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News Author:
Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd
Complete author affiliations
and disclosures, and other CME information, are available
at the end of this activity.
Release Date: September
13, 2005; Valid for
credit through September 13, 2006
Credits Available
Physicians - up to 0.25 AMA PRA Category 1 continuing physician education
credits ;
Family Physicians - up to 0.25 AAFP Prescribed continuing
physician education credits
All other healthcare professionals
completing continuing education credit for this activity will
be issued a certificate of participation.
Participants should claim only the number of hours actually
spent in completing the educational activity.
Sept. 13, 2005 — The American
Heart Association (AHA) and the National Heart, Lung, and
Blood Institute (NHLBI) have issued guidelines for the diagnosis
and management of the metabolic syndrome. The executive summary,
a synopsis of the full scientific statement explaining the
new guidelines, is published in the Sept. 12 Rapid Access
issue of Circulation.
"The metabolic syndrome
has received increased attention in the past few years,"
write Scott M. Grundy, MD, panel chair, and colleagues from
the AHA and the NHLBI. "It consists of multiple, interrelated
risk factors of metabolic origin that appear to directly promote
the development of atherosclerotic cardiovascular disease
(ASCVD). This constellation of metabolic risk factors is strongly
associated with type 2 diabetes mellitus [DM] or the risk
for this condition."
The panel found that the
metabolic syndrome is a complex disorder, with no single factor
as the cause. However, the most important risk factors were
abdominal obesity and insulin resistance. Other metabolic
risk factors are atherogenic dyslipidemia (elevated triglyceride
levels and apolipoprotein B, small low-density lipoprotein
cholesterol [LDL-C] particles, and low high-density lipoprotein
HDL cholesterol [HDL-C] concentrations), high blood pressure
(BP), high plasma glucose levels, a prothrombotic state, and
a proinflammatory state. Other conditions that may promote
the metabolic syndrome include sedentary lifestyle, aging,
hormonal imbalance, and genetic or ethnic predisposition.
Prospective population
studies suggest that the metabolic syndrome is associated
with approximately a twofold increase in relative risk for
ASCVD, and a fivefold increase in risk for developing diabetes.
"The presence of
the syndrome is associated with increased long-term risk for
both ASCVD and type 2 diabetes mellitus, and thus requires
attention in clinical practice," the authors write. "Lifestyle
interventions deserve prime consideration for risk reduction
across a lifetime; these interventions include weight control,
increased physical activity, and a diet designed to reduce
the risk for ASCVD."
Goals for lifestyle intervention
for abdominal obesity are to reduce body weight by 7% to 10%
during the first year of treatment and continued weight loss
thereafter to achieve desirable weight (body mass index, <
25 kg/m2) and waist circumference of less than 40 in. for men and less than
35 in. for women. Recommended physical activity is of moderate
intensity for 30 to 60 minutes five to seven days a week.
Diet should reduce intakes of saturated fat (< 7% of total
calories), trans fat, cholesterol levels (< 200 mg/day),
and total fat (25% - 35% of total calories). Most dietary
fat should be unsaturated, and simple sugars should be limited.
Other overall conclusions
of the panel were that the National Cholesterol Education
Program Adult Treatment Panel III (NCEP-ATP III) criteria
for clinical diagnosis of the metabolic syndrome were robust
and clinically useful, and they recommended maintaining the
NCEP-ATP III criteria with minor modifications.
The NCEP-ATP III definition
requires defined abnormalities in any three of five clinical
measures: waist circumference, elevated triglyceride levels,
HDL-C levels, BP, and fasting glucose level. Modifications
recommended by the panel include adjustment of waist circumference
to lower thresholds when individuals or ethnic groups are
prone to insulin resistance; considering triglyceride levels,
HDL-C levels, and BP to be abnormal when drug treatment is
prescribed; clarifying that elevated BP refers to a level
exceeding the threshold for either systolic or diastolic pressure;
and lowering the threshold for elevated fasting glucose level
from 110 to 100 mg per dL.
