1、Cardiometabolic Risk: Evaluation & Treatment in Your Patient Population,-Insert Here Speaker Title and Affiliation,Why Focus on Cardiometabolic Risk?,A comprehensive approach to patient care; Multiple disease pathways and risk factors are considered to facilitate earlier intervention Early assessmen
2、t and targeted intervention are needed to treat and prevent all risk factors associated with CVD and diabetes,Cardiometabolic Risk,Gives a comprehensive picture of a patients health and potential risk for future disease and complications Is inclusive of all risks related to metabolic changes associa
3、ted with CVD Accommodates emerging risk factors as useful predictive tools Focuses clinical attention to the value of systematic evaluation, education, disease prevention and treatment Supports an integrated approach to care,Kahn, et al. The Metabolic Syndrome: Time for a Critical Appraisal: Joint S
4、tatement From the American Diabetes Association and the European Association for the Study of Diabetes Diabetes Care. 2005;28 (9)2289-2304.,The State of Risk,2 out of 3 Americans are overweight or obeseMore than 70 million (nearly 1 in 4) Americans have varying degrees of insulin resistanceThere are
5、 an estimated 54 million (more than 1 in 6) Americans with prediabetesNearly 1 in 4 U.S. adults has high cholesterol1 in 3 American adults has high blood pressure,Direct and Indirect Cost of CVD and Diabetes,*Note: these figures may not account for potential overlap. Sources: 2008 statistics from th
6、e American Diabetes Association and American Heart Association.,Estimated Direct Medical Costs,Estimated Indirect Costs (disability, work loss, premature mortality),Abnormal Lipid Metabolism LDL ApoB HDL Trigly. ,Cardiometabolic Risk Global Diabetes / CVD Risk,Overweight / Obesity,Inflammation Hyper
7、coagulation,Hypertension,Smoking Physical Inactivity Unhealthy Eating,Cardiometabolic Risk - Graphic,Non-modifiable,Age Race/ethnicity Gender Family history,Overweight Abnormal lipid metabolism Inflammation, hypercoagulation Hypertension Smoking Physical inactivity Unhealthy diet Insulin resistance,
8、Cardiometabolic Risk Factors,Modifiable,Case - Mr. Martin,47-year-old African American man, hasnt seen doctor in years Works as a truck driver, eats mostly fast food Smokes 1 pack per day At health fair found to have BP = 146/86, total cholesterol = 210 Weight = 230 lbs; BMI = 29 kg/m Family history
9、 of HTN and diabetes,Whats Mr. Martins Cardiometabolic Risk?,Age 47 Race/ethnicity African American Gender Male Family history HTN and diabetesOverweight/obesity BMI = 29 Abnormal lipid metab TC = 210 Hypertension BP = 146/86 Smoking 1 pack per day Physical Inactivity Yes Unhealthy diet Fast food di
10、et,Non-Modifiable Risk Factors,Number,Est. New Diabetes Diagnoses by Age, 2005,Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2005. Atlanta, GA: U.S. Department of Health and Human Services, Cente
11、rs for Disease Control and Prevention, 2005.,Age Group,20-39,40-59,60+,Cardiovascular Risk Factor Trends Among U.S. Adults Aged 20-74,Centers for Disease Control & Prevention, Division for Heart Disease and Stroke Prevention, “Addressing the Nations Leading Killers: At A Glance 2007,33.6,28.2,27.2,1
12、9.0,17.0,30.8,33.1,26.3,14.9,39.2,36.0,29.3,26.4,1.8,3.5,3.4,4.6,5.0,14.8,Diagnosed Diabetes,Smoking,High Blood Pressure,High Total Cholesterol,1960-1962,1971-1975,1976-1980,1988-1994,1999-2000,Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national
13、 estimates on diabetes in the United States, 2005. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2005.,Hispanic/Latino Americans,Non-Hispanic Whites,American Indians/ Alaska Natives,Non-Hispanic Blacks,0,6,4,2,12,8,10,20,14,16,18,Insulin Resis
14、tance,Factors affecting insulin resistance,Overweight/ fat distribution Age Genetic predisposition Activity level Medications Puberty Pregnancy,IFG and IGT,Impaired Fasting Glucose (IFG): a condition in which the blood glucose level is between 100 mg/dL to 125mg/dL after an 8- to 12-hour fast.Impair
15、ed Glucose Tolerance (IGT): a condition in which the blood glucose level is between 140 and 199 mg/dL at 2 hours during an oral glucose tolerance test (OGTT).,Interpreting Blood Glucose Levels,Healthy BG FPG 100 mg/dLPre-diabetes FPG 100125 mg/dLDiabetes FPG 126 mg/dL,Criteria for testing for type 2
16、 diabetes in asymptomatic children50,Overweight (BMI 85th percentile for age and sex, weight for height 85th percentile, or weight 120 percent of ideal for height) Plus any two of the following: Family history Race/ethnicity Signs of insulin resistance or conditions associated with insulin resistanc
17、e Maternal history of diabetes or GDM,Criteria for testing for diabetes in asymptomatic adult individuals50,Testing should be considered in all overweight adults (BMI 25 kg/m2*) and have additional risk factors: Physical inactivity First-degree relative with diabetes Members of a high-risk ethnic po
