Hypertension--a treatable component of the cardiometabolic syndrome: challenges for the primary care physician

Abstract

Patients with the cardiometabolic syndrome (CMS) have an adverse cardiovascular risk factor profile, placing them at increased risk of stroke, coronary artery disease, chronic kidney disease, and type 2 diabetes mellitus. Although no specific treatments for CMS are available per se, prompt recognition and treatment of the individual components of the condition can prevent or delay the development of comorbidities. Primary care physicians are ideally positioned to identify patients with CMS and implement early intervention strategies. Hypertension contributes to many complications of CMS, and rigorous blood pressure control will help to delay or prevent end-organ vascular damage. Achieving blood pressure control to current guideline standards should be eagerly sought in the majority of patients through a combination of lifestyle modifications and appropriate pharmacologic therapy. Antihypertensive drug choice should be personalized, taking into account the CMS determinants present and any compelling indications for specific agents. As an initial approach, a thiazide diuretic is suitable for most cases of uncomplicated hypertension, although many patients will require additional antihypertensives from other classes to achieve their blood pressure goal. It is predicted that, due to the increase in unhealthy lifestyles, the prevalence of CMS will rise in the coming years. Therefore, by meeting the challenge of attaining and maintaining blood pressure control in patients with CMS, primary care physicians have the unique opportunity to markedly improve the health of the nation.

Figure 1

Prevalence of select risk factors among subjects with the cardiometabolic syndrome. Men: waist circumference (WC) >40 in (≥102 cm), blood pressure (BP) ≥130/85 mm Hg, triglycerides (TG) ≥150 mg/dL (≥1.69 mmol/L), high‐density lipoprotein cholesterol (HDL‐C) ≤40 mg/dL (≤1.03 mmol/L), low‐density lipoprotein cholesterol (LDL‐C) ≥130 mg/dL (≥3.36 mmol/L), and fasting glucose (FG) ≥110 mg/dL (≥6.11 mmol/L). Women: WC >35 inches (>88 cm), BP ≥130/8S mm Hg, TG ≥150 mg/dL (≥1.69 mmol/L), HDL‐C ≤50 mg/dL (≤1.29 mmol/L), LDL‐C ≥130 mg/dL (≥3.36 mmol/L), and FG ≥110 mg/dL (≥6.11 mmol/L). Reproduced with permission from Am J Cardiol. 2003;91:1421–1426. ³⁵

Figure 2

Algorithm for the treatment of hypertension. SBP=systolic blood pressure; DBP=diastolic blood pressure; ACEl=angiotensin‐converting enzyme inhibitor; ARB=angiotensin receptor blacker; BB=β blocker; CCB=calcium channel blocker; Aldo ANT=aldosterone antagonist. Adapted with permission from JAMA. 2003;289:2560–2572. ²⁸

Figure 3

Cumulative proportions of patients with the primary composite end point (doubling of baseline serum creatinine, development of end‐stage renal disease, or death from any cause) in 1715 patients with nephropathy due to type 2 diabetes treated with irbesartan 300 mg, amlodipine 10 mg, or placebo in the Irbesartan Diabetic Nephropathy Trial. Adapted with permission from N Engl J Med. 2001;345:851–860. ⁵³ Copyright ©2001 Massachusetts Medical Society. All rights reserved.