Pathophysiology and Optimal Management of Hypertension in Patients with Cardiometabolic Syndrome

Abstract

Metabolic syndrome (MS) is a common cardiometabolic disorder that increases in prevalence as the population becomes more obese and increases the risk for cardiovascular disease (CVD). MS is highly prevalent among hypertensive patients and hypertension (HTN) is a major risk factor for CVD. Therefore, strict blood pressure (BP) control is an important factor for prevention and proper management of CVD in patients with MS. The underlying mechanisms for development of HTN in the MS and obesity are very complicated and has not yet been fully elucidated. However, several pathophysiology including central obesity, insulin resistance and increased sympathetic nervous system (SNS) activity, renin-angiotensinaldosterone system (RAAS) activity and sodium reabsorption (salt sensitivity) have been proposed. In addition, the leptin-related brain system, endothelial dysfunction, natriuretic peptides and other various factors may be involved in the development of HTN in MS/ obese patients. Lifestyle modifications including weight loss with diet and exercise are very important strategy in management of HTN. For the treatment of HTN in this population, agents that block the RAAS, the SNS and renal sodium excretion are frequently required. In patients with MS, data from prospective studies are very limited, but many guidelines recommended angiotensin receptor blockers (ARBs) and angiotensin converting enzyme (ACE) inhibitors as initial antihypertensive drugs. Calcium channel blockers or low dose thiazide diuretic are recommended in addition to ARBs or ACE inhibitors, and then the use of a 3-drug combination comprising these 3 antihypertensive drugs. Further longer-term, prospective studies including new drugs and devices are needed.