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• W2087306711 abstract "Hypertension and obesity frequently coexist. While hypertension is the ‘old’ disease with well-established, albeit changing, guidelines for its investigation and management, the growing prevalence and severity of obesity presents new complexities. These are often in terms of varying types of presentation, assessment of diverse but important associated clinical risks, and management of increasing numbers of patients with raised blood pressure. Obesity is associated with more severe hypertension, a need for an increased number of anti-hypertensive medications, and an increased likelihood of never achieving blood pressure control 1. It is not just obesity, as defined by body mass index, that is important, but also fat distribution highlighted by, e.g., recent English data which have shown that men with a raised waist circumference are more than twice as likely to have high blood pressure as those with a waist circumference of 102 cm or less (51% compared with 23%) 2. This pattern was similar for women in that 42% of those with a raised waist circumference had high blood pressure, compared with 15% of those with a waist circumference of 88 cm or less 2. The interplay between obesity and blood pressure remains poorly recognized. For example, a search for the terms ‘obesity’ and ‘obstructive sleep apnoea’ in the UK National Institute for Health and Clinical Excellence (NICE) guidelines (published in 2006 3 and updated in 2011 4) identifies only one ‘hit’ and that relates to Cushing's syndrome. Last year, the European Association for the Study of Obesity (EASO) and the European Society for Hypertension produced a joint statement on obesity 5 and ‘difficult-to-treat’ arterial hypertension. This consensus document highlighted the growing clinical importance of this combination to all clinicians. Thirty years ago, it was thought that hypertension in obese individuals was driven by circulating volume expansion and increased cardiac output, rather than increased peripheral resistance. However, it is now known that the pathophysiology is complex, involving adipocytokines 6, insulin resistance, neuroendocrine dysfunction, nutritional factors associated with obesity (such as high fat, a high sodium diet 7, and possibly fructose consumption 8) as well as increased levels of physical inactivity. The EASO consensus statement considers ‘known knowns’ and ‘known unknowns’ 9. What is known? The starting point for detection and clinical care of hypertension in the obese individual is the ability to measure blood pressure accurately. The need for large cuff diameters for obese patients was recognized and detailed in the 1980s and yet, even today, this message has failed to permeate into clinical care. 45% of automated blood pressure devices assessed in 2010 failed to mention the need for an appropriate cuff size 10, and a recent audit of hospital blood pressure devices found that nearly 90% of the aneroid devices had only one cuff size available, suggesting that ‘miss-cuffing’ may be a serious cause of inaccurate blood pressure measurements 11. Lifestyle interventions are the mainstay of obesity management programmes and are also advocated in the prevention and treatment of arterial hypertension, but it is interesting that they are rarely adequately addressed in hypertension guidelines. Furthermore, anti-obesity drugs are known to lead to clinically meaningful reductions in blood pressure – especially in previously hypertensive subjects. However there are few approved pharmacological agents, and many have, or have had, unwanted effects on increasing heart rate that may offset the potential benefits of weight and blood pressure reduction. Concerns over cardiovascular safety have also dominated the thinking of the Committee on Human Medicinal Products of the European Medicines Agency, who now ipso facto require pre-approval cardiovascular outcome trials to establish safety. In terms of bariatric surgery, benefits have been repeatedly shown in terms of reducing all-cause and cardiovascular mortality and morbidity, although sustained effects on reducing blood pressure have been harder to demonstrate 12. Despite these ‘knowns’, there remain many important ‘unknowns’. Many obese patients do not achieve sufficient (or sufficiently durable) weight loss to control hypertension in the long term and so practitioners will often have to consider the use of anti-hypertensive medications. The EASO statement concludes that ‘remarkably, current hypertension guidelines do not provide specific recommendations for the choice of anti-hypertensive medications in obese patients (and). … there are no larger trials addressing the issue’. In the absence of high levels of evidence, the consensus view is that angiotensin-converting enzyme inhibitors, or angiotensin-receptor-blockers are the most appropriate first-line drugs in the obese hypertensive, in part because they have no adverse effects on the patient's metabolic profile. The demise in the importance and role of beta-blockers (in the latest NICE/British Hypertension Society [BHS]guidelines, they were relegated to step 4 3) is recapitulated with the added caution that in the obese they may have ‘enhanced’ hypotensive effects and worsen blood glucose levels, as well as hastening diabetes-related events. Furthermore, undertreatment of hypertension is common with only one-third of patients in the US controlled to guideline targets 13. Poor control appears more likely in the obese and also those with type 2 diabetes (amongst whom there would be a very high prevalence of obesity). Both patient factors (such as poor socio-economic status, lack of access to health care and poor concordance with treatment) as well as physician-related factors (e.g. lack of knowledge about guidelines and reluctance to add second or third drugs to regimens) largely account for this undertreatment, but there remains a small group of patients with what has been defined as ‘resistant hypertension’. The management of this condition in the obese may also pose particular problems and the efficacy of newer devices such as renal sympathetic denervation and baroreflex activation therapy need evaluation in the obese population. Hypertension represents another disease/risk factor in which obesity acts as a modulator of clinical care in those with a seemingly well-known disease, and highlights substantial areas of research that are still needed. Many other ‘traditional’ medical conditions are impacted on by obesity, such as sleep apnoea, non-alcoholic fatty liver disease and cancer, and significant challenges remain in knowing how to best tackle obesity within the confines of treating these problems. No conflict of interest was declared." @default.
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• W2087306711 date "2014-03-20" @default.
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• W2087306711 title "Obesity and difficult-to-treat arterial hypertension" @default.
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