Session Number 202 METABOLIC SYNDROME Joyce L. Ross, MSN, CRNP, CS, FNLA, FPCNA Diplomate Accrediation Council for Clinical Lipidiology President Preventive Cardiovascular Nurses Association Consultative Education Specialist, Cardiovascular Risk Intervention University of Pennsylvania Health System– Retired Philadelphia, Pennsylvania [email protected]Content Description Discussion will center on metabolic syndrome as a major risk factor for vascular disease. We will evaluate how this group of independent variables relates to the development of disease and its impact on the current population of the United States. Case study approach will be applied both for detection and treatment of the syndrome Learning Objectives At the end of this session the participant will be able to: 1. state five (5) components of the metabolic syndrome 2. understand that metabolic syndrome is not considered a cardiac equivalent but that the components are harbingers of vascular disease 3. use case study to create a treatment plan inclusive of education, lifestyle management, and pharmaceutical intervention for reducing components of the syndrome Summary of Key Points/Outline – See attached slide handout References American Journal of Epidemiology 2000; 152(10): 897-907Sakkinen PA, Wahl P, Cushman M, et al Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-2497 Ford ES. Atherosclerosis 2004;173:309-314 Inflammation in Atherothrombosis: How to Use High-Sensitivity C-Reactive Protein (hsCRP) in Clinical Paul M. Ridker, MD, MPH.Am Heart Hosp J (2004) 2;4 Suppl 1:4-9 Malik S et al. Diabetes Care. 2005;28:690-693 Meigs JB, et al. JAMA. 2000;283:221–228 2008 Heart and Stroke Statistical Update. American Heart Association Wilson PWF, et al. Arch Intern Med. 1999;159:1104–1109 Speaker Contact Information: [email protected]
21
Embed
202 Ross, J. Metabolic Syndrome - Critical care nursing · METABOLIC SYNDROME Joyce L. Ross, MSN, CRNP, CS, FNLA, ... 159:1104–1109 Speaker Contact Information: [email protected].
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Session Number 202
METABOLIC SYNDROME
Joyce L. Ross, MSN, CRNP, CS, FNLA, FPCNA Diplomate Accrediation Council for Clinical Lipidiology President Preventive Cardiovascular Nurses Association
Consultative Education Specialist, Cardiovascular Risk Intervention University of Pennsylvania Health System– Retired
Discussion will center on metabolic syndrome as a major risk factor for vascular disease. We will evaluate how this group of independent variables relates to the development of disease and its impact on the current population of the United States. Case study approach will be applied both for detection and treatment of the syndrome
Learning Objectives At the end of this session the participant will be able to: 1. state five (5) components of the metabolic syndrome 2. understand that metabolic syndrome is not considered a cardiac equivalent but that the
components are harbingers of vascular disease 3. use case study to create a treatment plan inclusive of education, lifestyle management, and
pharmaceutical intervention for reducing components of the syndrome Summary of Key Points/Outline – See attached slide handout
References
American Journal of Epidemiology 2000; 152(10): 897-907Sakkinen PA, Wahl P, Cushman M, et al Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-2497 Ford ES. Atherosclerosis 2004;173:309-314 Inflammation in Atherothrombosis: How to Use High-Sensitivity C-Reactive Protein (hsCRP) in Clinical Paul M. Ridker, MD, MPH.Am Heart Hosp J (2004) 2;4 Suppl 1:4-9 Malik S et al. Diabetes Care. 2005;28:690-693 Meigs JB, et al. JAMA. 2000;283:221–228 2008 Heart and Stroke Statistical Update. American Heart Association Wilson PWF, et al. Arch Intern Med. 1999;159:1104–1109 Speaker Contact Information: [email protected]
