SHA24/044001

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