Hypertension and the |Metabolic Hypertension and the |Metabolic SyndromeSyndrome
Karim SaidCardiology Department
Cairo University
• 54 –year old postmenopausal woman• Diabetes mellitus 10 years
On glibenclamide , 5 mg b.i.d• Hypertesion 8 years
On ACE-I• FH DM (mother) HTN (mother , brother) IHD (father)• Sedentary life
• On her last visit to the diabetes clinic, a BP
of 170/110 mmHg was found
• She is asymptomatic
• Compliant to ACE-I
• No recent drug intake
Clinical Examination
• BP: 160/104 mmHg &no postural hypotension• Truncal obesity (BMI : 32 kg/m2) • Mild hirsutism• Acne over the back• Bruit over the Rt. carotid artery• S4 over the cardiac apex• Weak bilateral ankle jerk• Normal vibration sensation• Fundus: GI
Possible causes of uncontrolled Possible causes of uncontrolled hypertension in this patient are :hypertension in this patient are :
1. Development of diabetic nephropathy
2. Cushing syndrome
3. Renal artery stenosis
4. Essential hypertension
5. All of the above
6. Either 1 or 3
• Diabetic nephropathy: development or recent elevation of BP in a diabetic
patient should raise the possibility of diabetic nephropathy. HTN is found in 90% of pts with diabetic nephropathy• Cushing syndrome hypertension – diabetes – truncal obesity – hirsutism
acne• Renal artery stenosis Rt. Carotid bruit• Essential hypertension still the most common cause
Blood ChemistryBlood Chemistry
• Fasting blood sugar : 160mg/dl• HbA1c : 8 %• Uric acid : 8.0 mg/dl• Creatinine : 0.6 mg/dl• Serum K : 3.9 mg/dl• Fasting lipogram: Triglycerides: 406 mg/dl T. cholesterol: 205 mg/dl LDL: 106 mg/dl
HDL: 42 mg/dl
UrinalysisUrinalysis
Protein : ++++
Sugar : ++
WBC :15 – 20 / HPF
RBC : 10 / HPF
Cells : epithelial
Casts : none
These urinalysis findings establish the These urinalysis findings establish the diagnosis of diabetic nephropathy: diagnosis of diabetic nephropathy:
1. Yes1. Yes
2. No2. No
Comment:
Presence of UTI:Presence of UTI:
can be the cause of proteinuria interferes with the laboratory diagnosis of diabetic
nephropathy difficult glycaemic control
• Urine culture : E-coli (10 x 105/ml)
• Oral Norfloxacin (400 mg b.i.d) for 1 week
• Urinalysis: Protein: trace WBC: 1 –2 /HPF RBC: 1 – 2 /HPF
• 24 hour urinary albumin : 150 mg/24 h
• BP: 156/104 mmHg
Comment
In diabetic nephropathy:In diabetic nephropathy: • hypertension usually manifest with macroalbuminuria
(> 300mg/dl)• In DM type 1 : HTN may occur with microalbuminuria ( < 300 mg/dl)• Diabetic retinopathy is common
AlbuminuriaAlbuminuria
• Microalbuminuria ( 30 – 300 mg/day)
- increased CV risks
- progression to macroalbumuria
• Macroalbuminuria ( > 300 mg /day)
- risk of ESRD
Cardiovascular Mortality in Diabetic PatientsCardiovascular Mortality in Diabetic Patients
The recommended initial screening test for The recommended initial screening test for Cushing syndrome in this patient is :Cushing syndrome in this patient is :
1. Serum cortisol level
2. ACTH stimulation test
3. Overnight dexamethasone suppression test
This patient has clinical features of the This patient has clinical features of the metabolic syndrome : metabolic syndrome :
1. Yes
2. No
Clinical features of metabolic syndromeClinical features of metabolic syndrome(NCEP – ATP III)(NCEP – ATP III)
FeatureFeature Diagnostic criteriaDiagnostic criteria
• Blood pressureBlood pressure > 130/ 85 mmHg
