Tratamiento de la hipertensión arterial en el paciente con síndrome metabólico

Metabolic syndrome affects about 25% to 45% of the Colombian population according to the diagnostic criteria proposed by the International Diabetes Federation, that in our population appear to be the most useful. It is well known that the metabolic syndrome is associated with an increased risk of three to six times in the development of diabetes and new hypertension cases. In Colombia, a cohort study realized in patients who suffered an acute myocardial infarct showed that insulin resistance was the main factor that predicted cardiovascular death or presence of new cardio-cerebral-vascular events. Furthermore, the presence of metabolic syndrome is more frequently associated with subclinical target organ damage. The main treatment in subjects with metabolic syndrome consists in decrease in body weight through the implementation of a low calorie diet and increase in physical exercise. Besides, patients with this syndrome need additional administration of antihypertensive medication, oral antidiabetic or hypolipemic drugs when there exists evident hypertension, diabetes or dyslipidemia. Given the high cardiovascular risk in hypertensive patients with metabolic syndrome, a rigorous blood pressure control maintaining levels always under 130/85 mm Hg, is needed. Unless there may be specific indications, in patients with metabolic syndrome the use of beta-blockers may be avoided given their well known adverse effects in weight increase, incidence of new cases of diabetes, insulin resistance and lipid profile. Tiazid diuretics have diabetogenic effects and other dysmetabolic actions, especially at high doses; for this reason they must not be used in patients with metabolic syndrome. Therefore, the recommended drugs as first choice in hypertensive subjects with metabolic syndrome are the angiotensin receptor blockers (ARBs) or the angiotensin-converting enzyme (ACE) inhibitors, that have shown to reduce the incidence of diabetes and to have favorable effects in the target organ damage. If the blood pressure is not controlled with monotherapy, a calcium antagonist is added to the ARB or ACE inhibitor. This combination produces a lower incidence of new cases of diabetes than the combination with beta-blockers or tiazid diuretics.