Update on selected markers used in risk assessment for vascular disease.

CVD remains the greatest health risk in the U.S.. Assessment of laboratory data in establishing risk and treatment modalities has come to the forefront in patient primary care. Guidelines published in the ATP III document by the NCEP have incorporated lower limits of lipids and included a number of risk factors and conditions, such as the metabolic syndrome associated with insulin-resistance, as a means for earlier detection and intervention in CVD. Endothelial dysfunction and the associated inflammatory process, including soluble plasma markers, have lead to the addition of hs-CRP as an adjunct to other laboratory indicators of CVD. The precise mechanisms and interrelationships between these factors and atherosclerosis have yielded some confusing data, along with investigations of a number of associated substances and conditions. An emerging theme is the body's response to injury and stress; a lack of metabolic balance. While currently outside the domain of routine laboratory testing, future CVD risk assessment may include the metabolic by-products generated by chronic external pressures, including genetic predisposition or alterations associated with socioeconomic factors. Further studies are needed to better understand the significance each plays in assessing the individual's development and CVD risk.     

Growth Outcomes of Preterm Infants in the Neonatal Intensive Care Unit: Long-term Considerations

Promoting growth is an important aspect of the management of preterm infants in the neonatal intensive care unit. However, this proves to be a difficult challenge. Most preterm infants have discharge weights less than the 10th percentile resulting in extrauterine growth retardation. Growth during the neonatal intensive care unit stay is associated with long-term outcomes. Slow growth velocity is associated with altered neurodevelopmental outcomes. There is increasing concern that strategies to improve growth are resulting in altered fat mass deposition and placing the infant at increased risk for the later development of clinical indications of metabolic syndrome. The minimal evidence available lends support to this hypothesis. Future research is needed to develop strategies that improve growth and neurodevelopmental outcomes while limiting the risk of metabolic syndrome.     

Managing cardiovascular risk inpatients with metabolic syndrome

The metabolic syndrome is a constellation of risk factors that contribute to the onset of type 2 diabetes mellitus and cardiovascular disease (CVD). CVD has been identified by the National Cholesterol Education Program (NCEP) as the primary clinical outcome of the metabolic syndrome. Although no algorithm is currently available for estimating the absolute risk of CVD for patients with the metabolic syndrome, screening for cardiovascular (CV) risk in these patients involves testing for lipoprotein abnormalities (namely, an analysis of specific low-density lipoprotein particle numbers) and an assessment of various surrogate markers for subclinical coronary artery disease. Such screening can be used to help predict the development of CVD and thereby allow for effective interventions to help prevent coronary events. Strategies for reducing CV risk in patients with the metabolic syndrome are multifactorial. In addition to placing an emphasis on therapeutic lifestyle changes that increase levels of physical activity, dietary modification, and weight reduction, several pharmacologic therapies are available. One novel approach for managing CV risk in patients with the metabolic syndrome involves the inhibition of the endocannabinoid system, including the use of rimonabant. A review of CV risk factors in patients with the metabolic syndrome is beneficial for clinicians to apply in the care of their patients, along with a discussion about strategies for identifying at-risk patients and managing CVD risk for these patients.     

Racial and Ethnic Differences in the Presentation of Metabolic Syndrome

This paper explores the effectiveness of the Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III) recommendations for diagnosing metabolic syndrome in people from specific racial and ethnic groups. More than 50 million adult Americans have metabolic syndrome. Some racial and ethnic minority groups have much higher percentages of the metabolic syndrome than general population estimates suggest. However, some minority populations in the United States such as Hispanics appear to be underdiagnosed. A literature review was conducted to determine whether the general ATP III guidelines have sufficient screening criteria for detecting metabolic syndrome in various racial and ethnic minority groups. Research articles published in the United States from 2000 to 2005 were reviewed. Studies were included that presented data related to black, Hispanic, and Asian American male and female subjects older than age 18. Waist circumference appears to be the most predictive screening factor among the metabolic syndrome criteria. Patients with normal body mass indexes may still have elevated waist circumferences that meet the ATP III risk criteria for metabolic syndrome. Blacks have high rates of hypertension even without considering metabolic syndrome, and they may have more disease risk than other populations. Hispanics have an increased risk of diabetes associated with metabolic syndrome. Because the criteria may not be sufficient to diagnose metabolic syndrome in Asian Americans as a result of different body types, the diagnosis might be missed in this group. There is a need for more research on how the diagnosis of metabolic syndrome presents in different racial and ethnic minority groups in the United States. Practitioners need evidence-based screening tools that will provide the most accurate information for evaluating persons of racial and ethnic groups who are most at risk of diabetes, cardiovascular disease, and stroke. The determination of the applicability of screening criteria to diverse patient populations is vital to providers who are obligated to provide culturally competent care to their patients. This paper synthesizes selected literature and presents recommendations to assist nurse practitioners in the assessment of metabolic syndrome in specific racial and ethnic minority groups.     