For patients with the
metabolic syndrome who have a relatively high 10-year risk
for ASCVD, the guidelines state that drug therapy of both
major and metabolic risk factors can help lower risk. They
suggest using pharmacotherapy according to present recommendations
by the AHA, NHLBI, and American Diabetes Association (ADA)
for individual risk factors, but not specifically to reduce
risk for type 2 DM independent of treatments to prevent ASCVD.
The panel described specific
treatment of metabolic risk factors for prevention of ASCVD
or treatment of type 2 DM, including treatment of atherogenic
dyslipidemia, hypertension, elevated glucose levels, prothrombotic
state, and proinflammatory state.
"Additional research
is required both to better understand the underlying pathophysiology
of the metabolic syndrome and to identify new targets for
therapy," the panel concludes.
Members of the writing
group disclose various financial arrangements with NHLBI,
AHA, Cincinnati Children's Hospital Medical Center, Pfizer,
Astra-Zeneca, Abbott Laboratories, University of Colorado
Health Sciences, William Beaumont Hospital, Pfizer, University
of Texas, Southwestern Medical Center, GlaxoSmithKline, Merck,
KOS Department of Veterans Affairs, Reynolds, National Institutes
of Health, Sanofi, Children's Hospital Oakland Research Institute,
Bristol-Myers Squibb, University of North Carolina Medical
School, Johnson & Johnson, Medtronic, Intuitive Surgery,
Saint Luke's Hospital of Kansas City, CV Therapeutics, CV
Outcomes, Outcomes Instruments, Inc., University of Washington,
Emory University, Atlanta VA Medical Center, Kidney Foundation,
Amcyte, Diamedica, Inc., Aventis, Diamedica, Inc., Kowa Research
Institute, Mankind Corp., Novartis, Sanyko, Sanofi-Synthelabo,
Sanofi Aventis, Takeda, Hartford Hospital, Schering-Plough,
Bristol-Myers Squibb, and/or Reliant.
Circulation. Posted online
Sept. 12, 2005.
Learning Objectives
for This Educational Activity
Upon completion
of this activity, participants will be able to:
- Describe modifications to the updated NCEP-ATP III criteria
for the metabolic syndrome by the AHA and NHLBI writing
group.
- Compare the similarities and differences in diagnosis
and management of the metabolic syndrome by the International
Diabetes Federation (IDF) vs the updated NCEP-ATP III reports.
Clinical Context
The metabolic syndrome
consists of multiple, interrelated risk factors that promote
the development of ASCVD, and the constellation strongly is
associated with type 2 DM or the risk for type 2 DM, according
to the current authors. Prospective population studies show
a twofold increased risk for ASCVD events in patients with
the metabolic syndrome and a fivefold risk of developing type
2 DM with relatively high long-term risks for both conditions.
The NCEP-ATP III proposed a simple set of diagnostic criteria
based on clinical measures that have been widely used in clinical
and epidemiologic studies, according to this report. This
executive summary is a synopsis of a full scientific statement
from the AHA and the NHLBI writing group that is intended
to provide up-to-date guidance for professionals on the diagnosis
and management of the metabolic syndrome in adults.
Study Highlights
- The NCEP-ATP III criteria for the metabolic syndrome
are based on the presence of 3 or more of the following:
increased waist circumference, elevated triglyceride levels,
BP, fasting glucose level, and reduced HDL-C levels.
- Increased waist circumference is not a required criterion
for diagnosing the metabolic syndrome in the NCEP-ATP III
criteria.
- The AHA and NHLBI writing group affirms the overall utility
and validity of the NCEP-ATP III criteria and proposed that
they should continue to be used with modifications.
- The recommended modifications are (1) adjustment of waist
circumference to lower thresholds when individuals or ethnic
groups are prone to insulin resistance, (2) allowing triglyceride
and HDL-C levels and BP to be counted as abnormal when a
person is prescribed drug treatment for these conditions,
(3) clarifying that elevated BP is defined as an elevation
of either systolic or diastolic BP, and (4) reducing the
threshold for elevated glucose level from 110 mg per dL
or higher to 100 mg per dL or higher in accordance with
the ADA revised definition of impaired fasting glucose (IFG).
