Cardiovascular and Metabolic Risk Factors: How Can We Improve Outcomes in the High-Risk Patient?

doi:10.1016/j.amjmed.2007.06.005

The American Journal of Medicine

Volume 120, Issue 9, Supplement 1, September 2007, Pages S3-S8

https://doi.org/10.1016/j.amjmed.2007.06.005 Get rights and content

Abstract

Risk assessment algorithms, such as that used in the third Adult Treatment Panel (ATP III) of the National Cholesterol Education Program (NCEP) for treating low-density lipoprotein cholesterol, can be used to classify patients’ risk for cardiovascular and metabolic problems and to determine the appropriate level of therapeutic intervention. Patients at highest risk should receive the most intensive therapy. The presence of the metabolic syndrome, a clustering of atherogenic risk factors including dyslipidemia, elevated blood pressure, elevated blood glucose, and other problems, confers additional risk for diabetes mellitus and atherosclerotic cardiovascular disease at every level of risk. Pharmacotherapy with lipid-lowering, antiplatelet, antihypertensive, or insulin-sensitizing agents to modify specific risk factors is indicated in patients at higher risk, but lifestyle change (e.g., smoking cessation, weight reduction, increased physical activity, and “heart-healthy” dietary modifications) and blood pressure control can be used across all categories of risk.

Section snippets

Global Atherosclerotic Cardiovascular Disease Risk Assessment: A Guide for Therapy

In 2001 the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) incorporated a risk assessment algorithm for ASCVD. Patients with coronary heart disease (CHD), other atherosclerotic disease, or diabetes are considered to be at high risk. For other patients, risk stratification occurs in 2 steps. First, for the purpose of cholesterol management, the clinician counts the number of major risk factors. In this case only 5 major risk factors apply: cigarette smoking,

The Metabolic Syndrome

In 2001, the ATP III introduced the metabolic syndrome as a clinically useful description of a commonly observed clustering of metabolic risk factors, including atherogenic dyslipidemia (e.g., high triglycerides and low HDL cholesterol), elevated blood pressure, elevated plasma glucose, a prothrombotic state, and a proinflammatory state.2, 5, 6 According to ATP III,¹ a diagnosis of metabolic syndrome can be made when ≥3 of 5 metabolic risk factors are present in an individual patient (Table 2).

Modifying Risk Factors

Lifestyle change is the first-line approach to the management of patients at high cardiovascular and metabolic risk. The therapeutic goal is to reduce underlying cardiovascular and metabolic risk factors such as overweight/obesity, physical inactivity, and atherogenic diet. Successful incorporation of healthy eating and fitness habits into a patient’s lifestyle can reduce every metabolic risk factor (Table 3).⁷ For patients at higher risk, specific lipid and metabolic risk factors are targets

A Risk Group–Guided Approach to Atherosclerotic Cardiovascular Disease Risk Management

Various management approaches are recommended for each of the different risk group categories of moderate risk, moderately high risk, high risk, and very high risk, as well as for the metabolic syndrome. In general, therapy intensifies with increasing level of risk. However, therapeutic lifestyle changes (e.g., smoking cessation, weight reduction, and “heart-healthy” dietary modifications) and blood pressure control are recommended across all categories of risk.

Summary

In clinical practice, risk assessment is a valuable guide to optimizing outcomes in the settings of both primary and secondary prevention. In general, risk modification therapy should be “stepped up” according to risk category. Patients at high or very high risk should receive intensive intervention for risk reduction. For example, it is reasonable to treat very-high-risk patients to an LDL cholesterol goal of <70 mg/dL. However, at all levels of risk, therapeutic lifestyle changes (e.g.,

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To determine the relationship between metabolic syndrome (MS) and socioeconomic level, life style, health status, family history of morbidity, and residence areas.
This is a cross-sectional cohort study. The random sample consisted of users of two primary healthcare units (Unidades Básicas de Saúde - UBSs) in the city of São Paulo — Jardim Comercial (UBS1), and Jardim Germânia (UBS2), a total of 452 subjects. The NCEP ATP III criterion was used to diagnose MS. Weight, height, abdominal and hip circumferences were measured for the anthropometric evaluation. A general questionnaire was used to obtain sociodemographic and socioeconomic data; family history; medical history; behavioral habits such as smoking, drinking, and physical activity. Multivariate logistic regression was used to establish the association between explanatory variables of interest and MS.
At UBS1, MS percentage was 56.1%; at UBS2, 34.0%. There was a direct and significant association between MS and age, female gender, race, smoking, drinking, physical activity level, stress, and family history of heart disease and diabetes mellitus. Education level showed an inverse association. Subjects living in a lower socioeconomic level neighborhood had a higher MS risk.
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MetS is a predictor of NAFLD and patients with multiple metabolic risk factors may harbour non-alcoholic steatohepatitis (NASH) predictive of operative and cardiovascular mortality. Pre-operative diagnosis of unsuspected NASH with the selective use of a liver biopsy can modify the operative strategy by limiting the extent of hepatic resection, avoiding or altering the pre-operative chemotherapy regimen and the utilization of portal vein embolization. Thiazolidinediones are therapeutic for MetS and NASH and Vitamin E for active NASH; however, their utility in improving the peri-operative outcome after hepatic resection is unknown. A short-term regimen for weight loss improves post-operative patient and liver-related outcomes in patients with >30% steatosis. Cardiovascular disease associated with MetS or NAFLD should be managed aggressively. Peri-operative measures to minimize thrombotic events and acute renal injury secondary to the pro-inflammatory, prothrombotic state of MetS may further improve the outcome.
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Despite these advances, there are still several risks associated with pharmacological and surgical intervention of obesity and the metabolic syndrome, suggesting that dietary modification may be the safest and most cost-effective option for those who are moderately obese [10–12]. To date, nutritional intervention is still the preferred method of treatment and prevention for obesity and the metabolic syndrome [9,13]. Tea (Camellia sinensis, Theaceae) is the second popular beverage in the world, next to water.
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Hostile individuals are known to report poorer lifestyle habits such as sedentary lifestyles, smoking, and heavy alcohol consumption, than others (Pulkki et al., 2003; Siegler et al., 1992). These behaviors, in turn, increase the risk for developing the metabolic syndrome (Eckel et al., 2005; Grundy, 2007) and systemic inflammation (Koenig et al., 2007). Another possible mechanism between hostility, metabolic syndrome and CRP involves bodily dysfunctions in autonomic nervous systems’ ability to control heart rate (autonomic cardiac control).
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View full text

Cardiovascular and Metabolic Risk Factors: How Can We Improve Outcomes in the High-Risk Patient?

Abstract

Section snippets

Global Atherosclerotic Cardiovascular Disease Risk Assessment: A Guide for Therapy

The Metabolic Syndrome

Modifying Risk Factors

A Risk Group–Guided Approach to Atherosclerotic Cardiovascular Disease Risk Management

Summary

J Am Coll Cardiol

Am J Cardiol

Lancet

Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)

JAMA

Definition of metabolic syndrome: report of the National Heart, Lung, and Blood Institute/American Heart Association Conference on scientific issues related to definition

Circulation

AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update endorsed by the National Heart, Lung, and Blood Institute

Circulation

Diabetes and coronary risk equivalency: what does it mean?

Diabetes Care

Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement

Circulation

Effect of lowering LDL cholesterol substantially below currently recommended levels inpatients with coronary heart disease and diabetes: the Treating to New Targets (TNT) study

Diabetes Care