Download Hypertension in Metabolic syndrome

The Era of Hips & Waists
Hypertension in Metabolic
syndrome
Common risk factors for chronic diseases
Deaths from 4 chronic diseases
Tobacco
Poor diet
Lack of exercice
3 risk factors
Deaths from all other causes
50% of all deaths
Cardiovascular
Chronic respiratory
disease
Type 2 diabetes
Cancer
4 chronic diseases
Oxford Health Alliance 2003
Relative risk
Obesity, Type 2 Diabetes, Hypertension or Dyslipidemia
0
Waist circumference (cm)
Adapted from Lee ZSK et al. Obes Rev 2002; 3: 173-82 and
Ko GT et al. Int J Obes Relat Metab Disord 1997; 21: 995-1001
History of MS
1923 - Kylin first to describe the
clustering of hypertension, hyperglycemia,
hyperuricemia
 1936 - Himsworth first reported Insulin
insensitivity in diabetics
 1965 - Yalow and Berson developed
insulin assay and correlated insulin levels
& glucose lowering effects in resistant and
non-resistant individuals

1988 - Reaven in his Banting lecture at
the ADA meeting coined the term
Syndrome X and brought into focus the
clustering of features of Metabolic
Syndrome
 Reaven now prefers the name, InsulinResistance Syndrome - feels insulin
resistance is the common denominator
for Metabolic Syndrome

Metabolic Syndrome
Etiology – not fully elucidated
 Insulin Resistance
 Acquired causes
 Overweight and central (visceral) obesity
 Physical inactivity, aging, ethnicity
 High CHO diets (>60%)
 Proinflammatory state, hormones
 Poly Genic causes
INSULIN RESISTANCE - MECHANISMS

Pre receptor ( abnormal insulin or insulin
antibodies)

Receptor ( decreased receptor number or affinity)

Postreceptor
(abnormal
signal transduction
phosphorylation)
and

Glucose transporter ( decreased GLUT 4 molecule)
INSULIN RESISTANCE &
HYPERTENSION
More than 50 % of hypertensives are found to
be Insulin Resistant and Hyperinsulinemic.
IR and Hyperinsulinemia have been
documented to be present even in lean
Hypertensives who are not Diabetic
MS Clustering of Components:





Hypertension: BP. > 140/90
Dyslipidemia: TG > 150 mg/ dL ( 1.7 mmol/L )
HDL- C < 35 mg/ dL (0.9 mmol/L)
Obesity (central): BMI > 30 kg/M2
Waist girth > 94 cm (37 inch)
Waist/Hip ratio > 0.9
Impaired Glucose Handling: IR , IGT or DM
FPG > 110 mg/dL (6.1mmol/L)
2hr.PG >200 mg/dL(11.1mmol/L)
Microalbuninuria (WHO)
Necessary Criteria to Make Diagnosis
WHO:
Impaired G handling + 2 other criteria.
◦ Also requires microalbuminuria - Albumen/
creatinine ratio >30 mg/gm creatinine
 NCEP/ATP III:
◦ Require three or more of the five criteria

IDF(2006):
Abdominal obesity plus two other components:
elevated BP, low HDL, elevated TG, or impaired
fasting glucose
Measurement of Waist
Visceral Fat Distribution
Normal
Visceral Adiposity
Courtesy of Wilfred Y. Fujimoto, MD.
IDF Waist Circumference
MS
2 times increase risk of HT
 3 times increase risk of CHD or stroke
 5 times increase risk of DM
 Chronic liver disease
 Increase risk of more than 60 diseases

Resulting Clinical Conditions:
Type 2 diabetes
 Essential hypertension
 Polycystic ovary syndrome (PCOS)
 Nonalcoholic fatty liver disease
 Sleep apnea
 Cardiovascular Disease (MI, PVD, Stroke)
 Cancer (Breast, Prostate, Colorectal,
Liver)

Hypertension in MS:

IDF:
◦ BP >130/85 or on Rx for previously Dxed
hypertension

WHO:
◦ BP >140/90

NCEP ATP III:
◦ BP >130/80
Obesity Effects on Blood Pressure
Mean DBP (mmHg)
Mean SBP (mmHg)
Intra-abdominal (Visceral) Fat Area Tertiles and 24-hour Ambulatory Blood
Pressure and Pulse Rate in Chinese Type 2 Diabetic Patients
Clock time (hours)
diastolic blood pressure DBP:
heart rate HR:
systolic blood pressure SBP:
Mean HR (bpm)
Clock time (hours)
Clock time (hours)
Copyright © 1997 American Diabetes Association
Adapted from Diabetes Care ®, Vol. 20, 1997; 1854-8
Reprinted with permission from The American Diabetes Association
Metabolic variables in white coat (WC) and
sustained (SUST) borderline hypertension
Tecumseh study
p<.001
p<.001
n.s.
Insulin Level
26
22
18
14
10
N=621
N=28
NORMAL
WC
Julius et al., Hypertension 16, 1990. Tecumseh
N=34
SUST
Hypertension is a very
prominent feature of the
metabolic syndrome,
present in up to 85% of
patients.
Metabolic Syndrome & Hypertension
Randomized prospective study in Italy
with >1700 people with HTN (mean
155/95) & no CVD, followed for a mean
of 4 years
 During follow up, 162 pts developed CV
events, a total of 593 pts had metabolic
syndrome using NCEP guidelines
 Those with MS had an almost double CV
event rate 3.23 vs 1.76per 100pt years.

Insulin Resistance and Hypertension Mechanisms
Hyperinsulinemia



Produces renal sodium retention.
Stimulates Sympathetic Nervous
activity
Vascular smooth muscle hypertrophy
(mitogenic action of insulin)


cytokines and other lipokines
Augmentation of the pressor and
aldosterone response to angiotensin II

Endothelial dysfunction and decreased
production of NO
Results of current long term
outcome studies support the
hemodynamic concept of
insulin
resistance in hypertension
HYPOTHESIS
If in addition to cardiovascular responses,
the metabolic responses were also decreased
in hypertension, the patient’s ability to
dissipate calories would be diminished and
they would gain more weight.
BP Control - How Important?

MRFIT and Framingham Heart Studies:
◦ Conclusively proved the increased risk of CVD
with long-term sustained hypertension
◦ Demonstrated a 10 year risk of cardiovascular
disease in treated patients vs non-treated patients
to be 0.40.
◦ 40% reduction in stroke with control of HTN
therapy
a multi-target approach based on the
assessment of the overall cardiovascular
risk should be applied;
 A-non-pharmacological therapy; sodium
restriction, alcohol and calorie restriction,
smoking cessation, weight reduction, and
increase physical activity.

Fit vs. Fat: Can you be both?

Overweight and obese people who are fit are less likely to
die prematurely than unfit people who are lean (Lee, CD, et al.,
Am J Clin Nutr 1999; 69:373-380)

Highly Fit men with 2 or 3 risk factors had about the
same mortality risk as Low Fit men with no risk (Blair, SN, et al.,
JAMA 1996; 276: 205-210)

Low Fitness is as significant a risk factor for premature
death as smoking, high blood pressure, diabetes, and high
blood cholesterol, regardless of weight ( Barlow et al., Int J Obes
Metab Disord, 19(suppl 4):41, 1995 and Wei et al., JAMA, 282: 1547, 1999)
-For preventive purposes
THANK YOU