18、pulation Women delivering baby weighing 9 lb or were diagnosed with GDM Hypertension (140/90 mmHg),Continued,Criteria for testing for diabetes in asymptomatic adult individuals50,HDL cholesterol level 250 mg/dl (2.82 mmol/l) Women with polycystic ovarian syndrome (PCOS) IGT or IFG on previous testin
19、g Other clinical conditions associated with insulin resistance (e.g., severe obesity and acanthosis nigricans) History of CVD,Criteria for testing for diabetes in asymptomatic adult individuals50,2. In the absence of the above criteria, testing for pre-diabetes and diabetes should begin at age 45 ye
20、ars 3. If results are normal, testing should be repeated at least at 3-year intervals, with consideration of more frequent testing depending on initial results and risk status.*At-risk BMI may be lower in some ethnic groups.,0,1,2,3,CHD mortality, per 1000,Fontbonne AM, et al. Diabetes Care. 1991;14
21、:461-469.,Quintiles (pmol) of fasting plasma insulin,P.01,Insulin Resistance and CHD Mortality Paris Prospective Study,Insulin Sensitive Insulin Resistant,(n=943),29 30-50 51-72 73-114 115,Insulin Sensitivity,Insulin Secretion,Associated Risk Factors,Hypertension,Dyslipidemia,Atherogenesis,Microvasc
22、ular,Complications,Type 2 Diabetes,Age (years),Fasting Blood Glucose,Proposed Metabolic Observations in the Natural History of Type 2 Diabetes,Overweight/Obesity,Understanding Cardiometabolic Risk: Broadening Risk Assessment and Management,Screening: Overweight,Measure BMI routinely at each regular
23、check-up. Classifications: BMI 18.5-24.9 = normal BMI 25-29.9 = overweight BMI 30-39.9 = obesity BMI 40 = extreme obesity,Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. NIH Publication # 98-4083, September 1998, National
24、 Institutes of Health.,Measuring Waist Circumference,Large waist circumference (WC) can identify some at increased risk over BMI alone If BMI and other cardiometabolic risk factors are assessed, currently there is insufficient evidence to: Substitute WC for BMI Measure WC in addition to BMI,Klein, e
25、t al. Waist Circumference and Cardiometabolic Risk. Diabetes Care. 2007 0: dc07-9921v1-0.,Primary Metabolic Disturbance,Intermediate Vascular Disease Risk Factor,Intravascular Pathology,Clinical Event,CVD,Despres JP, et al. Abdominal obesity and metabolic syndrome. Nature. 2006;444:881-887.,Multiple
26、 Factors Associated With Obesity Give Rise to Increased Risk of CVD,Overnutrition,Body Weight and CVD,100 110-129 130+ 110 110-129 130+,0,100,150,200,250,300,50,125,200,267,105,121,128,*Metropolitan Relative Weight percent(percentage of desirable weight),Hubert HB et al. Circulation. 1983;67:968-977
27、,Men,Women,Incidence of CVD per 1,000,n=56 n=75 n=30 n=191 n=199 n=78,Risk Management Overweight,Lifestyle modification Reduce caloric intake by 500-1000 kcal/day (depending on starting weight) Target 1-2 pound/week weight loss Increase physical activity Healthy diet Diabetes Prevention Program DASH
28、 diet,Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. NIH Publication # 98-4083, September 1998, National Institutes of Health. Diabetes Prevention Program (DPP) Diabetes Care 25:21652171, 2002. The Seventh Report of the
29、Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, NIH Publication No. 04-5230, August 2004,Risk Management, cont. Overweight,Consider pharmacologic treatment BMI 30 with no related risk factors or diseases, or BMI 27 with related risk factors or dis
30、eases As part of a comprehensive weight loss program incl. diet & physical activity Consider surgery BMI 40 or BMI 35 with comorbid conditions,Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. NIH Publication # 98-4083, Sep
31、tember 1998, National Institutes of Health. Diabetes Prevention Program (DPP) Diabetes Care 25:21652171, 2002,Abnormal Lipid Metabolism,Total Cholesterol Goals34,Desirable Less than 200 mg/dL Borderline high risk 200239 mg/dL High risk 240 mg/dL and over,American Diabetes Association. Understanding
32、Cardiometabolic Risk: Broadening Risk Assessment and Management, Dyslipidemia Richard M Bergenstal, MD International Diabetes Center,Abnormal Lipid Metabolism,Increased: Triglycerides VLDL LDL and small dense LDL ApoB,Decreased: HDL Apo A-I,American Diabetes Association. Diabetes Care. 2007;30:S4-41
33、.,Major Risk Factors Affecting Lipid Goals36,Cigarette smoking Hypertension (140/90 mm Hg or on antihypertensive medication) Low HDL-C (40 mg/dL) Family history of early heart disease Age (men 45 years; women 55 years),Statins (also called HMG-CoA reductase inhibitors) work by increasing hepatic LDL
