CARDIO-METABOLIC DISEASE Najeeb A Jaha,MD Interventional and Preventive Cardiologist
SBCC
CASE STUDY • • • • • • • • • • • •
50 Year old Saudi male patient. No DM, No Known risk Factors except obesity. C/O: A typical pricking chest pain. O/E: HR 78 BPM regular and normal volume pulse. Bp 145/90 , RR 12/min. Height 170 cm , weight 90 Kg Waist Circumference 103 cm FBS 6.6 RF Normal LFT Normal Lipid profile: T.C 200mg/dl LDL 135 mg/dl TG 200mg/dl HDL 37mg/dl EKG and Echocardiography is normal.
• What type of disease entity this patient have: a) b) c) d)
Simple obesity. Metabolic syndrome based on Asian definition. Simple obesity with border line hypertension. Metabolic syndrome based on European definition. e) Stable angina with borderline hypertension.
• What is the risk of CVD in this patient: a) The same as in general population. b) 5 time his calculated risk by Framingham with 10 time increased risk of having DM. c) He will have only increased risk of CVD and risk of having DM by 5%. d) He will have double or 3 fold risk of mortality from CVD and 5% risk of having DM in addition to other risk for having other disease. e) 50% increase risk of stroke.
• How would you treat this patient: a) Low salt diet, start statin only. b) Calcium channel blocker ( Amlor) , and statin. c) Give combination therapy of statin and fenofibrate. d) Strict life style modification with exercise , weight reduction , and diet modification. e) Life style with niacin therapy.
Estimate of 10-Year Risk for Men Age
-9
35-39
-4
40-44
0
45-49
3
50-54
6
60-64 65-69 70-74 75-79
point
>/= 60
-1
50-59
0
40-49
1
<40
2
Point
20-34
55-59
HDL (mg/dl)
8 10 11 12 13
Age
age
20-39
40-49
50-59
60-69
70-79
Non smoker
0
0
0
0
0
smoker
8
5
3
1
1
20-39
40-49
50-59
60-69
70-79
<160
0
0
0
0
0
160-199
4
3
2
1
0
200-239
7
5
3
1
0
240-279
9
6
4
2
1
â&#x2030;Ľ 280
11
8
5
3
Total cholesterol
Estimate of 10-Year Risk for Men
Point Total
10 year risk
<0
<1
0
1
1
1
2
1
3
1
4
1
5
2
6
2
7
3
8
4
Systolic BP (mmHg)
untreated
treated
<120
0
0
120-129
0
1
130-139
1
2
140-159
1
2
9
5
≥ 160
2
3
10
6
11
8
12
10
13
12
14
16
15
20
16
25
≥ 17
≥ 17
PREVALENCE OF METABOLIC SYNDROME
Viswanathan Mohan and Mohan Deepa, (2006) The prevalence rates were 25.8% in India, 13% in China, 30% in Iran, 28% in Korea,, 22% in Hong Kong, 18.5% in Vietnam, 17% in Oman and 15.2 % in Taiwan. Rajeev Gupta et al., (2004) studied 1800 Indians. MetS was present in 31.6% subjects; prevalence was 22.9% in men and 39.9% in women. Ford Earl S. et al., (2002) studied the prevalence rates among American adults and found that the prevalence of MetS was 23.7% . Thus they concluded that 47 million adults in the United States had metabolic
.
syndrome
PREVALENCE IN SAUDI ARABIA â&#x20AC;˘ Overall prevalence rate of metabolic syndrome as defined by the Adult Treatment Panel (ATP) III in 2001was 39.3%.
American Heart Association (AHA) and National Heart, Lung and Blood Institute (NHLBI), 2005 ANY 3 OF 5 CONSTITUTE DIAGNOSIS OF METABOLIC SYNDROME
Elevated Waist Circumference (cutoff for European Population) 94cm (37 inches) in Men 80 cm (31 inches) in Women Elevated Triglycerides 150 mg/dL(1.7 mmol/L) Or On drug treatment for elevated TG Reduced HDL-C <40 mg/dL in men /<50 mg/dL in women Or On drug treatment for reduced HDL-C Elevated Blood Pressure 130 mm Hg systolic blood pressure Or 85 mm Hg diastolic blood pressure Or On antihypertensive drug treatment Elevated Fasting Glucose 100mg/dl( 5.6 mmol/l)Or On drug treatment for elevated glucose
Cardiovascular Mortality Associated With Metabolic Syndrome
Incidence of CV Mortality
14 MS, 12
12 10 8 6 4
No MS, 2.2
2 0 No MS
MS
MS and outcome
Causes 2-3 fold increase in cardiovascular risk of mortality. Considered as a risk factor for CHD and precursor of Diabetes mellitus (up to 5% fold increase in risk). Even with 2 to 3 components- increased mortality from CVD and CHD. Risk of stroke increases 3 fold. Reduced cardio respiratory fitness. Associated with: Essential hypertension, Polycystic ovarian syndrome, Nonalcoholic fatty liver disease Gallstone disease, Cancer (i.e., breast cancer), Sleep apnea
FIRST LINE THERAPY……LIFESTYLE MODIFICATION WEIGHT REDUCTION DIETERY MODIFICATIONS PHYSICAL ACTIVITY
WEIGHT REDUCTION :
Reduce calorie intake and Exercise Reduction in 1 kg of body weight causes 2-5% reduction in visceral fat. Realistic Goal………. 7-10% reduction of body weight in 6-12 months.
EXRCISE PRESCRIPTION For Health Benefit/CVD
For Weight Loss/MS/DM
Most days
Most, preferably all
Moderate
Moderate
30 minutes or more
60 minutes of MORE
aerobic activity +resistence
Aerobic Activity+resistence
Heart Rate Method •
Keep exercise at a heart rate just below the level associated with ischemic changes on the stress test – For example if you start to see ST depression at 120bpm in stage 2 of Bruce, then your target exercise heart rate should be less than 120bpm (some say 10% below ischemic threshold).
If there are no ischemic ECG changes, then a heart rate range of about 5080% of heart rate reserve is a good start: For example: •
– – – – – – –
Resting heart rate 60bpm Max exercise heart rate if 160bpm Heart rate reserve (HRR) is (150-60) = 100bpm 50% of HRR = 50bpm 80% of HHR = 80bpm Add back in the resting rate (60) So exercise target heart rate is 110-140bpm
Perceived exertion method (RPE) • •
Use the Borg 10 or 20 point scale Rating of percieved exertion of 35 (ten point scale) is appropriate • Do not exercise at intensities above which ischemic symptoms occur • An RPE of 3-5 correlates with enough breath to carry on conversation, but not enough breath to sing continuously.
Rating of Perceived Exertion Scale (10 point scale) 0 Nothing at all 0.5 Very, very weak 1 Very weak 2 Weak 3 Moderate 4 Somewhat strong 5 Strong 6 7 Very strong 8 9 10 Very, very strong
THANKS