老年脑梗死合并代谢综合征患者临床特点、TOAST分型及预后分析

目的探讨老年脑梗死合并代谢综合征患者临床特点、TOAST分型及预后。方法选择162例老年急性期脑梗死患者为研究对象,其中合并代谢综合征者82例,非代谢综合征者80例。比较两组临床特点、TOAST分型及预后的差异。结果合并代谢综合征者胆固醇（TC）、低密度脂蛋白（LDL—C）、甘油三脂（TG）、空腹血糖、空腹胰岛素均显著高于非代谢综合征患者（P〈0．05）;合并代谢综合征者冠心病、高血压及肺部感染发生率显著高于非代谢综合征（P〈0．05）;两组TOAST分型差异具有统计学意义（P〈0．05）;非代谢综合征者治疗有效率显著高于合并代谢综合征者（P〈0．05）。结论代谢综合征是老年脑梗死危险因素,其TOAST分型与非代谢综合征者不同,患者预后差。     

Central obesity and the metabolic syndrome: implications for primary care providers

PURPOSE: To describe screening measures that will determine which clients are at risk for the metabolic syndrome, common manifestations of the syndrome, preventive diagnostic considerations, and management and treatment options that primary care providers can implement. DATA SOURCES: Review of the clinical and research literature, supplemented with specific diagnostic criteria. CONCLUSIONS: Central obesity is the cornerstone of the metabolic syndrome, which may lead to type 2 diabetes and cardiovascular disease. Generalized obesity is defined as body weight that is considerably greater than the ideal weight and that is distributed on all parts of the body. Generalized obesity has long been considered a significant risk factor for developing type 2 diabetes and cardiovascular disease. Those clients of ideal body weight have been considered at less risk for developing these conditions. However, this perception may not always be accurate. Weight distribution plays a major role in acquiring the metabolic syndrome. Because waist circumference is as important as overall body weight, central obesity is key to determining the risk. IMPLICATIONS FOR PRACTICE: The metabolic syndrome has now been given a CPT code (277.7). It is more likely that clients at risk for or with the metabolic syndrome may first be seen by a primary care provider. Primary care providers need to be able to diagnose, treat, and provide preventive interventions for the metabolic syndrome. Clients at risk will likely be identified during routine health screening. Early detection of and interventions focused on the metabolic syndrome may reduce the occurrence of type 2 diabetes and cardiovascular disease. Use of a tape measure to determine waist circumference may help the provider to identify at-risk clients who are of normal weight, and thus not previously believed to be at risk, as well as those more obviously at risk. It is necessary to determine not only patients' overall body weight but also their waist circumference. A measuring tape may be the key tool for establishing a patient's early risk for the metabolic syndrome and, ultimately, for prevention of type 2 diabetes and cardiovascular disease.     

The metabolic syndrome: concepts and controversy

The metabolic syndrome is an insulin-resistant state characterized by a cluster of cardiovascular risk factors, including various combinations of abdominal obesity, glucose intolerance, hypertension, and atherogenic dyslipidemia (elevated triglyceride values, low high-density lipoprotein cholesterol levels, and small dense low-density lipoprotein cholesterol particles). The current epidemic of obesity and physical inactivity has led to an increased prevalence of this disorder. In this review, we discuss the history and pathogenesis of the metabolic syndrome, the controversy regarding the appropriateness of considering it a distinct diagnosis, and the importance of lifestyle modification in its prevention and treatment. The need for all cardiovascular risk factors to be treated, whether or not they are components of the metabolic syndrome, is emphasized. Recent discussions in the literature regarding the continued use of the term metabolic syndrome should be considered a healthy academic debate that hopefully will stimulate Ideas and innovative research to improve patient care.     

Insulin resistance syndrome in children

Insulin resistance, a metabolic dysfunction in glucose metabolism, is associated with numerous physical health findings that have serious health consequences such as obesity, hyperlipidemia, hypertension, cardiovascular disease, and type 2 diabetes. The clustering of these diseases is termed insulin resistance syndrome, previously described as a metabolic condition exclusive to adults. Studies now indicate many of the components associated with insulin resistance syndrome are present in children and adolescents. Identifying children at risk for the development of insulin resistance is important for early prevention and intervention. Detecting early evidence of insulin resistance in children and adolescents can have a preventive effect on the disease components associated with insulin resistance. Primary care providers are in pivotal position for early recognition and treatment of insulin resistance in children.     

