Obesity and hypertensive heart disease:

focus on body composition and sex differences

Giovanni de Simone, Costantino Mancuzi, Raffaele Izzo, Maria Angela Losi, L.Aldo Ferrara 2016

Presented by :

Simon Siringoringo
1815043

Preceptor: dr. Pudji Rusmono,SpPD-KKV

Department of Internal Medicine

Faculty of Medicine Maranatha Christian University
2018
 Obesity as a comorbidity in arterial
hypertension
• More than 80 % of hypertensive patients present with additional risk factor,
including glucose intolerance, hyperinsulinemia, lipid disorders and obesity.
• More than 50 % of hypertensive patients present at least 2 of comorbidities
and, generally, one of those is obesity.
• Scattered longitudinal analyses also suggest that obesity is an important risk
factor also for incident hypertension, especially in women.
 Cardiovascular modification of obesity
• Observation of cardiovascular modifications of obesity during adolescence
are particularly helpful to highlight the consistency of abnormalities of
obesity with those found in the context of arterial hypertension.
• The traditional paradigm of cardiovascular modifications in obesity with
hypertension has been that obese individuals mostly mostly develop eccentric
LVH, due to the increased volume overload.
 Con’t
• in obese patient, the increase in relative wall thickness and LV mass is also
typically associated with evidence of subclinical LV systolic dysfunction,
especialy when hypertension coexist, such as depressed midwall shortening,
abnormal reduced tissue myocardial velocities, strain and strain rate.
• Many mechanism have been proposed to explain the association of obesity
with hypertensive target organ damage.
 Abnormal conditions associated with
cardiovascular modifications in obesity
1. Hemodynamic load
• OSA
• Masked Hypertension

2. Body composition
 Adipose mass and LV geometry
• According to the old paradigm of LV mass only related to fat-free mass,
lower LV mass could be expected in the obese individuals with relative fat
free mass deficiency.
• In contrast, though formed by the 90 % of women, this relatively sarcopenic
obesity subgroup exhibited larger LV chamber size and greater LV mass with
a clear trend toward concentric LV geometry.
 Con’t
• Women, in whom sarcopenia is much prevalent, exhibit levels of excess of
LV mass substantially greater than men, strongly suggesting, therefore, that
there might be alterations in the normal myocardial structure associated with
the increased LV mass.

• The complex of these finding forces to reconsider the old Virkow’s

definition of “fatty heart”
Blood pressure control in the obese patient
• Controlling blood pressure is difficult in the presence of obesity.
• In the Campania Salute Network, the probability to optimally control blood
pressure decreases with increasing BMI, despite the greater number of
medication use
• Aggresively therapy in obesity likely to be due to mechanism related to
autocrine and paracrine activity in perivascular fat, namely the production of
angiotensin II and aldosterone, making peculiar the origin of hypertension in
obese individual.
 Weight Loss and regression of cardiovascular
abnormalities
• Dietary intervention and bariatric surgery are the main stay for obesity
treatment.
• Abnormal LV geometry and function can substantially improve after weight
loss in both adults and adolescence.
• An extreme option is bariatric surgery, which is very effective to control the
cluster of obesity-related cardiovascular risk factors, hypertension and
diabetes.
Current reccomendations and need for research

• LVH is the most relevant marker of cardiovascular risk in arterial

hypertension and current guidelines strongly recommend decrease LV mass.
• Current guideline for arterial hyprtension do not have specific suggestions
for treatment of arterial hypertension and regression of LVH in the
presence obesity.
 Con’t
• We think that efforts should be oriented to characterize:
1. Whether LVH has the same pathofisiologycal meaning and, therefore,
prognostic impact in both obese and non-obese men and women.
2. The tissue characterization of the hyperthrophic heart in obese-
hypertensive patients, a possibility emerging from new technologies applied
to nuclear magnetic resonance.
 Con’t
3. Whether extensive assessment of hemodynamic loading conditions and
biological markers can help defining management of the association of
obesity with hypertension even beyond the crude intervention on loading
condition.
 Conclusion
• Obesity and hypertension are closely linked condition.
• Obesity exaggerates LV response to increased hemodynamic load in large
part throughout the effect of non hemodynamic mechanism elicited by
visceral adiposity.
• Fat mass is as important as, and perhaps more important than, fat-free mass
to promote increase in LV mass in visceral obesity, which is especially
evident in women, related to body composition.
 Con’t
• Body composition is likely to be a key factor in determining LV geometry in
the presence of obesity and is at the basis of paradoxical sex-difference
found in LV adaptation to arterial hypertension.
• Effectively controlling BP and reducing hypertensive LVH is difficult
without managing obesity.
• Research should be implemented to find more adequate approach to manage
this frequent combination.
THANK YOU