Scholze et al. BMC Public Health 2010, 10:529 http://www.biomedcentral.com/1471-2458/10/529 Page 8 of 12 Figure 5 Mean annual costs (Euros) per hypertensive patient according to the number of components of MetS; 2008. and the increase in prevalence of MetS components based on historical data trends. However, such forecasts do not take into account the potential impact of policy directives aimed at reducing the risk of developing one of the five MetS components. Future public health incentives will have an impact on future prevalence and costs however, these policies will be working against an increase in prevalence brought about by the aging popu- lation. The burden of illness in the future will therefore be dependent on how effective public health policies and guidelines are at preventing and treating MetS. A handful of studies have assessed the prevalence of hypertension in patients with MetS, but none to date have assessed its economic impact. Previous population studies using ATP III criteria have shown that approxi- mately 20% to 40% of the hypertensive population has MetS [20-23] giving rise to a prevalence in the general population of hypertension and MetS of 8% to 14% [20-22]. These estimates are similar to our estimates for Spain and Italy. Much higher estimates of the propor- tion of hypertensive subjects that have MetS are reported in primary care studies where the variation can be explained in part by the different sub-populations studied [13,17,24,25,27,53]. This study has highlighted the additional resource implications of hypertensive patients with MetS and the need to manage these patients effectively according to European guidelines to reduce the risk of cardiovascular disease and type 2 diabetes. However, a previous Eur- opean study reported that fewer than 30% of treated hypertensive patients had their blood pressure con- trolled to levels recommended by European guidelines and that uncontrolled hypertension was strongly asso- ciated with MetS [27]. Not achieving recommended tar- get levels of blood pressure control leaves these patients with elevated levels of risk. The study highlighted the importance of considering the patient’s entire cardiome- tabolic profile when considering appropriate treatment rather than focusing solely on blood pressure targets alone [27]. European guidelines advocate that appropriate man- agement of patients with hypertension should be based on their blood pressure level and overall cardiovascular risk profile. Guidelines recognise that due to the differ- ent mode of action of these classes, some drug groups are likely to offer greater benefits to different subgroups of patients [15,54,55]. In a recent reappraisal of guide- lines on hypertension management, they suggest that drug choice should take into account contraindications as well as favourable effects in specific clinic settings. The guidelines do not recommend specific drugs for the treatment of hypertensive patients with metabolic syn- drome, but do point out that ‘there is no doubt that beta-blockers and diuretics (especially when combined together) have adverse metabolic effects and facilitate new onset diabetes in predisposed patients such as those with metabolic syndrome or impaired glucose tolerance.’ They go on to point out that there is still controversy over whether drug-induced new onset diabetes carries the same negative prognosis as naturally occurring dia- betes [55]. In patients with diabetes the guidelines sug- gest that combination treatment is usually required and that ‘a renin-angiotensin receptor blocker should always be included because of the evidence of its superior