Challenges in the Primary Care Setting: Managing Metabolic Syndrome Health Disparities


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Challenges in the Primary Care Setting Managing
Metabolic Syndrome Health Disparities
Luther T. Clark MD SUNY Downstate Medical
Center Brooklyn NY James R. Gavin III MD
PhD Emory University School of Medicine
Atlanta GA Elijah Saunders MD University of
Maryland School of Medicine Baltimore MD
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Recognition Diagnosis and Prevention of CVDin
Patients With the Metabolic Syndrome
Luther T. Clark MD Chief Division of
Cardiovascular MedicineProfessor of Clinical
MedicineState University of New York Downstate
Medical Center Brooklyn NY
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The Metabolic Syndrome
A specific clustering of cardiovascular risk
factors in the same individual (abdominal
obesity atherogenic dyslipidemia elevated blood
pressure insulin resistance a prothrombotic
state and a proinflammatory state)
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Metabolic Syndrome

• Risk Factors do not occur randomly in the
  population and often cluster
• Clustering of RF described in 1960s and 1970s
• Syndrome X described by Reaven in 1987
• clustering of CVD risk factors
• insulin resistance suggested as cause

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The Metabolic Syndrome Risk Factor Cluster

• The metabolic syndrome is defined by 3 of the 5
  following risk factors coexisting
• Abdominal obesity
• Increased triglycerides
• Decreased HDL
• Increased blood pressure
• Elevated fasting blood glucose

Circulation 20021063143
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Clinical Identification of the Metabolic
Syndrome
Risk Factor
Defining Level
Abdominal obesity (waist circumference) Men
102 cm (40 in) Women 88 cm (35 in)
Triglycerides 150 mg/dl HDL Cholesterol
Men Blood pressure 130/ 85 mm Hg Fasting
glucose 110 mg/dl
JAMA 2002 2852486-2497. Circulation
20021063143
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NHANES III Age-Adjusted Prevalence of ³3 Risk
Factors for Metabolic Syndrome
NHANES IIIthird National Heath and Nutrition
Examination Survey ATPAdult Treatment
Panel. Criteria based on ATP III diabetics were
included in diagnosis overall unadjusted
prevalence was 21.8. Ford et al JAMA.
2002287356-359.
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NHANES III Age-Specific Prevalence of the
Metabolic Syndrome
50 45 40 35 30 25 20 15 10 5 0
Men Women

20-29 30-39 40-49
50-59 60-69 ³70
Age (y)
Data are presented as percentage (SE). Ford ES et
al. JAMA. 2002287356-359.
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Prevalence Of Selected Risk Factors Among
Patients With Metabolic Syndrome
95.1
86.5
84.6
84.2
82.9
80.5
76.7
73.2
62.6
57.6
Percent () of Metabolic Syndrome Subjects
22.2
16.7
Men
Women
Waist Cir.
BP
Triglycerides
Fasting Glucose
HDL-C
LDL-C
Wong et al Am J Cardiol. 2003911421-1426.
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Metabolic Syndrome

• Causes
• Acquired causes
• Overweight and obesity
• Physical inactivity
• High carbohydrate diets (60 of energy intake)
  in some persons
• Genetic causes

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Obesity Metabolic Syndrome and Type 2 Diabetes
Insulin resistance
Obesity
Metabolic syndrome
Diabetes
2 Risk
4 Risk
Cardiovascular disease
Luscher et al. Circulation. 20031081655. Reilly
and Rader. Circulation. 20031081546.
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CVD and All-cause Mortality Are Increased in Men
with the Metabolic Syndrome
Coronary Heart Disease Mortality
Cardiovascular Disease Mortality
All-Cause Mortality
20
20
20
15
15
15
RR (95 CI) 3.77 (1.74-8.17)
RR (95 CI) 3.55 (1.96-6.43)
RR (95 CI) 2.43 (1.64-3.51)
Cumulative Hazard
10
10
10
5
5
5
0
0
0
0
2
4
6
8
10
12
0
2
4
6
8
10
12
0
2
4
6
8
10
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No. at Risk Metabolic Syndrome Yes No
Follow-up y
Follow-up y
Follow-up y
866 852 834 292 866 852 834 292 866 852 834 292 86
7 279 234 100 288 279 234 100 288 279 234 100
As defined by NCEP ATP III.Lakka H et al.
JAMA. 20022882709-2716.
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Metabolic Syndrome Therapeutic Objectives