Metabolic Syndrome
TRENDS April 2013
Joyce L. Ross, MSN, CRNP, CS, FPCNA, FNLADiplomate Accreditation Council for Clinical Lipidology
Certified Clinical Lipid SpecialistUniversity of Pennsylvania Health System – Retired
American Journal of Epidemiology 2000; 152(10): 897-907Sakkinen PA, Wahl P, Cushman M, et al
The Damage from components of metabolic syndrome assert their
influence on the
CONTRIBUTING FACTORS IN VASCULAR DISEASE
lifestyle cholesterolHTN geneticsDiabetes
Ross, J 2005
Endothelial Dysfunction
FoamCells
FattyStreak
IntermediateLesion Atheroma
FibrousPlaque
ComplicatedLesion/Rupture
From first decade From third decade From fourth decade
Growth mainly by lipid accumulationSmoothmuscle
& collagen
Thrombosis,hematoma
Non-obstructive plaque
Endothelium
Plaque Cap
Glucose Metabolism
Insulin resistance caused by abdominal obesity may lead to the development of risk factors for CHD1
Abdominal adiposity and insulin resistance may independently affect hemostatic variables2
1. Wilson PWF, et al. 1. Wilson PWF, et al. Arch Intern Med.Arch Intern Med.1999;159:11041999;159:1104––1109.1109.2. Meigs JB, et al. 2. Meigs JB, et al. JAMA.JAMA. 2000;283:2212000;283:221––228.228.
Type 2 diabetes
Years from Years from diagnosisdiagnosis
0 5-10 -5 10 15
Pre-diabetes
Onset Diagnosis
Insulin secretion
Insulin resistanceInsulin resistance
Post-Meal glucose
Cardiovascular Complications
Ramlo-Halsted BA, Edelman SV. Prim Care. 1999;26:771-789Nathan DM. N Engl J Med. 2002;347:1342-1349
High levels associated with increased vascular events, MI, CVA
Assay precisely measures low levels of CRP
Inflammation is part of the sequence of events for MI
most studies demonstrate A 3 - 4 fold increased risk associated with the highest quartile compared with the lowest levels
stronger prediction when combined with the lipid panel
Inflammation in Atherothrombosis: How to Use High-Sensitivity C-Reactive Protein (hsCRP) in Clinical Paul M. Ridker, MD,MPH.Am Heart Hosp J (2004) 2;4 Suppl 1:4-9
DyslipidemiaDyslipidemia is a major risk factor for CHD, the leading cause of death in the United States1
The World Health Organization estimates that dyslipidemia is associated with >50% of global ischemic heart disease cases and >4 million deaths per year2
Two components of dyslipidemia are directly related to risk factors for metabolic syndrome, and one indirectly affects it.
1. Smith DG. Am J Manag Care. 2007;13:S68-S71. 2. World Health Organization. The World Health Report. 2002;4:47-97.
CHD = coronary heart disease.
Causes of Lipid DisordersPrimary and Secondary Causes Primary are related to genetics Secondary may be related to medical disorders,
and medications, that effect specific parameters of the lipid profile Metabolic endocrine
Diabetes Thyroid disease
Renal Hepatic drugs
Ross, J 2005
Serum TG Levels: NCEP/ATP III Goals and Cutpoints
ClassificationSerum TG Level
(mg/dL)
Normal <150
Borderline High 150-199
High 200-499
Very High ≥500
Third Report of the NCEP Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III). NIH Publication No. 02-5215; September 2002.
Features of ATP III -Triglycerides
Patients with triglycerides 200 mg/dL
LDL cholesterol: primary target of therapy
Non-HDL cholesterol: secondary target of therapy
Non HDL-C = total cholesterol – HDL cholesterol
Example: TC 270 minus HDL 50 = 220 non-HDL-C - Should not be higher than 30 points than LDL goal.