Metabolic syndrome in the acute care setting

The metabolic syndrome is a clinical condition that is a powerful predictor for cardiovascular morbidity and mortality. Hypertension, abdominal obesity, high blood glucose levels, and abnormal blood lipid levels characterize metabolic syndrome. Therapeutic treatment of the metabolic syndrome confers a significant risk reduction for both type 2 diabetes and premature cardiovascular events. In the hospital setting, the management of hyperglycemia, one of the clinical components of the metabolic syndrome, has been secondary in importance to the condition that prompted admission. Hyperglycemia in the hospitalized patient has been associated with increased lengths of stay, higher rates of hospital-acquired infections, and increased mortality. Early recognition and treatment of hyperglycemia and the associated metabolic components that comprise the metabolic syndrome may reduce morbidity and mortality in the hospital setting. More aggressive interventions will aid in reducing costs while simultaneously improving patient care and safety.     

Metabolic changes in persons after spinal cord injury

Persons with chronic SCI have several metabolic disturbances. As a consequence of inactivity and the body compositional changes of decreased skeletal muscle with a relative increase in adiposity, a state of insulin resistance and hyperinsulinemia has been demonstrated to exist, associated with abnormalities in oral carbohydrate handling. Elevated plasma insulin levels in persons with SCI probably contribute to the cause of frequent dyslipidemia and hypertension. This constellation of metabolic changes represents an atherogenic pattern of CHD risk factors with many of the distinctive features of a cardiovascular dysmetabolic syndrome that is called syndrome X. Reduction in modifiable risk factors for CHD should decrease the occurrence of catastrophic cardiovascular events. There is evidence to suggest that endogenous anabolic hormone levels are depressed in a proportion of individuals with SCI. Depression of serum testosterone and growth hormone/IGF-I levels may exacerbate the adverse lipid and body compositional changes, reduce exercise tolerance, and have deleterious effects on quality of life. Because of immobilization, individuals with paraplegia have osteoporosis of the pelvis and lower extremities, and those with tetraplegia also have osteoporosis of the upper extremities. In addition, there is evidence to suggest that bone loss progresses with time in persons with chronic SCI. This may be caused by chronic immobilization per se or may be a consequence of adverse hormonal changes, including deficiency of anabolic hormones or deficiency of vitamin D and calcium with secondary hyperparathyroidism. Serum thyroid function abnormalities resembling the euthyroid sick "low T3 syndrome" have been reported in those with acute and chronic spinal cord injury. Depressed serum T3 and elevated rT3 in chronic SCI may be caused by associated illness. Current practice has been hesitant to treat abnormal serum thyroid chemistries associated with nonthyroidal illness. Recognition of metabolic abnormalities in individuals with SCI is vital as a first step in improving clinical care. The application of appropriate interventions to correct or ameliorate these abnormalities promises to improve longevity and quality of life in persons with SCI.     

Metabolic syndrome in a multiethnic sample of school children: implications for the pediatric nurse

There is lack of translational work that may assist the pediatric nurse in identifying the child who is at risk for metabolic syndrome. Early identification of the syndrome could assist pediatric health care providers in intervening and in lowering child health risks. Fasting serum insulin, metabolic syndrome criteria, and dietary intake were examined in a multiethnic sample of children aged 9-15 years. Forty-seven percent had two or more risk factors for metabolic syndrome, and 28% had three or more risk factors. Insulin levels were negatively correlated with the recommended dietary allowance. A regression model, including gender, age, race, body mass index, serum glucose, high-density lipoprotein cholesterol, triglycerides, and blood pressure, explained 48% of insulin variance.     

Le syndrome obésité-hypoventilation: revue de la littérature

Obesity-hypoventilation syndrome (OHS) is a combination of obesity and hypercapnic chronic respiratory failure, without any other causes of hypercapnia. OHS is frequently associated with obstructive sleep apnea hypopnea syndrome (80%). Its prevalence is increasing in relation to the epidemics of obesity in Occidental countries. Clinical presentation including dyspnea and fatigue is not specific and may explain that OHS is under-recognized, responsible for many recurrent admissions in the intensive care unit for acute hypercapnic respiratory failure, generally associated with clinical right ventricular failure.Without any treatment, patients with OHS have a lower quality of life with increased healthcare expenses by recurrent hospitalisations and are at a higher risk for the development of pulmonary hypertension, metabolic and vascular morbidities as well as early mortality, in comparison to eucapnic obese patients. Available treatments include home continuous or bi-level positive airway pressure therapy, well-tolerated and effective to reduce mortality as well as different approaches for weight loss including bariatric surgery.     

