High BP in a compliant diabetic?

A 71-year-old man with well-controlled type 2 diabetes and no cardiovascular disease has a total cholesterol well below 200 mg/dL and an LDL <100 mg/dL, but his HDL ranges from 20-29 mg/dL. His systolic BP has been elevated (140-160 mm Hg) since age 18, but it drops to the 120s or 130s when taken a second or third time at rest. His diastolic BP is never >80 mm Hg. Should he be treated for hypertension according to current guidelines for diabetic patients?—
Edward Pierce, DO, Steilacoom, Wash.

In a diabetic patient, the target for office systolic BP would be <130/80. Home BP is a little lower, so the target would be 120-125/70-75. Given this man's age and the risk of possible adverse effects from overzealous attempts at BP control, a reasonable goal for average home systolic BP would be 130.

An important issue is how to determine what the home BP is. The generally accepted practice is for patients to put on the cuff, sit for a few minutes, take three readings, and then average the second and third readings. This should be done for a few morning and evening readings, which are then averaged again. Of course it would be wise at some point to validate the patient's home monitor in the office. Alternatively, ambulatory BP monitoring could be performed, which would provide the average daytime BP, for which a target <130 would also be appropriate. In addition, nighttime BP could be assessed. A nighttime systolic BP >130 would justify treatment.

This patient's diastolic BP appears well controlled and is not an issue.
—Samuel J. Mann, MD (120-17)

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