Feb 24, 2016
METABOLIC SYNDROME
SynonymsInsulin resistance syndrome(Metabolic) Syndrome XDysmetabolic syndromeMultiple metabolic syndrome
Metabolic Syndrome
46-year-old man (for new job) denies:
any complaints recent history of illness or injury except: "few aches&epigastric pain on and
off." PMH:
Negative last P/E: 10 years ago for a job-related
injury to his kneeD.HX:
negative
Case presentation:
F/H:mother and brother having heart disease, hypertension, and
obesity.Social /H:
High-fat, high-cholesterol dietModerate tobacco use
P/E: moderately obese(central), white man V/S :
Temp: 37.1°C HR:88 beats /minute RR:16 breaths /minute Average BP :144/90 mm Hg in both arms Wt: 107.7 kg Ht: 173 cm BMI: 36 kg/m2.
cont..
W/C: 112 cmThe rest of P/E: unremarkable
Diagnostic Assessment Results: ECG:NLFasting lipid profile:
Total C = 282 mg/dLLDL-C = 152 mg/dLHDL-C = 36 mg/dLTG= 248 mg/dL
FBS: 116 mg/dLCBC:NLU/A:NL
Cont...
Metabolic syndrome combination of medical disorders , increase
the risk of developing CVD & diabetes.
Prevalence: one in five people(U.S) increases with age
History:19501970
PATHOGENESIS:
InsulinResistance
HypertensionType 2 Diabetes
DisorderedFibrinolysis
ComplexDyslipidemia
TG, LDLHDL
EndothelialDysfunction
SystemicInflammation
Athero-sclerosis
VisceralObesity
CausesAcquired causes
Overweight and obesityPhysical inactivityHigh carbohydrate diets (>60% of energy
intake) Endocrine disorders such as:polycystic
ovarian syndromeAging
Genetic causes
Metabolic Syndrome
Defining Level Risk Factor
>102 cm (>40 in)
>88 cm (>35 in)
Abdominal obesity†
MenWomen
150 mg/dL or on Rx TGTG
<40 mg/dL<50 mg/dL or Rx ↓ HDL
HDL-C Men
Women
130/85 mm Hg or on Rx Blood pressure
100 mg/dL or on Rx Fasting glucose
*Dx: 3 of these R.F †Abd.obes: more highly correlated with metabolic risk factors than BMI. ‡Some men develop metabolic risk factors when circumference is only marginally increased.
Overweight and obesity
Sedentary lifestyle
Aging
Diabetes mellitus
Coronary heart disease
Lipodystrophy
Risk factors continues
Prolonged stree
BS Insulin resistance osteoporosis
HPA-axial dys
Cortisol secretion
Risk factors cont...
Lifestyle risk factors:
Abdominal obesity
Physical inactivity
Atherogenic diet
Year 1: reduce body weight 7-10 percent Continue weight loss to goal BMI <25 kg/m2
At least 30 min ( preferably ≥60 min) continuous exercise 5X/wk, preferably daily
Reduced intake saturate fat, trans fat, chol
Metabolic risk factor:Dyslipidemia
Elevated BP
Elevated glucose
Prothrombotic state
High risk: <100 mg/dL optional <70 mg/dL Moderate risk: <130 mg/dL Lower risk: <160 mg/dL
Reduce to at least <140/90 (<130/80 if DM)
For IFG, weight reduction &exercise For type 2 DM, target A1C <7%
Low dose aspirin for high risk patients
THERAPEUTIC GOALS FOR MANAGE OF METABOLIC SYN...
Diabetes mellitus
Overview of Diabetes in the United States
Now,145000pts are affected,estimated to be 400000,in 2030
more than 1.5 million: DM in Iran the prevalence of DM in Yazd: 7.3%
Overall, 20% of the Iranian aged 30yr/old& over at risk of DM
Prevalence of `DM in 30 yr old & over in various locations of IRAN
Diabetes mellitusDiabetes mellitus, which is characterized by high concentrations of blood glucose resulting from defects in insulin secretion and/or insulin action
type 2 diabetesmost common : 90% to 95%
type 1 diabetes:5% to 10%.