Abdominal obesity is essential for the risk of venous thromboembolism in the metabolic syndrome: the Tromsø study

Summary.  Background:  The metabolic syndrome is a cluster of cardiovascular risk factors, including abdominal obesity, hypertension, dyslipidemia and insulin resistance, associated with increased risk of cardiovascular diseases and all cause mortality. Objectives:  The purpose of the study was to assess the impact of the metabolic syndrome, and its individual components, on the risk of venous thromboembolism (VTE) in a prospective population-based study. Methods:  Individual components of the metabolic syndrome were registered in 6170 subjects aged 25–84 years in the Tromsø Study in 1994–1995, and first ever VTE events were registered until 1 September 2007. Results:  The metabolic syndrome was present in 21.9% (1350 subjects) of the population. There were 194 validated first VTE events (2.92 per 1000 person-years) during a mean of 10.8 years of follow-up. Presence of metabolic syndrome was associated with increased risk of VTE (HR, 1.65; 95% CI, 1.22–2.23) in age- and gender-adjusted analysis. The risk of VTE increased with the number of components in the metabolic syndrome ( P  < 0.001). Abdominal obesity was the only component significantly associated with VTE in multivariable analysis including age, gender, and the individual components of the syndrome (HR, 2.03; 95% CI, 1.49–2.75). When abdominal obesity was omitted as a diagnostic criterion, none of the other components, alone or in cluster, was associated with increased risk of VTE. Conclusions:  Our study provides evidence for the metabolic syndrome as a risk factor for TE. Abdominal obesity appeared to be the pivotal risk factor among the individual components of the syndrome.     

Prevention in occupational health care--a societal challenge]

The metabolic syndrome, increasingly appearing amongst the elderly and recently in younger people with a most sudden increase in the age group < 30 years, is one of the main threats to European health in this century. Early diagnosis is the most efficient way to manage and to prevent metabolic syndrome from developing. Recent studies have convincingly demonstrated that lifestyle intervention, addressing diet and exercise, reduced the risk of developing diabetes and metabolic syndrome. The challenges today are to develop and implement efficient strategies to identify those on risk and to implement prevention management programs for clinical practice. Company medical officers could play an important role while identifying persons with increased risk for the metabolic syndrome, because they are addressing patients and healthy working persons but also reaching persons who normally are not reached by the health-care system. The occupational medical health promotion has the structural requirement to implement preventive intervention also by using its influence to establish healthy workplaces. Implementing managed prevention programs in the occupational medical care setting will enable prevention of the metabolic syndrome without consuming large resources. This process will be challenging and must be sustainable requiring many partners but resulting in a profitable chance for occupational health care.     

Linking preeclampsia and cardiovascular disease later in life

Preeclampsia (PE), which is defined as new onset hypertension after 20 weeks of pregnancy accompanied by proteinuria, is characterized by inadequate placentation, oxidative stress, inflammation and widespread endothelial dysfunction. A link between PE and long-term risk of cardiovascular disease (CVD) was suggested by retrospective studies, which found that PE was associated with a 2–3-fold risk of CVD later in life, with a 5–7-fold risk in the case of severe and/or early-onset PE. Recently, meta-analyses and prospective studies have confirmed the association between PE and the emergence of an unfavorable CVD risk profile, in particular a 3–5-fold increased prevalence of the metabolic syndrome only 8 years after the index pregnancy. PE and CVD share many risk factors, including obesity, hypertension, dyslipidemia, hypercoagulability, insulin resistance and both entities are characterized by endothelial dysfunction. PE and CVD are complex traits sharing common risk factors and pathophysiological processes, but the genetic link between both remains to be elucidated. However, recent evidence suggests that genetic determinants associated with the metabolic syndrome, inflammation and subsequent endothelial dysfunction are involved. As the evidence now supports that PE represents a risk factor for the emergence of the metabolic syndrome and CVD later in life, the importance of long-term follow-up assessment of CVD risk beginning early in women with a history of PE must be considered and translated into new preventive measures.     

The prevalence of obesity

During the past several decades, obesity has increased substantially, making it a true epidemic and a public health crisis that both health care providers and the public are going to have to face. Currently, 61% of the US population is overweight or obese and therefore at increased risk for a number of diseases that are associated with increased body fat. Indeed, the obesity epidemic already is leading to dramatic increases in type 2 diabetes and the metabolic syndrome. Almost a quarter of the population currently has metabolic syndrome, which places them at high risk for the development of coronary heart disease. The future of the general health of the US population depends on identifying and providing the best treatment and prevention strategies for obesity in the years ahead.     

