Management of arterial hypertension in obese patients

Correlation Between Body Mass Index and Blood Pressure Levels Among Hypertensive Patients: A Gender-Based Comparison

Objective

Blood pressure (BP) has been found to rise among populations due to the high body mass index (BMI). Overweight and persons who have high BP are prone to develop heart diseases. The objective of this study was to evaluate the correlation between BMI and BP among hypertensive patients in both males and females aged 18 years and above.

Methodology

A cross-sectional study was carried out among patients with a self-reported history of hypertension and anti-hypertensive medication. After taking ethical approval, a total of 337 patients aged 18 or above were selected by using convenience sampling. The duration of the study was six months. A detailed history was taken from each patient about hypertension associated symptoms with the help of a self-designed questionnaire. The BMI of the patients was assessed. Statistical Package for Social Sciences (SPSS) Version 20.0 (IBM Corp., Armonk, NY, USA) was used to analyze the collected data. Spearman correlation was used, and p-value <0.05 was considered significant.

Results

In a total of 337 patients, the mean age of the patients was 45.87±13.38 years. In which 176 (52.2%) were males and 161 (47.8%) were females. Their mean BMI level was 26.83±5.83 kg/m², and the mean systolic blood pressure level was 141.78±13.00 mm Hg whereas the diastolic blood pressure was 85.21±10.03 mm Hg. The results also showed that among males the BMI had a significant negative correlation with both systolic blood pressure level (ρ = -0.212, p = 0.011) and diastolic blood pressure level (ρ = -0.208, p = 0.013), while in females the correlation was insignificant.

Conclusion

Our study results concluded that the BMI of the patients had a significant weak negative correlation with both systolic blood pressure level and diastolic blood pressure level in males; however, no significant correlation was found in females.

Treatment of hypertension in obese patients

Obesity is a global pandemic and with its rise, its associated co-morbidities are increasing in prevalence, particularly uncontrolled hypertension. Lifestyle changes should be an anchor for the management of obesity-related hypertension; however, they are difficult to sustain. Drug therapy is often necessary to achieve blood pressure control. Diuretics, inhibitors of the renin-angiotensin system, and dihydropyridine calcium channel blockers are often used as first trio, with subsequent additions of mineralocorticoid receptor antagonists and/or dual alpha/beta blocking agents. While a number of agents are currently available, 50 % of hypertensive patients remain uncontrolled. A number of novel drug and invasive therapies are in development and hold significant potential for the effective management of obesity-related hypertension.

The renin-angiotensin system: a target of and contributor to dyslipidemias, altered glucose homeostasis, and hypertension of the metabolic syndrome

The renin-angiotensin system (RAS) is an important therapeutic target in the treatment of hypertension. Obesity has emerged as a primary contributor to essential hypertension in the United States and clusters with other metabolic disorders (hyperglycemia, hypertension, high triglycerides, low HDL cholesterol) defined within the metabolic syndrome. In addition to hypertension, RAS blockade may also serve as an effective treatment strategy to control impaired glucose and insulin tolerance and dyslipidemias in patients with the metabolic syndrome. Hyperglycemia, insulin resistance, and/or specific cholesterol metabolites have been demonstrated to activate components required for the synthesis [angiotensinogen, renin, angiotensin-converting enzyme (ACE)], degradation (ACE2), or responsiveness (angiotensin II type 1 receptors, Mas receptors) to angiotensin peptides in cell types (e.g., pancreatic islet cells, adipocytes, macrophages) that mediate specific disorders of the metabolic syndrome. An activated local RAS in these cell types may contribute to dysregulated function by promoting oxidative stress, apoptosis, and inflammation. This review will discuss data demonstrating the regulation of components of the RAS by cholesterol and its metabolites, glucose, and/or insulin in cell types implicated in disorders of the metabolic syndrome. In addition, we discuss data supporting a role for an activated local RAS in dyslipidemias and glucose intolerance/insulin resistance and the development of hypertension in the metabolic syndrome. Identification of an activated RAS as a common thread contributing to several disorders of the metabolic syndrome makes the use of angiotensin receptor blockers and ACE inhibitors an intriguing and novel option for multisymptom treatment.

Obesity-related hypertension: epidemiology, pathophysiology, and clinical management

The prevalence of obesity, including childhood obesity, is increasing worldwide. Weight gain is associated with increases in arterial pressure, and it has been estimated that 60-70% of hypertension in adults is attributable to adiposity. Centrally located body fat, associated with insulin resistance and dyslipidemia, is a more potent determinant of blood pressure elevation than peripheral body fat. Obesity-related hypertension may be a distinct hypertensive phenotype with distinct genetic determinants. Mechanisms of obesity-related hypertension include insulin resistance, sodium retention, increased sympathetic nervous system activity, activation of renin-angiotensin-aldosterone, and altered vascular function. In overweight individuals, weight loss results in a reduction of blood pressure, however, this effect may be attenuated in the long term. An increasing number of community-based programs (including school programs and worksite programs) are being developed for the prevention and treatment of obesity. Assessment and treatment of the obese hypertensive patient should address overall cardiovascular disease (CVD) risk. There are no compelling clinical trial data to indicate that any one class of antihypertensive agents is superior to others, and in general the principles of pharmacotherapy for obese hypertensive patients are not different from nonobese patients. Future research directions might include: (i) development of effective, culturally sensitive strategies for the prevention and treatment of obesity; (ii) clinical trials to identify the most effective drug therapies for reducing CVD in obese, hypertensive patients; (iii) continued search for the genetic determinants of the obese, hypertensive phenotype.

Aliskiren-based therapy lowers blood pressure more effectively than hydrochlorothiazide-based therapy in obese patients with hypertension: sub-analysis of a 52-week, randomized, double-blind trial

OBJECTIVES

To compare the long-term efficacy, safety and tolerability of the direct renin inhibitor aliskiren against the diuretic hydrochlorothiazide (HCTZ) in obese patients with hypertension.

METHODS

A post hoc analysis of 396 obese patients (body mass index > or = 30 kg/m2) in a 52-week study in 1124 patients with hypertension was performed. Patients were randomized to receive aliskiren 150 mg or HCTZ 12.5 mg for 3 weeks, or placebo for 6 weeks. At week 3, active treatment doses were doubled. Patients receiving placebo were randomized to aliskiren 300 mg or HCTZ 25 mg at week 6. Add-on amlodipine 5-10 mg was permitted from week 12 to achieve blood pressure (BP) control (<140/90 mmHg).

RESULTS

In the subgroup of obese patients, aliskiren monotherapy provided significantly greater BP reductions than HCTZ at week 12 endpoint (-16.7/-12.3 vs. -12.2/-9.1 mmHg, P < or = 0.001). Reductions were also greater with aliskiren-based therapy than HCTZ-based therapy at week 52 endpoint (-19.9/-15.5 vs. -17.5/-13.3 mmHg; P = 0.138 for systolic BP and P = 0.007 for diastolic BP). Mean BP reductions from baseline with aliskiren-based therapy were similar in obese and nonobese patients. By contrast, HCTZ-based therapy provided significantly smaller mean reductions in BP from baseline in obese patients vs. nonobese patients (P < 0.05). Aliskiren-based therapy was generally well tolerated in obese patients, and was associated with a significantly lower incidence of hypokalemia (1.0 vs. 14.0%, P < 0.0001) than HCTZ-based therapy.

CONCLUSION

Aliskiren-based therapy provided superior BP reductions to HCTZ-based therapy with good tolerability in obese patients with hypertension.