Other forms( 1% to 2% ):specific genetic syndromes surgeryDrugsMalnutritioninfections
ethnic groups Latin Americans African Americans
strong F.HX
PCOS, or GDM
IGT,IFG:(25-40% in5later)
dyslipidemia
Hypertension
central obesity
Who are at risk?Diabetes mellitus…
Prevalence of R.F for DM2 in Iran
Dx & Classification of D.MDiagnosis Glucose test Diagnostic level Comments
Diabetes Random>200mg/dL Plus classic symptoms*
Diabetes Fasting>126mg/dL
8-hour fast; need confirmation
Diabetes B.S (75g)>200mg/dL at 2h Need confirmation
Diabetes HbA1c≥6.5% New
Prediabetes IFG Fasting100-126mg/dL Decreased insulin secretion
Prediabetes IGT B.S (75g)140-199mg/dL at 2h� Increased insulin resistance
Prediabetes HbA1c5.7-6.4%� New
IN pts with DM:
CVD:primary cause of death(55%)
IHD:40% of death
Risk of mortality 2-4 times higher than others
CVD &DM:
With Type 2 Diabetes With or Without Previous MI
Degree of glycemic control:
Preprandial 70-130� mg/dL; <110 ideallyPostprandial (1 to 2h) <180 minimal; <140 ideally•HbA1c <7% minimally; 6% or less if possible in selected patients early in disease course
•
• Management of CV risk factors:BP<130/80LDL <100mg/dL; optional <70mg/dL Non-HDL <130mg/dL; optional <100mg/dLHDL >40mg/dL (men); >50mg/dL (women)Triglycerides <150mg/dL
Treatment goals:D.M…
• Non-pharmacologic therapy
•Diet
•Exercise
•Intensive lifestyle modification
• Medical therapy
Treatment continue..
Intervention advantages disadvantages dose
500mg TIDMAX:850mg TID
Broad benefits
Weight neutral
Insufficient for most at first
GI side effects, contraindicated with CRD
Step 1:
Lifestyle :Wt loss& inc. Act
metformin
2.5-10mg Bid-Qid(tab5mg)2.5-10mgBid-Qid(tab5mg)
No dose limit rapideffec,improve lipid profile
Rapidly effective
1-4inj.dailymonitore Bs
Wtgain,hypoglycemia (especially withglibenclamid
Step 2 :Insulin
Sulfonylurea Glibenclamide
glipizide
Improved lipid profile
Weight loss
Edema, HF, wt gain, bone fx, expensive
2 inj daily, GI side effects, long-term safety not docum..