Chobanian AV, et al. JAMA 2003;289:2560Chobanian AV, et al. JAMA 2003;289:2560--7272
Systolic Goal mm Hg Diastolic Goal mm HgSystolic Goal mm Hg Diastolic Goal mm HgMost PatientsMost Patients < 140< 140 < 90< 90DiabetesDiabetes < 130< 130 < 80< 80Chronic Kidney DiseaseChronic Kidney Disease < 130< 130 < 80< 80
JNC 7: Causes of Secondary HypertensionJNC 7: Causes of Secondary Hypertension
Medical Conditions
Chronic kidney disease
Primary hyperaldosteronism
Renovascular disease
Chronic steroid therapy
Cushing’s syndrome
Pheochromocytoma
Aortic coarctation
Thyroid or parathyroid disease
Sleep apnea
Drugs
NSAIDS
Oral contraceptives
Adrenal steroids
Sympathomimetics
Cyclosporine or tacrolimus
Erythropoietin
Ephedra, mu huang, bitter orange
Cocaine or amphetamines
Alcohol
Chobanian AV et al. JAMA. 2003;289:2560-2572
NSAIDS=Non-steroidal anti-inflammatory drugs
JNC 7 - Features and Key Message
Persons > age 50 SBP is a more important cardiovascular risk factor than DBP
Starting at 115/75 CVD risk doubles for each increase of 20/10 mmHg
Normotensive patients at age 50 90% lifetime risk of developing hypertension
Those with SBP 120-139 or DBP 80-89 “prehypertensive” and should receive lifestyle modification to
prevent CVD
Chobanian AV, et al. JAMA 2003;289:2560Chobanian AV, et al. JAMA 2003;289:2560--7272
Treatment Approach to Metabolic Syndrome
Kendall DM, Harmel AP. The metabolic syndrome, type 2 diabetes, and cardiovascular disease:understanding the role of insulin resistance. Am J Manag Care. 2002;8(Suppl 20):S635-S653
Risk Reduction Therapy
Risk Behavior % Mortality – 10 years
Smoke Cessation 35 – 45 %LDL Reduction to goal 25 – 35 %BP management to goal 10 – 15 %ASA 10 % ACE Inhibitor Use 20 – 30 %Weight Loss 20 %Exercise 20 %
Grundy 9/2000
Involve the patient
Enhanced communication improves patient adherence, outcomes, and satisfaction
Barrier PA et al. Mayo Clin Proc. 2003;78:211-4.
Patient-centered approach facilitates identification of risk
conditions
Provider-centered approach may lead to missed diagnoses and
poor adherence
Treatment of Components of Metabolic Syndrome
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-2497.
Metabolic Syndrome and Subclinical Atherosclerosis
1. Wing RR, et al. 1. Wing RR, et al. Arch Intern MedArch Intern Med. 1987;147:1749. 1987;147:1749––1753.1753.2. Goldstein DJ. 2. Goldstein DJ. Int J ObesInt J Obes. 1992;16:397. 1992;16:397––415.415.3. Thomas PR, ed. 3. Thomas PR, ed. Weighing the Options.Weighing the Options. 19951995..
Health Benefits of Weight Loss
Weight loss of 5%–10% in obese individuals with type 2 diabetes, hypertension or dyslipidemia resulted in:
Improved glycemic control1
Reduced blood pressure2
Improved lipid profile2
“Several studies demonstrate that small losses...help reduce obesity-related comorbidities and that improvements in these risk factors persist with maintenance of these modest weight losses.”3
— Institute of Medicine
Alcohol and CHDThere is a “U-shaped” curve
One drink lowers CHD risk vs. risk in teetotalers
Increasing amounts lead to increasing total mortality
No difference between red and white wine in ecological, epidemiological studies
Resveratrol in red wine may CV benefits via ↓LDL oxidation, ↑ nitric acid, or by changes in thrombogenicity, ischemia, or vascular tone1
Observational data
Alcohol intake may be causally related to lower risk of CHD through changes in lipids (HDL-C, Apo AI, TG) and hemostatic factors2
1. Opie LH, et al. Eur Heart J. 2007;28:1683-1693.2. Rimm EB, et al. BMJ. 1999;319:1523-1528.
If You Consume Alcohol, Do So in Moderation
Corrao G, et al. Prev Med. 2004;38:613-619.