34、-C removal from the blood.Resins (also called bile acid sequestrants) bind to bile acids in the intestines and prevent their reabsorption, leading to increased hepatic LDL-C removal from the blood.Cholesterol absorption inhibitors help lower LDL-C by reducing the amount of cholesterol absorbed in th
35、e intestines; increases LDL receptor activity.,Fibrates (also called fibric acid derivatives) activate an enzyme that speeds the breakdown of triglyceriderich lipoproteins while also increasing HDL-C.Niacin (also called nicotinic acid) reduces the livers ability to produce VLDL. When given at high d
36、oses, it can also increase HDL-C.,American Diabetes Association. Understanding Cardiometabolic risk: Broadening risk Assessment and Management, Dyslipidemia Richard M Bergenstal, MD International Diabetes Center,Cholesterol Management,For patients 20 years of age, cholesterol should be checked every
37、 5 yearsOrdering a fasting lipid panel is preferred to gauge the patients total cholesterol, LDL-C, HDL-C and triglyceridesTreatment priorities,Cholesterol Management,LDL-C-lowering,Cholesterol Management,Improve glucose control if diabetes is present Weight loss if overweight Daily exercise Smoking
38、 cessation Dietary modifications including low saturated fat (fat intake less than 30% of total calories and saturated fat less than 7% of total calories), low cholesterol (no more than 200 mg daily) diet Pharmacologic treatment frequently necessary Risk factors include hypertension; HDL 45 years ol
39、d; female 55 years old; smoking.,Risk of CHD by Triglyceride Level: The Framingham Heart Study,Men,Women,n=5,127,Triglyceride Level, mg/dL,50,100,150,200,250,300,350,400,Relative Risk,0,0.5,1,1.5,2,2.5,3,Castelli WP. Epidemiology of triglycerides: a view from Framingham American Journal of Cardiolog
40、y. 1992;70:3H-9H.,Reaven GM, et al. J Clin Invest. 1993;92:141-146.,Association Between Small, Dense LDL and Insulin Resistance,Mean Steady State Plasma Glucose (mmol/L) at Identical Plasma Insulin,A Larger LDL particle pattern,Intermediate pattern,B Small LDL particle pattern,0,2,6,10,12,8,4,LDL-Si
41、ze Phenotype,(n=52),(n=19),(n=29),Low HDL-C: Independent Predictor of CHD Risk, Even When LDL-C is Low,LDL-C (mg/dL),HDL-C (mg/dL),Risk of CHD,.,Gordon T, Castelli WP, Hjortland MC, Kannel WB, Dawber TR. High density lipoprotein as a protective factor against coronary heart disease. The Framingham S
42、tudy. American Journal of Medicine. 1977;62:707-14.,Screening for Dyslipidemia,Persons without Diabetes Test at least every 5 years, starting at age 20, including adults with low-risk values Persons with Diabetes In adults, test at least annually Lipoproteins: measure at after initial blood glucose
43、control is achieved as hyperglycemia may alter results,Preventing Cancer, Cardiovascular Disease, and Diabetes: A Common Agenda for The American Cancer Society, the American Diabetes Association, and the American Heart Association. Circulation. 2004;109:3244-3255. American Diabetes Association. Stan
44、dards of Medical Care in Diabetes 2007. Available at: http:/care.diabetesjournals.org/cgi/reprint/30/suppl_1/S4,Healthy Lipid Goals Targets for Patients Without DM or CVD,Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Bl
45、ood Cholesterol in Adults (Adult Treatment Panel III); National Cholesterol Education Program, National Heart, Lung, and Blood Institute, National Institutes of Health. NIH Publication No. 01-3670, May 2001,Risk Management Abnormal Lipids,Lifestyle modification Increased physical activity Diet: redu
46、ced saturated fat, trans fat, and cholesterol Weight loss, if indicated,American Diabetes Association. Diabetes Care. 2007;30:S4-41.,Pharmacologic treatment: primary goal is LDL lowering Without overt CVD: If over 40, statin therapy recommended to achieve 30-40% LDL reduction With overt CVD: All pat
47、ients should receive statin therapy to achieve 30-40% LDL reduction Lowering triglycerides and raising HDL with a fibrate is associated with fewer cardiovascular events in patients with clinical CVD, low HDL, and near-normal LDL,American Diabetes Association. Diabetes Care. 2007;30:S4-41.,Risk Manag
48、ement Abnormal Lipids,Hypertension,Hypertension: Evaluation and Screening,Persons without Diabetes BP should be measured at each regular visit or at least once every 2 years if BP 120/80 mmHg BP measured seated after 5 min rest in office,Persons with Diabetes BP should be measured at each regular vi
49、sit BP measured seated after 5 min rest in office Patients with 130 or 80 mmHg should have BP confirmed on a separate day,Preventing Cancer, Cardiovascular Disease, and Diabetes A Common Agenda for the American Cancer Society, the American Diabetes Association, and the American Heart Association. Circulation. 2004;109:3244-3255. American Diabetes Association. Diabetes Care. 2007;30:S4-41.,