Association of Smoking Status, Weight Change, and Incident Metabolic Syndrome in Men: A 3-Year Follow-Up Study

OBJECTIVE

We investigated the incidence of the metabolic syndrome and assessed the effect of smoking status and weight change on incident metabolic syndrome.

RESEARCH DESIGN AND METHODS

This study included 4,542 men without metabolic syndrome at baseline who were followed for an average of 3 years. Subjects were divided into four categories according to smoking status at baseline and at the 3-year follow-up.

RESULTS

The overall incidence of metabolic syndrome was 10.6%: 8.0% in nonsmokers, 7.1% in new smokers, 17.1% in ex-smokers, and 13.9% in sustained smokers (P < 0.001). In a multivariate regression model, ex-smokers had significantly increased odds for incident metabolic syndrome with a mean 1.45 (95% CI 1.06–1.98) compared with sustained smokers. This was no longer significant after including weight change.

CONCLUSIONS

Smoking cessation within 3 years may be a higher risk factor for incident metabolic syndrome than sustained smoking, indicating that weight control in ex-smokers is critical to attenuate the additional risk for incident metabolic syndrome.As the number of smokers who quit cigarette smoking is increasing, recent research has focused on the impact of prior smoking on cardiometabolic disorders. Several epidemiological studies have reported that smoking cessation is associated with an increased prevalence of the metabolic syndrome (1,2) compared with that of nonsmokers. However, the studies were cross-sectional and could not exactly evaluate the effects of smoking status on the risk of incident metabolic syndrome. The aim of the present study was to investigate the 3-year incidence of metabolic syndrome in men who did not have metabolic syndrome at baseline and to assess the effect of smoking status and weight change on the risk of incident metabolic syndrome.     

Highly active antiretroviral therapy-associated metabolic syndrome: pathogenesis and cardiovascular risk

The introduction of highly active antiretroviral therapy (HAART) has significantly modified the course of HIV disease, with longer survival and improved quality of life of HIV-infected subjects. However, HAART regimens, especially those including protease inhibitors (PIs) have been shown to cause in a high proportion of HIV-infected patients a metabolic syndrome that may be associated with an increased risk of cardiovascular disease (about 1.4 cardiac events per 1,000 years of therapy according to the Framingham score). Metabolic features associated with somatic changes (lipodystrophy/lipoatrophy) include dyslipidemia (about 70% of patients), insulin resistance (elevated C-peptide and insulin), type 2 diabetes mellitus (8%-10% of the patients), hypertension (up to 75% of patients), coagulation abnormalities (25% of patients), lactic acidemia, and elevated hepatic transaminases (nonalcoholic steatohepatitis). HAART-associated metabolic syndrome is an increasingly recognized clinical entity. A better understanding of the molecular mechanisms responsible for this syndrome will lead to the discovery of new drugs that will reduce the cardiovascular risk in patients under HAART. A careful stratification of the cardiovascular risk and cardiovascular monitoring of patients under HAART is needed according to the most recent clinical guidelines.     

Metabolic syndrome and risk of restenosis in patients undergoing percutaneous coronary intervention

OBJECTIVE: Patients with metabolic syndrome have increased risk of cardiovascular events. The number of patients with metabolic syndrome is rapidly increasing, and these patients often need revascularization. However, only limited data are available on the effect of metabolic syndrome on restenosis in patients undergoing percutaneous coronary intervention (PCI). RESEARCH DESIGN AND METHODS: To assess the role of metabolic syndrome in the development of restenosis, we performed an analysis in a population of patients from the GENetic DEterminants of Restenosis (GENDER) study. The GENDER project, a multicenter prospective study, included consecutive patients after successful PCI and was designed to study the predictive value of various genetic and other risk factors for subsequent clinical restenosis, defined as target vessel revascularization (TVR) or combined end point of death, myocardial infarction, and TVR. This subpopulation of GENDER consisted of 901 patients, 448 of whom (49.7%) had metabolic syndrome. RESULTS: On multivariable Cox regression analysis, controlling for age, sex, previous myocardial infarction, stent length, current smoking, and statin therapy, there was no association between increased risk of TVR (hazard ratio 1.03 [95% CI 0.68-1.57]) or the combined end point (1.05 [0.71-1.55]) and the presence of metabolic syndrome. CONCLUSIONS: This study demonstrates that metabolic syndrome is not associated with TVR or the combined end point after PCI. Furthermore, accumulating characteristics of metabolic syndrome were neither associated with increased risk of TVR nor with the combined end point. Therefore, PCI has equal beneficial results in patients with or without metabolic syndrome. This is important information in light of the pandemic proportion of metabolic syndrome that the medical community will face.