Relative risk alcohol consumption and the risk of CHD
One drink equals:•12 oz beer• 4 oz wine•1.5 oz 80 proof spirits
10 g alcohol equates to:• 1 shot liquor• 1 regular can beer• 1 glass table wine
•1 drink/day females•2 drink/day males
•With meals
TLC Teaching Tips: Three F’s for a Healthier Diet
Fiber: More whole grain products, dietary fiber
Fruits and vegetables: Dietary sources of antioxidants
Fish and plant sources of omega-3 fatty acid intake shown to reduce CHD death Secondary prevention studies:
1. Swinburn BA, et al. Am J Public Health. 1998;88:288-291.2. Wee CC. JAMA. 2001;286:717-719.FIT = Frequency Intensity Time
Atherogenic dyslipidemia is an important target of therapy for CV risk management, and commonly occurs in patients with the metabolic syndrome and/or diabetes
A substantial proportion of patients with atherogenic dyslipidemia are not at lipid goals
Guidelines recommend non-HDL-C as a secondary target in patients with atherogenic dyslipidemia, including combination therapy with a fibrate and statin
Atherogenic Dyslipidemia as a Target of Therapy
Lipid Therapy Options for Dyslipidemia
1. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. 2. Zetia® (ezetimibe) [package insert]. Merck/Schering-Plough Pharmaceuticals. North Wales, PA; 2008. 3. Lovaza™ (omega-3-acid ethyl esters) capsules [package insert]. Reliant Pharmaceuticals. Durham, NC; 2007.
Dose Efficacy of Statin-Based Therapies for LDL-C Reduction (%)1
Dose Efficacy in STELLAR1*
Drug 10 mg 20 mg 40 mg 80 mg
CRESTOR® (rosuvastatin calcium)
46 52 55
Lipitor® (atorvastatin calcium) 37 43 48 51
Pravachol®
(pravastatin sodium)20 24 30 *
Zocor® (simvastatin) 28 35 39 46
•VytorinTM (ezetimibe 10 mg/simvastatin)* reduces LDL-C by 46% to 59%2*
•Data derived from the prescribing information for Vytorin
Combination Therapies for Hypertriglyceridemia
Fibrates & statin therapy
Niacin & statin therapy
Prescription omega-3 fatty acids & statin
Combination Therapy:Adding Fibrate to a Statin
Better TG and HDL-C
non-HDL-C
PROS
May myositis/ myopathy risk
cost and complexity
LDL particle size
Potential for other drug interactions
CONS apo B
VLDL
Grundy SM. Am J Cardiol. 2005;95:462-468.
Jones PH. Am J Cardiol. 2005;95:120-122.
Number of Reports of Rhabdomyolysis for Fibrate/Statin Therapies (1998 to 2002)
MedicationNo. Cases Reported*
No. Prescriptions Dispensed†
No. Cases reported
per Million Prescriptions
FenofibrateWith cerivastatinWith other statinsFenofibrate total
142
16
100,0003,419,0003,519,000
1400.584.5
GemfibrozilWith cerivastatinWith other statinsGemfibrozil total
53357
590
116,0006,641,0006,757,000
46008.6
87
15xincrease
Jones PH, Davidson MH. Am J Cardiol. 2005;95:120-122.
* Food and Drug Administration’s Adverse Event Reporting System (January1, 1998 to March 31, 2002).† Calculated from data from the National Prescription Audit Plus Report, IMS Health (January 1, 1998 to March
31, 2002), and a Verispan, LLC Concomitancy Report (January 1, 1998 to March 31, 2002).
JNC 7 Goal Blood Pressures
Most patients <140/90 mm Hg
Patients with diabetes or chronic kidney disease <130/80 mm Hg Based mostly on observational data,
not prospective clinical trialsPatients with metabolic syndrome No specific recommendation
Chobanian AV et al. JNC 7: Complete Report. Available at: http://hyper.ahajournals.org/cgi/content/full/42/6/1206.
