Source: Grundy SM, Cleeman JI, Daniels SR, et al. Diagnosis and management of the metabolic syndrome. An American Heart Association/National
Heart, Lung, and Blood Institute scientific statement. Circ 2005; 112:2735-52.
Critical to management of metabolic syndrome, or the clustering of cardiovascular risk factors in an individual, is the assessment
of lifestyle risk factors, such as abdominal obesity, physical inactivity, and atherogenic diet. The recommendations from
the American Heart Association/National Heart, Lung and Blood Institute encourage physicians to:
- urge patients to maintain or reduce current weight
- engage in a consistent exercise program, and
- reduce intake of specific fats and cholesterol.
Metabolic syndrome's clustered risk factors include dyslipidemia, high triglycerides, low HDL, high blood pressure (BP), elevated
glucose (eg, diabetes), tendency for thrombosis and a prothrombotic state, and tendency for inflammation. Currently, it is
not evident whether metabolic syndrome has one cause, and it appears that it may be caused by multiple underlying risk factors
– the most significant being obesity and insulin resistance.
"If you took the worst form of this clustering, it occurs in people with type 2 diabetes, which we know is quite common in
older people," Scott M. Grundy, MD, PhD, told GERIATRICS. Grundy is the recommendations' panel chair and lead author. "In
treating diabetes, you have to treat all risk factors, not just glucose. Many physicians may not recognize that cardiovascular
disease is the #1 killer of older patients with diabetes. To prevent development of cardiovascular disease, it's important
to concentrate on all the risk factors like BP, cholesterol, HDL, diabetes, as well as smoking cessation."
What's new
Table Criteria for clinical diagnosis of metabolic syndrome
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This latest guideline from AHA/NHLBI provides more detailed rationale of previous recommendations. "It's a consolidation of
what we knew," says Grundy, director of the center for human nutrition, University of Texas Southwestern Medical Center, Dallas.
"There have been some changes in the measurements that define metabolic syndrome (see table). This paper is somewhat of an
evolution."
The latest recommendations note that the primary goal of metabolic syndrome management is to reduce risk for clinical atherosclerotic
disease. The recommendations support management of metabolic syndrome, while tending to cardiovascular disease prevention
efforts. For reducing CVD events, first-line therapy is to limit or diminish major risk factors (high cholesterol, BP, glucose
levels) to recommended goals. Combined with that goal is the move to decrease type 2 diabetes risk in those who are not yet
presenting with clinical diabetes.
Lifestyle changes critical
The lifestyle change component of the recommendations is significant for management of long- and short-term risk of metabolic
syndrome. Grundy says that weight reduction and exercise combined can treat all risk factors at once.
Weight reduction after age 65
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"Weight reduction and exercise are extremely important parts of treatment of metabolic syndrome or type 2 diabetes. Many physicians
have the feeling that not much can be done about lifestyle, but I don't agree," he said. "Most people with metabolic syndrome
will be overweight. Many of them have high glucose levels. Lifestyle changes certainly would help them."
The central goal of the recommendations, Grundy says: prevent diabetes. "About the only way you're going to do that right
now, effectively, is through lifestyle change. These people have multiple risk factors, so you want to prevent heart disease
as well. That's true for older people as well as middle age."
Drug treatment
For those with higher 10-year risk of metabolic syndrome, consideration should be given to specific therapies for metabolic
risk factors. No specific drugs are being recommended at present for those with metabolic syndrome, except for drugs most
appropriate for specific abnormal risk factors.
Take Home Points
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The recommendations support drug treatment based on the risk factors a patient has. "If you already have diabetes, most people
might be on a cholesterol-lowering drug," Grundy says. "Their LDL should be less than 100. The goals for treatment that involve
drugs are pretty well outlined in the guidelines for blood pressure, cholesterol, diabetes."
"Whether there are specific drugs that are better for people with metabolic syndrome is controversial," Grundy adds. "Most
people feel that getting to the goals of treatment takes priority over how you get there. There may be some drugs that are
not quite as good as others, like ACE inhibitors for blood pressure; or ARBs may be better than diuretics and beta blockers.
However, beta blockers and diuretics are less expensive and their effects are not all that bad. So that's a little controversial
— which one you'd use."
Aspirin is yet another significant consideration because of its effectiveness in heart attack prevention. "That's a physician-recommendation
— whether a patient is a candidate for aspirin. But people with metabolic syndrome should be considered for aspirin treatment,
particularly if they are older, but it will have to depend on whether there are contraindications," he noted.
Management challenges
How well are physicians managing metabolic syndrome? While Grundy said they are doing an adequate service, "they could do
better yet."
For example, he said, when people have high glucose, that tends to get most of the attention and there is undertreatment of
cholesterol and blood pressure. "This is an area where we need to encourage physicians to go after all the risk factors, which may ultimately reduce stroke and heart attack. There's a big payoff."
"Once patients develop diabetes, it's not easy to treat...in fact, it's difficult to treat. We need new approaches to controlling
blood sugar. We need to pay more attention," he said.
He encourages patients to be actively involved in their management of metabolic syndrome and diabetes. He advises patients
to monitor blood sugar and blood pressure at home. He recommends that patients use home blood pressure cuffs to take BP every
day and write it down to make sure it's well controlled—don't just wait until the next visit to the doctor.
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