- The IDF has proposed clinical criteria similar to those
of the NCEP-ATP III with identical thresholds for triglyceride
and HDL-C levels, BP, and plasma glucose.
- The IDF criteria are different in that the waist circumference
thresholds are adjusted to different ethnic groups.
- The IDF criteria require that increased waist circumference
be an element of the metabolic syndrome because abdominal
obesity reflects both concepts of obesity and insulin resistance.
- In the U.S. population, updated NCEP-ATP III and IDF
criteria identify essentially the same people as having
the metabolic syndrome.
- Clinical Management of Metabolic Syndrome:
- Recommendations for management of the metabolic syndrome
are virtually identical in the updated NCEP-ATP III and
IDF reports.
- First-line recommendations for reducing ASCVD risk include
smoking cessation, reducing LDL-C levels, BP, and glucose
levels to recommended goals.
- Long-term risks are of high priority in management.
- Lifestyle interventions include weight loss in obese
subjects, increased physical activity, and dietary modification.
- Recommendations for drug therapy follow those of the
AHA, NHLBI, and ADA.
- For dyslipidemia, the 10-year risks for ASCVD are defined
by four risk categories of elevated LDL-C levels: high
risk (> 20%), moderately high risk (10% - 20% with
2 or more risk factors), moderate risk (< 10% with
2 or more risk factors), and lower risk (< 10% with
0 - 1 risk factor).
- Risk stratification is used for target LDL-C levels.
- LDL-lowering standard drugs include statins, ezetimibe,
and bile-acid sequestrants. Other drugs that promote moderate
reduction are nicotinic acid and fibrates, which are considered
to be secondary drugs.
- If the triglyceride level is higher than 500 mg per
dL, then lowering the triglyceride level to 500 mg per
dL or less takes primacy over LDL-C lowering.
- After LDL-C and non HDL-C goals are achieved, a tertiary
target is raising HDL-C level. No specific goals for raising
HDL-C levels are specified.
- BP management follows the Joint National Committee 7
guidelines. Individuals with prehypertension should use
lifestyle modification, whereas those with higher BPs
should use drug therapy. In the presence of renal disease
or type 2 DM, the goal of BP reduction should be less
than 130/80 mm Hg.
- Subjects with IFG should practice lifestyle change,
especially weight reduction and increased physical activity.
Drug therapies are not recommended.
- In patients with ASCVD in whom aspirin is contraindicated,
clopidogrel should be considered.
Pearls for
Practice
- The AHA and NHLBI recommends modifications to the NCEP-ATP
III criteria as follows: (1) adjustment of waist circumference
to lower thresholds when individuals or ethnic groups are
prone to insulin resistance, (2) allowing triglyceride and
HDL-C levels and BP to be counted as abnormal when a person
is prescribed drug treatment for these conditions, (3) clarifying
that elevated BP is defined as an elevation of either systolic
or diastolic BP, and (4) reducing the threshold for elevated
glucose level from 110 mg per dL or higher to 100 mg per
dL or higher in accordance with the ADA revised definition
of IFG.
- The NCEP-ATP III and IDF have similar management guidelines
for the metabolic syndrome but differ in that the IDF requires
increased waist circumference to be a criterion for diagnosis
and adjusts the definition of increased waist circumference
to ethnicity.
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News Author
Laurie Barclay, MD
is a freelance writer for Medscape.
Disclosure: Laurie Barclay,
MD, has disclosed no relevant financial relationships.
Clinical Reviewer
Gary Vogin, MD
Senior Medical Editor, Medscape
Disclosure: Gary Vogin,
MD, has disclosed no relevant financial relationships.
CME Author
Desiree Lie, MD, MSEd
Clinical Professor of Family Medicine; Director, Division
of Faculty Development, University of California, Irvine School
of Medicine, Irvine, California
Disclosure: Desiree Lie,
MD, MSEd, has disclosed no relevant financial relationships.
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New Guidelines for Diagnosis
and Management of Metabolic Syndrome(诊断及治疗代谢性综合征的新指南)
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