Treatment of Arterial Hypertension in Obese Patients

Obesity is an increasingly observed pathologic entity in the industrialized world and causally linked to the development of hypertension. Consequently, not only the prevalence of obesity but also the prevalence of obesity hypertension is increasing worldwide. In the context of antihypertensive treatment, data from clinical trials indicate that all first-line antihypertensive drugs possess a similar efficacy in reducing systemic blood pressure and hypertension-related end-organ damage in obese hypertensive subjects. Nevertheless, some antihypertensive agents, such as β-blockers or thiazide diuretics, may have unwanted side effects on the metabolic and hemodynamic abnormalities that occur in both obesity and hypertension. However, current guidelines still do not include recommendations for state-of-the-art treatment of obese patients with hypertension. Hence, the aim of this article is to provide recommendations for the appropriate use of antihypertensive agents in obese patients mostly based on personal expertise and pathophysiologic assumptions. For instance, thiazide diuretics and β-blockers are reported to reduce insulin sensitivity and (at least transiently) increase triglyceride and low-density lipoprotein cholesterol levels, whereas calcium channel blockers are metabolically neutral and angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, and renin inhibition may increase insulin sensitivity. The renin-angiotensin-aldosterone system in the adipose tissue has been implicated in the development of arterial hypertension and sodium retention plays a central role in the development of obesity-related hypertension. Therefore, treatment with a blocker of the renin-angiotensin-aldosterone-system and a thiazide diuretic should be considered as first-line antihypertensive drug therapy in obesity hypertension.