Step3:less validatedTZDs
GLP-1 agonist
intervention frequency noteHx&P/E:
Blood pressure Every visit Goal <130/80Dilated eye examination
Annually onset of DM2& 3 - 5 yr after onset of DM1,retinopathy,Exam more than annually
Foot examination Annually Every visit if PVDxor neuropathy
Laboratory studies :Fasting lipid profile Annually every 2 years if profile is
low riskHbA1C Every 3 to 6 months Goal <7%
Microalbuminuria Annually 3 to 5 yrs after onset of DM1, Pr exc and serum Cr, should monitore if persistent alburea
Serum creatinine Initially, as indicatedVaccinations :
Pneumococcus One time Pts > 65 need a second dose if received ≥5 years previously
Influenza Annually
ABDOMINAL OBESITY
CLASSIFICATION
TERM BMI kg/m2
Obesity class
WC & risk of dx Men ≤102 cm >102
cmWomen ≤88 cm >88 cm
Underweight <18.5 - - -
normal 18.5-24.9 - - -
overweight 25-29.9 - Increased High
obesity 30-34.9 I High Very high
35-39.9 II Very high
Extreme obesity >40 III Extremely high
Etiologic classification of obesityIatrogenic causes
Drugs cause weight gain Hypothalamic surgery
Dietary obesity Infant feeding practices Frequency of eating High fat diets Overeating
Neuroendocrine obesities Seasonal affective disorder Cushing's syndrome Polycystic ovary syndrome Hypogonadis&def of G.H
Genetic (dysmorphic) obesities X-linked traits Chromosomal abnormalities
Elevated Cholesterol, Triglycerides…
Major modifiable R.F for CHD
Dyslipidemia
Screening/Detection:
Complete lipoprotein profile : Fasting total chol, LDL, HDL, TG
Secondary option: Non-fasting total cholesterol and HDL If TC 200 mg/dL or HDL <40 mg/dL:
Proceed to lipoprotein profile
New Features of ATP III (continued)
STEP1: determine
LDL Cholesterol (mg/dL)<100 Optimal
100–129 Near optimal/above optimal
130–159 Borderline high
160–189 High
190 Very high
NCEP/ ATP III Lipid Classification
Total Cholesterol (mg/dL):<200 Desirable
200–239 Borderline high
240 High
HDL –c (mg/dL):<40 low
>60 High
ATP III Lipid Classification (continued)
step1
Step 2: CHD equivalents risk factors:(10-year risk for hard CHD >20%)
Diabetes
Framingham projections of 10-year CHD risk(age,HTN,T-chol&HDL)
metabolic syndrome
Symptomatic carotid artery dx
Peripheral artery dx
Abdominal aortic aneurysm
New Features of ATP III
Cigarette smoking
HTN : BP 140/90 mmHg or on Rx
Low HDL chol (<40 mg/dL)
F.H of premature CHD: CHD in male first degree relative <55 years CHD in female first degree relative <65 years
Age: (men 45 years; women 55 years)
Step 3 :Major CHD factors other than LDL
† HDL cholesterol 60 mg/dL counts as a “negative” risk factor; its presence removes one risk factor from the total count.
New Features of ATP III (continued)
Risk Category LDL-C Goal LDL-C Level for Initiate TLC
LDL-C Level for Drug Therapy
CHD or CHD risk equivalents (10-year risk >20%)
<100 mg/dL ≥100 mg/dL ≥130 mg/dL (100-129 mg/dL, drug optional
2+ (10-year risk ≤20%)
<130 mg/dL ≥130 mg/dL ≥160mg/dl
0 OR +1(<10%)
<160 mg/dL ≥160 mg/dL ≥190 mg/dL (160-189 �mg/dL, drug optional)
Step 4 : initiate therapeutic lifestyle change(TLC)& drug Tx
Treatment:
Therapeutic Lifestyle Changes (TLC)
Drug therapies
New Features of ATP III (continued)
TLC Diet
Reduced intake:Saturated fats <7% of total caloriesDietary cholesterol <200 mg / day
LDL-lowering therapeutic: Plant sterols (2 g /day)Viscous (soluble) fiber (10–25 g / day)
Weight reduction
Increased physical activity
Lifestyle …
Limit intake of food rich in cholesterol and saturated fats
Treatment: DIET
fish more than meat or poultryLimit intake of egg yolks to 3-4 times a week more of dried beans, peas and legumesmore cereals and grains
Treatment: DIET
30-60 min of aerobic exercise 3-4 times a week
Increase physical activity at home and at work
Treatment: EXERCISE
• Reinforce saturated
• Increase fiber intake
• Refere
• Tx MetabolicSyndrome
• Intensify wt &ph.act
• refere
6 wks 6 wks 4-6 mo
•
saturated fat &chol
moderate ph.act• refere
Visit I
Lifestyle
Visit 2
LDL response?