• Reduce underlying causes Overweight and
  obesity Physical inactivity
• Treat associated lipid and nonlipid risk
  factors Hypertension Prothrombotic state
  Atherogenic dyslipidemia (lipid triad)

Circulation. 20021063143.
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Therapeutic Approach To The Metabolic Syndrome
Clark Ferdinand Ferdinand. Cardiology Special
2003947-54
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Therapeutic Approach To The Metabolic Syndrome
Drug therapy should not be routinely used in
patients with IFG/IGT or to prevent diabetes
pending the results of ongoing clinical
trials.ASA aspirin BP Blood pressure CHD
coronary heart disease HDL-C high density
lipoprotein cholesterol IFG impaired fasting
glucose IGT impaired glucose tolerance LDL-C
low-density lipoprotein cholesterol TG
triglycerides Clark Ferinand Caardiology
Special Edition 2003
Clark Ferdinand Ferdinand. Cardiology Special
Edition 2003947-54
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CHD Events Prevented By Simultaneous Control of
BP HDL-C And LDL-C to Normal and Optimal Levels
in Patients With Metabolic Syndrome
Controlled to Normal
Controlled to Optimal
Uncontrolled
Events Prevented
Events Prevented
Patients with MetS(1000s) 14631847150619
436761 15381953176131448395
10-YrCHD Risk .0890.1657.2692.3936.2377 .01
26.0460.0989.1167.0775
Events(1000s) 130 306 407
7651607 19.4 89.8174367651
(1000s) 68.1163223371825 8.0
36.7 73.2159277
PAR() 52.353.255.048.551.3 41.340.942.1
43.342.6
(1000s) 106 233 334 6001293
15.5 73.4142302534
PAR() 81.082.682.478.580.5 80.281.781.4
82.482.1
Age yrs Men3039404950596074Total Wo
men3039404950596074Total
MetS metabolic syndrome PAR events in
controlled to normal or controlled to
optimal/events in uncontrolled. Normal HDL-C
45-49 mg/dL in men and 50-59 mg/dL in women
optimal HDL-C 50 mg/dL Normal LDL-C 120-129
mg/dL optimal LDL-C 120-129/80-84 mm Hg optimal BP Hg Wong ND et al Am J Cardiol. 2003911421-1426.
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Unanswered Questions

• What is the incremental quantitative risk added
  by MS risk factors not in the FHS (obesity
  elevated TG IFG)
• What are the treatment goals (beyond LDL) in
  patients with the metabolic syndrome (BP IFG wt
  loss)
• Are there gene-gene and/or gene-environment
  interactions that predict metabolic syndrome and
  CV risk

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Conclusions

• African Americans are 1.5 times more likely than
  whites to have multiple CHD risk factors
• Metabolic syndrome is particularly common in
  African-American women (25)
• Metabolic syndrome increases risk for diabetes
  and cardiovascular disease
• Optimal control of metabolic syndrome may
  decrease CHD events by 80

CHDcoronary heart disease.
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Conclusions

• Treatment strategies for MS should focus on
  overall CVD risks rather than single risk factors
• The mainstays of effective therapy are weight
  reduction and increased physical activity
• Drug therapy often also needed for control of
  HBP elevated blood glucose and triglycerides
• The lipid targets (LDL and non-HDL) should be
  achieved
• Integration of risk factor modification may be
  key to improving improve outcomes