Patients With Hypertension and the Cardiometabolic Syndrome: The Potential Impact of Inflammatory Biomarkers

E.M. is a 54-year-old African American woman who presents to her physician for an annual examination. She has been reading extensively concerning the prevention of heart disease and wants to keep her risk as low as possible. E.M. has a personal history of hypertension and has been taking antihypertensive medications since the age of 46. Physical examination reveals an obese woman with a body mass index of 31.4 kg ⁄m, waist circumference of 36 inches, and blood pressure (BP) of 146 ⁄92 mm Hg. The remainder of the physical examination is unremarkable. Laboratory evaluation shows a fasting glucose of 106 mg ⁄dL, high-density lipoprotein cholesterol level of 52 mg ⁄dL, low-density lipoprotein level of 136 mg ⁄dL, and triglycerides 122 mg ⁄dL. She asks you if she should have a Creactive protein (hs-CRP) level checked with her other annual laboratory values. Based on her elevated BP, fasting glucose, and lipid profile, what do you advise her about her risk and how do you manage her risk factor profile? African Americans have a higher prevalence of coronary heart disease and a higher coronary heart disease mortality rate than white Americans. Much of this excess morbidity and mortality is due to the burden of hypertension-related target organ damage along with the increased prevalence of multiple risk factors for coronary heart disease, including higher levels of obesity, especially in women; insulin resistance; and sedentary lifestyle. However, compared with other groups, most of the data have shown that African Americans may have similar or even better lipid profiles than whites, including lower total cholesterol, lower low-density lipoprotein, and higher high-density lipoprotein levels. The combination of better lipid profiles despite worse insulin resistance, higher BP, and more prevalent obesity has led to data showing an unexpectedly overall low prevalence of the metabolic syndrome in population-based epidemiologic studies. Newer data suggest that targeting emerging cardiovascular disease (CVD) risk factors in addition to traditional CVD risk factors may improve outcomes. These considerations are particularly relevant because a large body of data has suggested that African Americans tend to have higher levels of hs-CRP and other inflammatory biomarkers. Developing approaches to assess cardiac risk include using biomarkers in addition to traditional CVD risk factors to help target more intense therapeutic goals for patients previously considered to be at low to intermediate risk for future CVD events. hs-CRP is the most extensively studied of the inflammatory biomarkers, with higher levels of hsCRP being associated with increased risk of CVD. In previous analyses, race and sex have both been shown to be independent predictors of elevated hs-CRP, with African American race and female sex associated with higher levels. Accordingly, From the Division of Cardiology, Emory University School of Medicine, Atlanta, GA Address for correspondence: Alanna Morris, MD, Emory University School of Medicine, 1364 Clifton Road NE, Suite D407B Atlanta, GA 30322 E-mail: aamorr3@emory.edu