not: Treatment
Visit 3LDL response? not :add drug Tx
Therapeutic Lifestyle Changes (TLC):
MonitorTLC
Visit N
Drug class Dosing Major side effects Statins (HMG CoA ):
AtorvastatinLovastatinSimvastatin
LDL 18–55%
10-80 mgd/(tab10-20-40-80)20-80mg/d(tab 20mg)5-80 mg/d(tab 10-20mg)
Headachenausea; sleep disturb; elevate LFT Myositis rhabdomyolysis
Fibric acid
Gemfibrosilclofibrate
TG 20–50%
600 mg BID(cap300) 1000mg BID
May raise LDL-C (with high TG)
Potentiates warfarin action
Nicotinic acid
Raise HDL 15–35%
(Tab 100-500mg)
After 6 weeks: Check: lipids, glu , LFT, uric acid.
Bile acid
cholestyramine
Reduce LDL-C 15–30%
4-24 g/d(powder)
May increase TG
Ezetimibe 10 mg/dayNeomycin 1 g BID(tab500mg) Ototoxic, nephrotoxic
Probucol 500 mg BID Loose stools; QT prolong; edema.
For patients with TG 200 mg/dL
LDL cholesterol: primary target
Non-HDL cholesterol: secondary
New Features of ATP III (continued)
Non HDL-C = total cholesterol – HDL cholesterol
Drug Therapy in Primary Prevention
LDL response?Not: intensify therapy
LDL response? intensify drug therapy or refer to a lipid specialist
Monitor response & adherence to therapy
statin
bile acid
nicotinic acid
• higher dose of statin
or
• add a bileacid or
• nicotinic acid
6 wks 6 wks Q 4-6 moInitiate:
HYPERTENSION
Types:
Primary/ Essential Hypertension no medications/ Lifestyle Modification
Secondary Hypertension(with medications)a. Kidney Diseaseb. Thyroid Diseasec. Adrenal Disease
Office or White Coat Hypertension - may affect as 50% of hypertensive patients.
HYPERTENSION:
Risk factors:Controllable
Obesity
Eating too much salt
Alcohol
Lack of exercise
Stress
Uncontrollable
Race
Heredity
Age
Signs and Symptoms:Headache
Neck Pains
Blurring of Vision
Dizziness/ Sweating
Palpitation
Chest pain
Difficulty of Breathing
HYPERTENSION…
Usually asymptomatic
Not refer to being tense, nervous or hyperactive
only way to detect is to checked it
A single high BP no maen for HTN But
it is a sign to watch carefully
HYPERTENSION…
Diagnostic Work-Up:
CBC
U/A
CXR
Lipid Profile
Other Blood Chemistry (SGPT/SGOT/BUN/Cr/Uric Acid)
ECG
2D- Echo
Hypertension…
Management of HTN by BP ClassificationInitial Drug Therapy
BP Classification Lifestyle Without Indication With Indication
Normal<120/80 mmHg
Encouraged
Pre- Hypertension120-139/80-89 mmHg
Yes No drug indicated Drug(s) for indications
Stage I Hypertension140-159/90-99 mmHg
Yes Thiazide ACE-I, ARB, BB, CCB, or combination
Drug(s) for indications
Stage 2 Hypertension> 160/100mmHg
Yes 2- drug usually :thiazide-type diuretic & Ace-I, ARB, BB, or CCB)
Drug(s) for indications
Modification Recommendation Ave SBP Reduc.Range
Weight Reduction BMI= 18.5-24.9 5-20 mmHg/10 kg
Eating plan fruits, vegetables, low fat dairy 8-14 mm Hg
Dietary sodium reduction Reduce dietary sodium intake to (2.4 g Na or 6 g NaCl)
2-8 mm Hg
Aerobic physical activity Regular aerobic physical activity (eg: brisk walking) atleast 30
minutes/day
4-9 mm Hg
Moderation of alcohol consumption
Men: limit to ≤ 2 drinks/d* Women : Limit to ≤ 1 drink per /d
2-4 mm Hg
*1 drink = 15 mL ethanol
Lifestyle Modification Recommendations
: بزنید �چرت خواهید می ساعت یک
: بروید نیک پیک به بخو�اهید روز یک
: بروید تعطیالت به بخواهید هفته یک
: کنید ازدواج بخواهید ماه !!یک
: ببرید �ارث به �ثروت بخواهید سال یک
خواهید عمریک می :
داشته دوست را میدهید انجام که کاری بگیرید یادباشید
برای خوشبختیاگر را :
A leading cause of SICKNESS and DEATH
Coronary Heart Disease
- also known as Ischemic Heart Disease, Myocardial Infarction
- Blockage of blood flow due to focal narrowing of coronary arteries as a result of Atheromatous plaqu.