• Fasting blood sugarFasting blood sugar > 110 mg / dl
• Waist circumfrenceWaist circumfrence
male
female>101 cm
>88 cm• TriglyceridesTriglycerides > 150 mg / dl
• HDLHDL
male
female< 50 mg / dl
< 40 mg / dl
• Prevalence of metabolic syndromePrevalence of metabolic syndrome
- 24% of whole population
- 40% of people > 60 years
- 80% of patients with type 2 diabetes
Hypertension in Metabolic Syndrome
Hypertension in Metabolic Syndrome
• Salt & water retension• Potentiation of vasopressors (AII,VP, Endothelin)• Endothelial dysfunction• VSMCs proliferation• Renal cell proliferation
Other features of metabolic syndromeOther features of metabolic syndrome
• Hyperuricaemia• Hyperandrogenism• Albumiuria• Elevated CRP• Fatty liver• Polycystic ovary syndrome• Hypercoagulability
For management of hypertension in this For management of hypertension in this patient:patient:
1. Increase the dose of ACE-I
2. Add another antihypertensive agent
3. Shift to another antihypertensive agent
Best antihypertensive drug to be added :Best antihypertensive drug to be added :
1. Beta blocker
2. Alpha blocker
3. Thiazide diuretic
4. Calcium channel blocker ( dihydropyridine)
5. Calcium channel blocker (Non dihydropyridine)
Comment
Thiazide diuretics - improves CV outcomes(ALLHAT , SHIP) - volume overload – low renin status
CCA - dihydropyridine: controversial - non-dihydropyridine: effective with proteinuria
• Beta-BlockerBeta-BlockerUKPDS 39UKPDS 39
• Beta-BlockerBeta-BlockerUKPDS 39UKPDS 39
Slight weight gain
↑withdrawal rate
↓ mortality rate (post –MI)
• Alpha –blocker Alpha –blocker (ALLHAT: Doxazosin Vs. Chlothalidone)(ALLHAT: Doxazosin Vs. Chlothalidone)
-- Increased risk of CHF (114%)Increased risk of CHF (114%)
- Increased risk of stroke (20%)- Increased risk of stroke (20%)
- Increaesd risk of angina (16%)- Increaesd risk of angina (16%)
Target blood pressure in this patient:Target blood pressure in this patient:
1. <140/90 mmHg
2. <130/85 mmHg
3. <120/ 75 mmHg
UKPDS (tight BP control)
Anti- diabetic therapy in this patient: Anti- diabetic therapy in this patient:
1. Continue on glibenclamide
2. Shift to metformin
3. Shift to glimepride
4. Shift to insulin
Comment
Metformin
UKPDS :Intensive glycaemic control in overweight type 2 DM patients :
32 % reduction in diabetes related endpoints42 % in diabetes – related deathsDoes not induce weight gainFewer hypoglycaemic episodes
Would you add aspirin to this patient ?:Would you add aspirin to this patient ?:
1. Yes
2. No
• ACE.I + hydrochlorothiazide ( 25mg)• Metformin (850 mg , b.i.d)• Aspirin (150 mg daily)• Weight reduction• Physical activity• Low CHO deit
• 3 months later :
- Weight loss: 6 Kg
- BP: 144/90 mm Hg
- FBS: 138 mg/dl
- HbA1C: 7.3%
- Fasting lipogram : Triglycerides: 360mg/dl T. cholesterol: 202 mg/dl LDL: 103 mg/dl HDL: 40 mg/dl
Would you suggest adding triglycerides Would you suggest adding triglycerides lowering agent to this patient ?: lowering agent to this patient ?:
1. Yes
2. No
Comment
Isolated Hypertriglyceridaemia
CAD present : fibrates may be prescribed especially in the presence of low HDL (VA –HIT)
ATP III : - DM : considered as CAD equivalent - Triglycerides: 200 – 499 mg/dl - Especially in the presence of low HDL - Glycaemic control is mandatory - Weight reduction & physical activity
Thank YouThank You