Diabetes and the Younger/Middle-Aged Hypertensive Subject; Obesity, Sympathetic Nerve Activity and Treatment Implications

Summary and conclusion There is an obesity/type-2 diabetes/hypertension epidemic in developed countries around the world. Central obesity is closely linked to hypertension and type-2 diabetes in young/middle-age. In this younger, probably obese, age-group diastolic hypertension is linked to increased sympathetic nerve activity (via raised plasma insulin and leptin levels acting upon the hypothalamic region), particularly in the presence of type-2 diabetes. Chronically raised sympathetic nerve activity and beta-receptor levels (in lymphocytes), independent of blood pressure, are powerful predictors of myocardial infarction in the middle-aged. This has treatment implications for the young/middle-aged hypertensive subjects, with or without type-2 diabetes. Antihypertensive agents that increase sympathetic nerve activity e.g. dihydropyridine calcium blockers, thiazide-type diuretics, and angiotensin receptor blockers, do not reduce (and may increase) the risk of myocardial infarction in the younger/middle-aged hypertensive subject. Beta- 1 blockade, effective in reversing and stabilizing coronary atheromataous plaque, is at least as good as ACE-inhibition in preventing hard cardiovascular endpoints (including myocardial infarction, and is significantly superior in preventing all-cause death). Thus, beta-1 blockade is a highly reasonable first-line treatment in young/middle-aged hypertension with or without type-2 diabetes.