additional laboratory tests such as complete blood count, thyroid function tests, and lipid profile to assess for other potential contributing factors.

5. Microalbuminuria, as detected in this woman, is a marker of early kidney damage and is associated with an increased risk of cardiovascular disease in patients with diabetes. It indicates leakage of small amounts of albumin into the urine, which can be a precursor to more severe kidney disease (nephropathy). Additionally, microalbuminuria is considered a significant risk factor for cardiovascular events such as heart attack and stroke in individuals with diabetes. Tight blood pressure control and management of other risk factors are essential to reduce the progression of kidney disease and lower cardiovascular risk in patients with microalbuminuria.