Metabolic Syndrome in Hypertension - Treatment Challenges and Goals

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Abstract

Abstract
Changes in lifestyle in the developed world are promoting growth in overweight and obesity, leading to several metabolic abnormalities lipids, glucose and blood pressure) and increasing the future risk of type 2 diabetes, cardiovascular events and death. Metabolic syndrome represents the combination of abdominal obesity, insulin resistance, atherogenic dyslipidaemia and pro-thrombotic and pro-inflammatory states. Although some controversies in the pathogenesis and clinical importance of metabolic syndrome still remain, the development of useful clinical tools to more easily identify these patients has led to an increased recognition in the adult population. Management of patients with metabolic syndrome is a clinical challenge and requires a multifactorial, multidisciplinary approach. Changes in lifestyle are obviously the first therapeutic step and include both dietary modifications and increased daily exercise. Several questions remain to be elucidated with respect to pharmacological treatment. The blood pressure levels required to initiate antihypertensive treatment, goal to be achieved and the possibility of including a renin├óÔé¼ÔÇ£angiotensin system blocker as a part of pharmacological treatmen are still under discussion. Moreover, there is a lack of/poor evidence of the need for specific drugs to reduce triglycerides, increase high-density lipoprotein cholesterol, improve insulin sensitivity and decrease abdominal obesity. Independently, it is generally accepted that earlier and more aggressive therapy in ubjects with metabolic syndrome will result in a decrease in future cardiovascular morbidity and mortality worldwide.

Keywords
Cardiometabolic risk, metabolic syndrome, hypertension, antihypertensive agents, type 2 diabetes

Disclosure: Alejandro de la Sierra has received honoraria for participation in meetings and/or advisory boards from Abbott, AstraZeneca, Bayer-Schering Pharma, Boehringer- Ingelheim, Daiichi Sankyo, Novartis, Pfizer and Servier.
Received: 21 November 2009 Accepted: 14 December 2009
Correspondence: Alejandro de la Sierra, Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Dr Robert, 5, 08221-Terrassa, Spain. E: adelasierra@mutuaterrassa.es; asierra@ub.edu

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The Concepts of Metabolic Syndrome and Cardiometabolic Risk
Cardiometabolic risk represents a situation where the possibilities of developing atherosclerotic cardiovascular disease and diabetes are significantly enhanced as a consequence of the presence of insulin resistance and atherogenic dyslipidaemia. Dyslipidaemia is characterised by the presence of low high-density lipoprotein (HDL) cholesterol and high triglyceride levels.1,2 Clinical diagnosis of this situation is through the finding of an enhanced waist circumference (>102cm in males and >88cm in females) accompanied by the abovequoted alterations in lipid profile (HDL cholesterol <40mg/dl in males and <50mg/dl in females plus serum triglycerides >150mg/dl).

Cardiometabolic risk is particularly prevalent in patients diagnosed as having metabolic syndrome (MS). For a correct diagnosis of MS, patients need an increased waist circumference, low HDL cholesterol and elevated triglycerides, the potential presence of blood pressure (BP) values >130/85mmHg and a fasting serum glucose >100mg/dl.3,4 The International Diabetes Federation (IDF) has defined MS in those of European descent by the presence of a waist circumference >94cm in males and >80cm in females, accompanied by two out of the four criteria that remain unchanged from the Adult Treatment Panel (ATP)-III definition5 (see Table 1).