Metabolic syndrome and insulin resistance in the TROPHY sub-study: contrasting views in patients with high-normal blood pressure.

BACKGROUND: Although insulin resistance and metabolic syndrome are often used synonymously, concordance is not established. METHODS: Metabolic, hemodynamic, and hormonal data were analyzed on 141 patients in the Trial of Preventing Hypertension (TROPHY) Sub-Study with high-normal blood pressure (BP) (130 to 139/85 to 89 mm Hg [mean +/- SD, 133 +/- 8/85 +/- 6 mm Hg]; age, 48 +/- 9 years; body mass index 30 +/- 5 kg/m(2)). RESULTS: Fifty-three of 141 subjects (37.6%; approximately 3/8) had the metabolic syndrome based on three or more of the five risk factors (BP, waist circumference, fasting triglycerides, HDL-cholesterol, glucose). To maintain consistency in proportions, insulin resistance was defined as the upper 3/8 of the distribution on the homeostatic model assessment (HOMA), which uses fasting glucose and insulin and a modified Matsuda-DeFronzo index, based on fasting, 1- and 2-h glucose and insulin values. Among metabolic syndrome patients, 57% and 55% were in the upper 3/8 of the distribution for insulin resistance by HOMA and Matsuda-DeFronzo, respectively. Among subjects without the metabolic syndrome, 26% and 27% were insulin resistant by HOMA and Matsuda-DeFronzo criteria. The proportion of patients with metabolic syndrome and insulin resistance increased strongly and similarly with increasing body mass index. However, metabolic syndrome and insulin resistance were different compared with their respective controls in the lower 5/8 of the distribution, in waist/hip ratios, fasting and 1-h insulin, HDL-cholesterol, heart rate, and systolic BP responses to exercise and plasma renin, angiotensin, and aldosterone. CONCLUSIONS: The findings suggest that metabolic syndrome and insulin resistance are not synonymous anthropometrically, metabolically, hemodynamically, or hormonally in patients with high-normal BP.

Ethnic, gender, and age-related differences in treatment and control of dyslipidemia in hypertensive patients.

BACKGROUND: Demographic differences in management of concomitant lipid disorders among hypertensive patients may contribute to health disparities. OBJECTIVES: Assess demographic differences in lipid control rates and treatment patterns among dyslipidemic hypertensive patients in primary care. METHODS: Demographic information, blood pressure, LDL-cholesterol, and medications were obtained on 72,351 hypertensive patients from 262 primary care providers at 69 sites in the Southeast. Analysis focused on a dyslipidemic hypertensive subset. RESULTS: Among 72,351 hypertensives, 38,116 were dyslipidemic. Fifty-two percent of patients did not have a cholesterol measurement documented in the past year. Women and patients <40 years old were less likely to have an annual cholesterol measurement than men and older, same-race counterparts (P < or = .001). Thirty-five percent of all hypertensive dyslipidemic patients had not been prescribed any anti-lipidemic medication, whereas 15% were on a statin and another anti-lipidemic. Women received fewer statin prescriptions than men (47.7% vs 65.1%, P < or = .0001). Fewer African Americans (AA) than Caucasians (C) reached LDL levels of <100 or <130 mg/dL (P < or = .0001). Among C and AA patients, those <40 years old were less likely than older, same-race counterparts to have reached LDL < 100 or <130 mg/dL (p < or = 001). Younger patients had fewer annual cholesterol measurements and were less likely to receive antilipidemic medication and to have LDL controlled than older, same-race counter-parts in each ethnic group (P < or = .0001). CONCLUSIONS: Demographic characteristics of hypertensive patients, especially younger age group, are associated with significant differences in diagnostic testing, treatment, and control of hyperlipidemia in primary care. This primary care information can be used to guide education and policy interventions to improve outcomes and reduce disparities.

A systematic approach to managing hypertension and the metabolic syndrome in primary care.

OBJECTIVES: Obesity is driving a high prevalence of hypertension and metabolic syndrome-related risk and disease. This report summarizes the impact of a standardized, evidence-based approach to managing high blood pressure and associated metabolic syndrome abnormalities that was developed and implemented by one Clinical Hypertension Specialist. METHODS: Longitudinal data on blood pressure, low-density lipoprotein cholesterol (LDL-C), hemoglobin A1c (HbA1c), cardiovascular and renal comorbidities, and treatment medications were obtained on all 817 hypertensive patients seen from January 1, 2000 to June 30, 2003. RESULTS: The hypertensive patients were 72 +/- 11 (SD) years old, and more than 55% of them were high risk based on target organ damage, clinical cardiovascular disease, or diabetes mellitus. Blood pressure was < 140/90 mm Hg in 77% of all patients. Among the high-risk patients, mean blood pressure was 126 +/- 14/71 +/- 10 on 2.8 +/- 1.4 antihypertensive medications, with 88% on angiotensin converting enzyme inhibitors or angiotensin receptor blockers, 59% on diuretics, 49% on calcium channel blockers, and 36% on beta-blockers. Among dyslipidemic hypertensives, LDL-C was controlled to < 130 mg/dL in 84% (510/605) overall and to < 100 mg/dL in 70% of the high-risk group (299/427). Among diabetic hypertensives, the mean HbA1c was 6.8%, with 64% (155/242) less than 7%. New patients demonstrated improved blood pressure, LDL-C, and hemoglobin A1c control over time as the management algorithm was applied. CONCLUSIONS: A high prevalence of complicated hypertension was documented. Blood pressure, LDL-C, and HbA1c were controlled to goal in a high proportion of patients. The findings demonstrate that application of an evidence-based management algorithm can facilitate higher rates of cardiovascular risk factor control than are generally reported in primary care practices.

A statewide primary care approach to cardiovascular risk factor control in high-risk diabetic and nondiabetic patients with hypertension.

Patients with multiple cardiovascular risk factors benefit from having them all controlled, but this rarely occurs. Fifty-seven primary care providers were enrolled in a program to monitor cardiovascular risk factor control. Data were obtained on 7315 hypertensives. This analysis focuses on 3460 high-risk hypertensives including 2199 with diabetes and 1261 with clinical cardiovascular disease. Blood pressures were <140/90 mm Hg and <130/80 mm Hg in only 44.3% and 20.4% of diabetics and 49.6% and 26.6% nondiabetics, respectively, despite the use of an average of 2.7+/-1.8 antihypertensive medications. Among high-risk dyslipidemic hypertensives, the low-density lipoprotein cholesterol level was <100 mg/dL in only 34% of diabetic and 33% of nondiabetic patients. Among 1696 diabetic hypertensives, the most recent glycosylated hemoglobin value averaged 7.5%, with 46.6% less than 7%. Among 805 diabetic, dyslipidemic hypertensives, all three risk factors were controlled to goal in only 6.6% with higher rates in whites than in African Americans (14.8% vs. 1.6%, p<0.001). An angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, or both were prescribed in 89.9% of diabetic and 70.8% of nondiabetic patients, p<0.05. Primary care providers use evidence-based combination therapy in high-risk hypertensive patients with and without diabetes. These findings confirm the low rates of multiple risk factor control and highlight challenges of reaching evidence-based goals in primary care.