JNC 7 - Features and Key Message
Most patients require 2 or more drugs to reach BP goal
If BP is > 20/10 mmHg above goal
initiate therapy with 2 agents either as fixed-dose combination or separately
Chobanian AV, et al. JAMA 2003;289:2560Chobanian AV, et al. JAMA 2003;289:2560--7272
LIFESTYLE MODIFICATIONS
Not at Goal BP (<140/90 mm Hg or <130/80 mm Hg for patients with diabetes or chronic kidney disease)
Without Compelling Indications With Compelling Indications
Stage 1 HypertensionThiazide-type diuretics for
most; may consider ACEI, ARB, BB, CCB,
or combination.
Stage 2 Hypertension 2-drug combinations for
most (usually thiazide-type diuretics and ACEI,
or ARB, or BB, or CCB).
Drug(s) for Compelling Indications
Other antihypertensive drugs (diuretic, ACEI, ARB,
BB, CCB) as needed.
If not at goal BP, optimize dosages or add additional drugs until goal BP is achieved. Consider consultation with hypertension specialist.
INITIAL DRUG CHOICES
JNC 7: Algorithm for Hypertension
Chobanian AV et al. JNC 7: Complete Report.Available at: http://hyper.ahajournals.org/cgi/content/full/42/6/1206.
Controlling Insulin Resistance in Metabolic Syndrome
80% of subjects with metabolic syndrome are nondiabeticDiabetes mellitus prevention can significantly limit cardiovascular risk complications in these patientsLifestyle interventions, including weight loss and physical activity, can significantly reduce the risk of type 2 diabetes mellitus in those with either impaired fasting glucose or impaired glucose toleranceStrategies to prevent type 2 diabetes mellitus and reduce the CHD risk might focus on insulin-sensitizing rather than insulin-secretion interventions
The Framingham score may underestimate risk in women, especially those with the metabolic syndrome The risk for CHD and diabetes may be very different in a patient with the metabolic syndrome Avoidance of diabetes is a strong motivator for patients
to lose weightPatients with metabolic syndrome but without diabetes or CVD, and ≥2 major CV risk-factors need to be treated to goal LDL-C: <100 mg/dL, non–HDL-C: <130 mg/dL, apo B:
<90 mg/dL5%–10% weight-loss can greatly improve lipid profile, BP and markedly reduce the risk of diabetes in a patient with IFGStatin treatment in women > 60 yr with hs-CRP > 2 mg/L can significantly reduce CVD risk
Take Home Messages
Take Home MessagesMetabolic Syndrome (MetSyn) represents a constellation of clinical findings associated with increased risk for diabetes and CHD
Increasing obesity, physical inactivity and insulin resistance are associated with increased triglycerides
Patients with MetSyn often have normal LDL-C values but elevated levels of apoB containing lipoproteins
Mixed dyslipidemia (low HDL-C, high TG and increased numbers of small LDL-P) is common in the metabolic syndrome and diabetes
Understanding the pathophysiology of MetSyn helps us to identify treatment targets for the prevention of CVD
We have our work cut out for usMany to work with who need our care
and expertise ARE YOU UP & READY TO MEET THE CHALLENGE ?
References
American Journal of Epidemiology 2000; 152(10): 897-907Sakkinen PA, Wahl P, Cushman M, et al
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-2497
Ford ES. Atherosclerosis 2004;173:309-314
Inflammation in Atherothrombosis: How to Use High-Sensitivity C-Reactive Protein (hsCRP) in Clinical Paul M. Ridker, MD,
MPH.Am Heart Hosp J (2004) 2;4 Suppl 1:4-9
Malik S et al. Diabetes Care. 2005;28:690-693
Meigs JB, et al. JAMA. 2000;283:221–228
2010 Heart and Stroke Statistical Update. American Heart Association
Wilson PWF, et al. Arch Intern Med. 1999;159:1104–1109