A 60-year-old man who was recently diagnosed with hypertension comes to the office for follow-up. He was treated with lisinopril but stopped a week ago due to a dry, nagging cough. Past medical history is notable for type 2 diabetes mellitus with moderately increased albuminuria but normal creatinine clearance. His other medications include metformin and rosuvastatin. The patient does not smoke or drink alcohol. His blood pressure is 150/92 mm Hg. BMI is 31 kg/m². Physical examination, including the heart and lungs, is unremarkable. Which of the following is the best treatment for this patient's hypertension?

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Diabetes causes impaired autoregulation of glomerular blood flow, leading to significant elevations of intraglomerular pressures and chronic glomerular injury. Patients with diabetes and hypertension are at especially high long-term risk for chronic kidney disease. Angiotensin-converting enzyme (ACE) inhibitors (eg, lisinopril) cause preferential dilation of the glomerular efferent arteriole, lowering intraglomerular pressures and reducing the risk of chronic glomerular injury. In addition to converting angiotensin I to angiotensin II, ACE normally degrades bradykinin and substance P. Inhibition of ACE leads to elevated bradykinin and substance P levels and a nonproductive cough. Angiotensin receptor blockers (ARBs) have hemodynamic effects similar to those of ACE inhibitors but do not affect bradykinin levels and do not cause a cough. Replacing this patient's ACE inhibitor with an ARB (eg, losartan, valsartan) will eliminate the cough while still providing the same long-term renovascular benefits. (Choices A, B, and C) Careful blood pressure control can help reduce the long-term risk of kidney injury, regardless of the agent used. However, none of these drugs are as effective as ACE inhibitors or ARBs for preventing the progression of chronic kidney disease. (Choice D) Replacement of one ACE inhibitor with another carries a high likelihood of inducing the same nonproductive cough. Educational objective: Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) reduce the risk of chronic kidney disease in patients with hypertension and diabetes. ACE inhibitors raise levels of bradykinin and can cause a nonproductive cough, an effect not seen with ARBs. __________ References: The RAAS in the pathogenesis and treatment of diabetic nephropathy. (http://www.ncbi.nlm.nih.gov/pubmed/20440277) Angiotensin-converting enzyme inhibitor-induced cough: ACCP evidence-based clinical practice guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/16428706)

A 60-Year-Old Man Who Was Recently Diagnosed with Hypertension Comes