Health & Medical Cardiovascular Health

Prehypertension and the Cardiometabolic Syndrome

´╗┐Prehypertension and the Cardiometabolic Syndrome

Expert Commentary & Five-year View

Prehypertension represents the view that individuals with BPs below the current threshold for the diagnosis of hypertension are at risk for a rise in BP and for a cardiovascular morbid event. It is unlikely that all patients with pressure in the prehypertensive range are at similar risk, and it is clear that not all such patients develop hypertensive levels of BP before they experience a morbid event. Identifying early cardiovascular disease in asymptomatic individuals provides a better guide to the need for individualized preventive therapy than traditional risk factor assessment. Correcting the vascular phenotype early in the stage of prehypertension, at the molecular, cellular, functional and structural level, may allow preventing incident hypertension or the increased severity of BP elevation, and may help reduce the burden of cardiovascular disease and mortality.

Obesity is increasingly recognized as a global pandemic that threatens the health of millions of people. There is increasing evidence that patients with elevated BMI may be better off than others if they develop 'wasting disease' such as heart disease or renal disease. This phenomenon has been described as the 'obesity paradox' or 'reverse epidemiology'. Future studies are needed to differentiate the risk with obesity versus the metabolic syndrome and the need to identify the risk in overweight and obese subjects in function of their BMI, fat distribution, inflammation and insulin resistance.

Within the changing healthcare environment and health-economical conditions there is a large need for research and debate about individualized medicine versus standard of care regarding the metabolic syndrome. The health care organizations are looking more toward standard of care based on the results of evidence-based medicine trials.

Despite these clinical trials guide us in our clinical diagnostic and therapeutic approaches, we may not ignore that inclusion and exclusion criteria lead to a selection bias. Therefore it is more difficult to implement the results in different age categories, ethnic groups which were not studied in a particular clinical trial. Most of the risk scores are based on a biostatistical risk approach. The development of genomics will lead to a better individual care, easier early disease diagnosis and subjects with an abnormal genetic profile can be more frequently followed for development of the disease. Pharmacogenetics will be helpful in tailoring potential drug therapy with more efficiency, safety and less side effects. This will lead to a better patient selection for certain therapies and better therapeutic adherence leading to a better life quality and more health-economical benefits.

Prehypertension is a vascular phenotype of functional and structural abnormalities and it is associated with increased cardiovascular risk. Current guidelines recommend only lifestyle changes in prehypertension. There are a few clinical trials which demonstrated that antihypertensive treatment can delay the development of future hypertension. Whether long-term treatment can reduce the cardiovascular outcome need to be answered by larger interventional trials. The growing epidemic of obesity has led to a cluster of risk factors of abdominal obesity, prehypertension, prediabetes, dyslipidemia which is defined as the metabolic syndrome. It is associated with inflammation and insulin resistance. Future studies are necessary to determine the optimal treatment of the individual risk factors or the global treatment of the metabolic syndrome beyond the life style changes and their benefit on cardiovascular outcome.

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