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Cardiometabolic syndrome

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Cardiometabolic syndrome

  1. 1. Cardiometabolic Syndrome DR HOSAM ATEF Lecturer of anesthesia&ICU
  2. 2. Clustering of ComponentsClustering of Components:: • Hypertension: BP. > 140/90 • Dyslipidemia: TG > 150 mg/ dL ( 1.7 mmol/L ) HDL- C < 35 mg/ dL (0.9 mmol/L) • Obesity (central): BMI > 30 kg/M2 Waist girth > 94 cm (37 inch) Waist/Hip ratio > 0.9 • Impaired Glucose Handling: IR , IGT or DM FPG > 110 mg/dL (6.1mmol/L) 2hr.PG >200 mg/dL(11.1mmol/L) • Microalbuninuria (WHO)
  3. 3. Global cardiometabolic risk*
  4. 4. The new IDF definition focusses on abdominal obesity rather than insulin resistance International Diabetes Federation (IDF) Consensus Definition 2005
  5. 5. Why a New Definition of the MeS: IDF Objectives Needs: • To identify individuals at high risk of developing cardiovascular disease (and diabetes) • To be useful for clinicians • To be useful for international comparisons
  6. 6. Fat Topography In Type 2 Diabetic Subjects Intramuscular Intrahepatic Subcutaneous Intra- abdominal FFA* TNF-alpha* Leptin* IL-6 (CRP)* Tissue Factor* PAI-1* Angiotensinogen*
  7. 7. Obesity is a Cardiovascular Risk Factor: • Linear Increase in Risk for Cardiovascular Disease with increase in BMI from 25 to 35 (unrelated to HDL, and LDL)
  8. 8. Abdominal obesity and increased risk of cardiovascular events Adjustedrelativerisk 1 1 1 1.17 1.16 1.14 1.29 1.27 1.35 0.8 1 1.2 1.4 CVD death MI All-cause deaths Tertile 1 Tertile 2 Tertile 3 Men Women <95 95–103 >103 <87 87–98 >98 Waist circumference (cm): The HOPE study
  9. 9. Abdominal obesity increases the risk of developing type 2 diabetes <71 71–75.9 76–81 81.1–86 86.1–91 91.1–96.3 >96.3 24 20 16 12 8 4 0 Relativerisk Waist circumference (cm)
  10. 10. Abdominal obesity is linked to an increased risk of coronary heart disease Waist circumference has been shown to be independently associated with increased age-adjusted risk of CHD, even after adjusting for BMI and other cardiovascular risk factors 0.0 0.5 1.0 1.5 2.0 2.5 3.0 <69.8 69.8−<74.2 74.2−<79.2 79.2−<86.3 86.3−<139.7 1.27 2.06 2.31 2.44p for trend = 0.007 Relativerisk Quintiles of waist circumference (cm)
  11. 11. Diabetes in the new millennium Interdisciplinary problem Diabetes
  12. 12. Diabetes in the new millennium Interdisciplinary problem OBESITY
  13. 13. Diabetes in the new millennium Interdisciplinary problem DIAB ESITY
  14. 14. Look at your patient’s shape
  15. 15. TargetingTargeting Cardiometabolic RiskCardiometabolic Risk
  16. 16. Insulin Resistance: Associated Conditions
  17. 17. Linked Metabolic AbnormalitiesLinked Metabolic Abnormalities:: • Impaired glucose handling/ insulin resistance • Atherogenic dyslipidemia • Endothelial dysfunction • Prothrombotic state • Hemodynamic changes • Proinflammatory state • Excess ovarian testosterone production • Sleep-disordered breathing
  18. 18. Resulting Clinical ConditionsResulting Clinical Conditions:: • Type 2 diabetes • Essential hypertension • Polycystic ovary syndrome (PCOS) • Nonalcoholic fatty liver disease • Sleep apnea • Cardiovascular Disease (MI, PVD, Stroke) • Cancer (Breast, Prostate, Colorectal, Liver)
  19. 19. Multiple Risk Factor ManagementMultiple Risk Factor Management • Obesity • Glucose Intolerance • Insulin Resistance • Lipid Disorders • Hypertension • Goals:Goals: Minimize Risk of Type 2Minimize Risk of Type 2 Diabetes and Cardiovascular DiseaseDiabetes and Cardiovascular Disease
  20. 20. Glucose AbnormalitiesGlucose Abnormalities:: • IDF:IDF: – FPG >100 mg/dL (5.6 mmol. L) or previously diagnosed type 2 diabetes – (ADA: FBS >100 mg/dL [ 5.6 mmol/L ])
  21. 21. HypertensionHypertension:: • IDF:IDF: –BP >130/85 or on Rx for previously diagnosed hypertensionhypertension
  22. 22. DyslipidemiaDyslipidemia:: • IDF:IDF: –Triglycerides - >150mg/dL (1.7 mmol /L) – HDL - <40 mg/dL (men), <50 mg/dL (women)
  23. 23. EBM Recommendations • Any person at high risk who has lifestyle- related risk factors (e.g., obesity, physical inactivity, elevated triglyceride, low HDL-C, or metabolic syndrome) is a candidate for therapeutic lifestyle changes to modify these risk factors regardless of LDL-C level
  24. 24. EBM Recommendations (cont • There is some evidence that insulin sensitizing agents such as metformin are effective in treating features of metabolic syndrome.
  25. 25. Current Treatments • Weight reduction • TLC: Diet and Exercise • Lower BP goals • Lower LDL goals • Statins • Metformin • Aspirin therapy
  26. 26. Screening/Public Health ApproachScreening/Public Health Approach • Public Education • Screening for at risk individuals: – Blood Sugar/ HbA1c – Lipids – Blood pressure – Tobacco use – Body habitus – Family history
  27. 27. Life-Style Modification: Is it Important?Life-Style Modification: Is it Important? • Exercise – Improves CV fitness, weight control, sensitivity to insulin, reduces incidence of diabetes • Weight loss – Improves lipids, insulin sensitivity, BP levels, reduces incidence of diabetes • Goals:Goals: Brisk walking - 30 min./dayBrisk walking - 30 min./day 10% reduction in body wt.10% reduction in body wt.
