Metabolic%20Syndrome,%20Diabetes,%20and%20Cardiovascular%20Disease:%20Implications%20for%20Preventive%20Cardiology

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Metabolic Syndrome, Diabetes, and Cardiovascular
Disease Implications for Preventive Cardiology

• Nathan D. Wong, PhD, FACC, FAHA
• Professor and Director
• Heart Disease Prevention Program
• Division of Cardiology
• University of California, Irvine

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Overview of Diabetes in the United States
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Diabetes Prevalence, 1990-1998
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Age-adjusted prevalence of physician-diagnosed
diabetes in Adults age 18 and older by
race/ethnicity and sex (NHANES 1999-2004).
Source NCHS and NHLBI. NH non-Hispanic.
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Risk of Cardiovascular Events in Diabetics
Framingham Study
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• Age-adjusted
• Biennial Rate Age-adjusted
• Per 1000 Risk Ratio
• Cardiovascular Event Men Women Men
  Women
• Coronary Disease 39 21 1.5
  2.2
• Stroke 15 6 2.9 2.6
• Peripheral Artery Dis. 18 18 3.4
  6.4
• Cardiac Failure 23 21 4.4
  7.8
• All CVD Events 76 65
  2.2 3.7
• Subjects 35-64 36-year Follow-up
  Plt.001,Plt.0001

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Insulin Resistance
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Natural History of Type 2 Diabetes
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Development of Type 2 Diabetes
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Hyperglycemia in Type 2 Diabetes Results From
Three Major Metabolic Defects
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Relationship Between Obesity andInsulin
Resistance and Dyslipidemia
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Insulin Resistance Associated Conditions
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New Cases of ESRD in the United States
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New Cases of ESRD in the United States by Cause
and Ethnicity, 1998
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Microalbuminuria
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Cardiovascular Disease and Diabetes
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Probability of Death From CHD in Patients With
Type 2 Diabetes With or Without Previous MI
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Framingham Heart Study 30-Year Follow-UpCVD
Events in Patients With Diabetes (Ages 35-64)
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10
9
Men
Women
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11
Risk ratio
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30
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4
9
6
38
20
3
2
0
Total CVD
CHD
Cardiac failure
Intermittent claudication
Stroke
Age-adjusted annual rate/1,000
Plt0.001 for all values except Plt0.05. Wilson
PWF, Kannel WB. In Hyperglycemia, Diabetes and
Vascular Disease. Ruderman N et al, eds. Oxford
1992.
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Presentation

• Name WJC
• Age 54 years old
• Professional former chief executive
• Personal wife lives principally in Washington,
  DC he has a personal cook in his suburban NY
  home
• Lifestyle
• Occasional use of cigars
• has had a long-term weight problem
• likes to play golf

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Presentation (contd)

• Examination
• Height 6 ft 2 in
• Weight 220 lb (BMI 28 kg/m2)
• Waist circumference 41 in
• BP 150/88 mm Hg
• P 64 bpm
• RR 12 breaths/min
• Cardiopulmonary exam normal

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Presentation (contd)

• Medications
• sildenafil 50 mg prn
• amlodipine 5 mg/d
• Laboratory results
• TC 220 mg/dL
• HDL-C 36 mg/dL
• LDL-C 140 mg/dL
• TG 220 mg/dL
• FBS 120 mg/dL

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The Metabolic Syndrome
Endothelial
Systemic
Complex
Dysfunction
Inflammation
Dyslipidemia
TG, LDL
HDL
Athero- sclerosis
Insulin
Disordered
Resistance
Fibrinolysis
Hypertension
Visceral
Obesity
Type 2 Diabetes
Adapted from the ADA. Diabetes Care.
199821310-314Pradhan AD et al. JAMA.
2001286327-334.
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Revised ATP III Metabolic Syndrome Oct 2005
Diagnosis is established when ?3 of these risk
factors are present. Abdominal obesity is more
highly correlated with metabolic risk factors
than is ?BMI.

Some men develop metabolic risk factors when
circumference is only marginally increased.
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International Diabetes Federation Definition
Abdominal obesity plus two other components
elevated BP, low HDL, elevated TG, or impaired
fasting glucose
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Prevalence of the Metabolic Syndrome Among US
Adults NHANES 1988-1994
Age (years)
Ford E et al. JAMA. 2002(287)356.
1999-2002 Prevalence by IDF vs. NCEP Definitions
(Ford ES, Diabetes Care 2005 28 2745-9)
(unadjusted, age 20) NCEP 33.7 in men and
35.4 in women IDF 39.9 in men and 38.1
in women
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Prevalence of the NCEP Metabolic Syndrome
NHANES III by Sex and Race/Ethnicity
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28
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25
23
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Prevalence,
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Men
Women
Ford ES et al. JAMA 2002287356-359.
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Cardiovascular Disease (CVD) and Total Mortality
US Men and Women Ages 30-74(age, gender, and
risk-factor adjusted Cox regression) NHANES II
Follow-Up (n6255)(Malik and Wong, et al.,
Circulation 2004 110 1245-1250)



















plt.05, plt.01, plt.0001 compared to none
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Metabolic Syndrome, CVD Events, and Mortality

• European cohort studies (6156 men and 5356
  women) Modified WHO definition of MetS
  associated with all-cause mortality (RR1.44
  1.17-1.84 in men and 1.38 1.02-1.87 in women)
  and CVD mortality (RR2.26 1.61-3.17 in men and
  2.78 1.57-4.94 in women) (Hu et al. Arch Intern
  Med 2004 164 1066-76)
• Atherosclerosis Risk in Communities (ARIC) study
  (12,089 men and women) 11 year follow-up, ATP
  III MetS associated with 1.5-2-fold greater
  likelihood of developing CHD and stroke, but MetS
  did not improve prediction over FRS (McNeill et
  al. Diab Care 2005 28 385-90)
• Cardiovascular Health Study (CHS) (2,175 elderly
  subjects) ATP III definition associated with 38
  increased risk (plt0.01) of coronary/cerebrovascula
  r events (Scuteri et al., Diab Care 2005 28
  882-7)