- Injury to the heart muscle- caused by a loss of blood supply- resulting to “heart attack”
CORONARY ARTERY DISEASE
Non-modifiable
SEX
AGE
• FAMILY HISTORY
DIABETES
SMOKING
OBESITY
DYSLIPIDEMIA
• HYPERTENSION
Risk factors:modifiable
Diagnosis:
1) Hx&P/E (Typical signs and symptoms)2) 3) Lab: CBC, Electrolytes, BT, PTT,PT
4) Cardiac Enzymes: CPK-MB, Troponin
5) ECG
6) CXR (PA & lateral)
7) Nuclear Scan
8) 2-D Echo/3 D-Echo with Doppler
9) Coronary Catheterization/Angiogram
Coronary Heart Disease
Need for Hospitalization1) 02 administration2) Need for Surgical Procedures
Percutaneous Transluminal Coronary Angioplasty (PTCA)
Coronary Artery Bypass Graft (CABG)1 vessel, 2 vessels, 3 vessels
Cardiac Rehabilitation Medications Lifestyle changes Emotional issues
TREATMENT
:Social /H:High-fat, high-cholesterol diet
Moderate tobacco use P/E: BP :144/90
Wt: 107.7 kgBMI: 36 kg/m2.
W/C: 112 cm(centrally)Diagnostic Assessment Results:
Total C = 282 mg/dLLDL-C = 152 mg/dLHDL-C = 36 mg/dLTG= 248 mg/dL
FBS: 116 mg/dL
SUMMARY...
F.H:mother and brother having heart disease,HTN, and obesity
.
Follow-up :
Due to his age and F.hx& examination( include obesity, stage I hypertension, and metabolic syndrome.)
SHOULD consider DM2 and atherosclerotic CVD
the primary purpose is to establish treatment goals for associated risk factors such as:
HTN,HLP&hyperinsulinemia all of which result in increased CVA&CVD and
mortality
Case present...
Teaching Plan:
A F/U visit for TLC:
Weight reductioneating plan, including fruits, vegetables, low-fat dairy,
whole grains, fish, and nuts; and minimal amounts of fats, red meat, sweets...
Reduction in dietary sodium intake
Increased physical activity
Stop smoking
Case presentation:
Pharmacologic Considerations:
low-dose ACE I: to control HTN stageI
atorvastatin (Lipitor): to reduce his LDL-C & TG levels
Fibrates : effective in lowering TG
(Combination therapy with a fibrate and a statin useful for patients with atherogenic lipid profiles)
Metformin(optional)
Case present...
ده قرار �ارامش و صلح برای ای ...مراوسیله : بکارم عشق بذر است تنفر جا هر بگذار
ببخشایم هست ازردگی جا هر , امید هست یاس جا هر ایمان هست شک جا هر
کنم نثار شادی غم جای و روشنائی است تاریکی جا هرکنم دردی هم همدردی طلب از �بیش ده توفیقم الهی
کنم درک را دیگران بفهمند مرا انکه از پیشستانیم می که است کردن عطا در زیرا
شویم می بخشیده که است بخشیدن در وع ... بیم یا می ابدی حیات که است مردن در و
:خدایا
Thanks for your attention