  28. 28. Smoking Cessation / AvoidanceSmoking Cessation / Avoidance:: • A risk factor for development in children and adults • Both passive and active exposure harmful • A major risk factor for: – insulin resistance and metabolic syndrome – macrovascular disease (PVD, MI, Stroke) – microvascular complications of diabetes – pulmonary disease, etc.
  29. 29. Diabetes Control - How ImportantDiabetes Control - How Important?? GoalsGoals: • FBS - premeal <110,FBS - premeal <110, • postmealpostmeal <180.<180. • HbA1c <7%HbA1c <7% • For every 1% rise in Hb A1c there is an 18% rise in risk of cardiovascular events & a 28% increase in peripheral arterial disease • Evidence is accumulating to show that tight blood sugar control in both Type 1 and Type 2 diabetes reduces risk of CVD
  30. 30. Lifestyle modification • Diet • Exercise • Weight loss • Smoking cessation If a 1% reduction in HbA1c is achieved, you could expect a reduction in risk of: • 21% for any diabetes- related endpoint • 37% for microvascular complications • 14% for myocardial infarction However, compliance is poor and most patients will require oral pharmacotherapy within a few years of diagnosis
  31. 31. BP Control - How ImportantBP Control - How Important?? • Goal: BP.BP.<130/80<130/80 – Conclusively proved the increased risk of CVD with long-term sustained hypertension – Demonstrated a 10 year risk of cardiovascular disease in treated patients vs non-treated patients to be 0.40. – 40% reduction in stroke with control of HTN • Precedes literature on Metabolic Syndrome
  32. 32. Lipid Control - How ImportantLipid Control - How Important?? • Goals:Goals: HDL >40 mg% (>1.1 mmol /l)HDL >40 mg% (>1.1 mmol /l) LDLLDL <100 mg/dL (<3.0 mmol /l)<100 mg/dL (<3.0 mmol /l) TG <150 mg% (<1.7 mmol /l)TG <150 mg% (<1.7 mmol /l) • Multiple major studies show 24 - 37% reductions in cardiovascular disease risk with use of statins and fibrates in the control of hyperlipidemia.
  33. 33. MedicationsMedications:: • Hypertension: – ACE inhibitors, ARBs – Others - thiazides, calcium channel blockers, beta blockers, alpha blockers • Dylipidemia: – Statins, Fibrates – Platelet inhibitors:ASA, clopidogrel
  34. 34. A Critical Look at the Metabolic SyndromeA Critical Look at the Metabolic Syndrome Is it a Syndrome?*Is it a Syndrome?* • “…too much clinically important information is missing to warrant its designations as a syndrome.” • Unclear pathogenesis, Insulin resistance is not a consistent finding in some definitions. • CVD risks has not shown to be greater than the sum of it’s individual components. *ADA
  35. 35. A Critical Look at the Metabolic SyndromeA Critical Look at the Metabolic Syndrome Research • “Until much needed research is completed, clinicians should evaluate and treat all CVD risk factors without regard to whether a patient meets the criteria for diagnosis of the ‘metabolic syndrome’.”
  36. 36. A Critical Look at the Metabolic SyndromeA Critical Look at the Metabolic Syndrome Lifestyle • The advice remains to treat individual risk factors when present & to prescribe therapeutic lifestyle changes & weight management for obese patients with multiple risk factors.
  37. 37. Central obesity: a driving force for cardiovascular disease & diabetes “Balzac” by Rodin Front Back
  38. 38. International Diabetes Federation (IDF) Consensus Definition 2005 Central Obesity Waist circumference – ethnicity specific* – for Europids: Male > 94 cm Female > 80 cm plus any two of the following: Raised triglycerides > 150 mg/dL (1.7 mmol/L) or specific treatment for this lipid abnormality Reduced HDL cholesterol < 40 mg/dL (1.03 mmol/L) in males < 50 mg/dL (1.29 mmol/L) in females or specific treatment for this lipid abnormality Raised blood pressure Systolic : > 130 mmHg or Diastolic: > 85 mmHg or Treatment of previously diagnosed hypertension Raised fasting plasma glucose Fasting plasma glucose > 100 mg/dL (5.6 mmol/L) or Previously diagnosed type 2 diabetes If above 5.6 mmol/L or 100 mg/dL, OGTT is strongly recommended but is not necessary to define presence of the syndrome.
  39. 39. Treatment of Metabolic Syndrome: 2005 Aspirin Diet, Exercise, Lifestyle change Stop smoking CB1 Receptor Blocker Oral hypoglycaemics Antihypertensives Statins & Fibrates Insulin ACEI &/or A2 receptor blockers
  40. 40. Primary management for the Metabolic Syndrome is healthy lifestyle promotion. This includes: • moderate calorie restriction (to achieve a 5-10% loss of body weight in the first year) • moderate increases in physical activity • change dietary composition to reduce saturated fat and total intake, increase fibre and, if appropriate, reduce salt intake. Recommendations for treatment
  41. 41. • Appropriate & aggressive therapy is essential for reducing patient risk of cardiovascular disease • Lifestyle measures should be the first action • Pharmacotherapy should have beneficial effects on – Glucose intolerance/diabetes – Obesity – Hypertension – Dyslipidaemia • Ideally, treatment should address all of the components of the syndrome and not the individual components Management of the Metabolic Syndrome

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