metabolic syndrome, diabetes, and cardiovascular disease: implications for preventive cardiology
DESCRIPTION
Metabolic Syndrome, Diabetes, and Cardiovascular Disease: Implications for Preventive Cardiology. Nathan D. Wong, PhD, FACC, FAHA Professor and Director Heart Disease Prevention Program Division of Cardiology University of California, Irvine. Overview of Diabetes in the United States. - PowerPoint PPT PresentationTRANSCRIPT
Metabolic Syndrome, Diabetes, and Cardiovascular Disease: Implications
for Preventive Cardiology
Nathan D. Wong, PhD, FACC, FAHA
Professor and Director
Heart Disease Prevention Program
Division of Cardiology
University of California, Irvine
Overview of Diabetes in the United States
Diabetes Prevalence, 1990-1998
Age-adjusted prevalence of physician-diagnosed diabetes in Adults age 18 and older by race/ethnicity and sex (NHANES: 1999-2004). Source: NCHS and NHLBI. NH – non-Hispanic.
Risk of Cardiovascular Events in Diabetics Framingham Study
Age-adjusted
Biennial Rate Age-adjusted
Per 1000 Risk Ratio
Cardiovascular Event Men Women Men Women
Coronary Disease 39 21 1.5** 2.2***
Stroke 15 6 2.9*** 2.6***
Peripheral Artery Dis. 18 18 3.4*** 6.4***
Cardiac Failure 23 21 4.4*** 7.8***
All CVD Events 76 65 2.2*** 3.7***
Subjects 35-64 36-year Follow-up **P<.001,***P<.0001
_________________________________________________________________
_________________________________________________________________
Insulin Resistance
Natural History of Type 2 Diabetes
Development of Type 2 Diabetes
Hyperglycemia in Type 2 Diabetes Results From Three
Major Metabolic Defects
Relationship Between Obesity and
Insulin Resistance and Dyslipidemia
Insulin Resistance: Associated Conditions
New Cases of ESRD in the United States
New Cases of ESRD in the United States
by Cause and Ethnicity, 1998
Microalbuminuria
Cardiovascular Disease and Diabetes
Probability of Death From CHD in Patients With Type 2 Diabetes With
or Without Previous MI
Framingham Heart Study 30-Year Follow-Up:CVD Events in Patients With Diabetes (Ages 35-64)
109
20
11
9 63819
3*
30
0
2
4
6
8
10
Age-adjusted annual rate/1,000
Men Women
Total CVD
CHD Cardiac failure
Intermittent claudication
Stroke
Riskratio
P<0.001 for all values except *P<0.05.
Wilson PWF, Kannel WB. In: Hyperglycemia, Diabetes and Vascular Disease. Ruderman N et al, eds. Oxford; 1992.
Presentation• Name: WJC • Age: 54 years old • Professional: former chief executive • Personal: wife lives principally in
Washington, DC; he has a personal cook in his suburban NY home
• Lifestyle: – Occasional use of cigars– has had a long-term weight problem– likes to play golf
Presentation (cont’d)
• Examination:– Height: 6 ft 2 in– Weight: 220 lb (BMI 28 kg/m2)– Waist circumference: 41 in– BP: 150/88 mm Hg– P: 64 bpm – RR: 12 breaths/min
• Cardiopulmonary exam: normal
Presentation (cont’d)
• Medications: – sildenafil 50 mg prn– amlodipine 5 mg/d
• Laboratory results: – TC: 220 mg/dL– HDL-C: 36 mg/dL– LDL-C: 140 mg/dL– TG: 220 mg/dL– FBS: 120 mg/dL
The Metabolic Syndrome
InsulinResistance
Hypertension
Type 2 Diabetes
DisorderedFibrinolysis
ComplexDyslipidemia
TG, LDL
HDL
EndothelialDysfunction
SystemicInflammation
Athero-sclerosis
VisceralObesity
Adapted from the ADA. Diabetes Care. 1998;21:310-314;Pradhan AD et al. JAMA. 2001;286:327-334.
Revised ATP III Metabolic Syndrome Oct 2005
*Diagnosis is established when 3 of these risk factors are present.†Abdominal obesity is more highly correlated with metabolic risk factors than is BMI. ‡Some men develop metabolic risk factors when circumference is only marginally increased.
<40 mg/dL<50 mg/dL or Rx for ↓ HDL
MenWomen
>102 cm (>40 in)>88 cm (>35 in)
MenWomen
100 mg/dL or Rx for ↑ glucoseFasting glucose130/85 mm Hg or on HTN RxBlood pressure
HDL-C150 mg/dL or Rx for ↑ TGTG
Abdominal obesity† (Waist circumference‡)
Defining LevelRisk Factor
International Diabetes Federation Definition:
Abdominal obesity plus two other components: elevated BP, low HDL, elevated TG, or impaired fasting glucose
Prevalence of the Metabolic Syndrome Among US Adults NHANES 1988-1994Prevalence of the Metabolic Syndrome Among US Adults NHANES 1988-1994
Pre
vale
nc
e (
%)
P
reva
len
ce
(%
)
05
10
15
2025
3035
40
45
20-29 30-39 40-49 50-59 60-69 > 70
MenMenWomenWomen
Age (years)Age (years)Ford E et al. JAMA. 2002(287):356.Ford E et al. JAMA. 2002(287):356.
1999-2002 Prevalence by IDF vs. NCEP Definitions (Ford ES, Diabetes Care 2005; 28: 2745-9) (unadjusted, age 20+)NCEP : 33.7% in men and 35.4% in women IDF: 39.9% in men and 38.1% in women
0%
10%
20%
30%
40%
Prevalence of the NCEP Metabolic Syndrome: NHANES III by Sex and Race/Ethnicity
Pre
vale
nce
, %
MenFord ES et al. JAMA 2002;287:356-359.
Women
WhiteAfrican AmericanMexican AmericanOther
25%25%
16%16%
28%28%
21%21%23%23%
26%26%
36%36%
20%20%
Cardiovascular Disease (CVD) and Total Mortality: US Men and Women Ages 30-74
(age, gender, and risk-factor adjusted Cox regression) NHANES II Follow-Up (n=6255)(Malik and Wong, et al., Circulation 2004; 110: 1245-
1250)
0
1
2
3
4
5
6
7
Rel
ativ
e R
isk
CHD Mortality CVD Mortality Total Mortality
None
MetS
Diabetes
CVD
CVD+Diabetes
* p<.05, ** p<.01, **** p<.0001 compared to none
*
***
***
***
**
***
***
***
******
***
Metabolic Syndrome, CVD Events, and Mortality• European cohort studies (6156 men and 5356 women): Modified
WHO definition of MetS associated with all-cause mortality (RR=1.44 [1.17-1.84] in men and 1.38 [1.02-1.87] in women) and CVD mortality (RR=2.26 [1.61-3.17] in men and 2.78 [1.57-4.94 in women) (Hu et al. Arch Intern Med 2004; 164: 1066-76)
• Atherosclerosis Risk in Communities (ARIC) study (12,089 men and women): 11 year follow-up, ATP III MetS associated with 1.5-2-fold greater likelihood of developing CHD and stroke, but MetS did not improve prediction over FRS (McNeill et al. Diab Care 2005; 28: 385-90)
• Cardiovascular Health Study (CHS) (2,175 elderly subjects): ATP III definition associated with 38% increased risk (p<0.01) of coronary/cerebrovascular events (Scuteri et al., Diab Care 2005; 28: 882-7)