The National Heart, Lung, and Blood Institute (NHLBI) estimates that almost 25% of US adults have a constellation of abnormalities constituting what was once called “syndrome X” and, later, “metabolic syndrome” or “insulin resistance syndrome.”1 The component disorders include central adiposity defined by waist circumference or hip-waist ratio, elevated triglycerides, low levels of high-density lipoprotein, hypertension, and elevated blood glucose levels. Most people with one cardiometabolic abnormality have others as well, and the cumulative effect is a predisposition to atherosclerotic plaque development, inflammation, and thrombosis, ultimately resulting in cardiovascular disease that is often premature. In fact, the Third Report of the National Cholesterol Education Program–Adult Treatment Panel (ATP III) states that having 3 or more of these abnormalities confers the same cardiovascular risk as does existing coronary artery disease.2 Diabetes alone also carries increased risk similar to that seen among confirmed heart disease patients.2
The public health impact of cardiometabolic abnormalities becomes clearer when one considers that 38.9% of US adults report a prescription drug expense for a cardiovascular agent and 28.9% report a prescription drug expense for a metabolic agent. Furthermore, metabolic agents are the No. 1 type of medication prescribed in the United States, accounting for an expenditure of $38.1 billion annually, and cardiovascular agents rank No. 2 at $33.1 billion annually.3
Efforts to develop effective management strategies for patients with a cluster of cardiometabolic abnormalities have been confounded by the differing definitions of and treatment guidelines for “metabolic syndrome” issued by various government entities and organizations. The NHLBI and the American Heart Association collaborate to update the ATP metabolic syndrome criteria and treatment guidelines.4 The World Health Organization and the International Diabetes Federation also recognize metabolic syndrome, but their criteria differ from each other and also from ATP III; the European Group for the Study of Insulin Resistance has yet another set of criteria (see Table).5–7
A further complication for healthcare professionals seeking to identify the most appropriate treatment strategies from current guidelines is that the American Diabetes Association (ADA) and the European Association for the Study of Diabetes do not recognize “metabolic syndrome” per se. Instead, they recommend that any patient with one cardiometabolic disorder be screened for the others and that each component disorder be treated to its individual target.8 In addition, current guidelines from the NHLBI-sponsored Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) recommend a lower blood pressure goal for patients with diabetes than does ATP III,9 and current ADA treatment guidelines recommend earlier drug treatment—at the prediabetes level—especially for patients with other risk factors for developing type 2 diabetes, including hypertension, low HDL, elevated triglycerides, and obesity.10
Not only do the various treatment parameters conflict, they are updated often. For example, the NHLBI has convened experts to update both ATP and JNC guidelines, and the proposed new versions are expected to be available for public comment in December 2009. The ADA released its updated clinical practice guidelines earlier this year.10
An estimated 47 million Americans have double the average risk of heart disease because they are affected by a complex constellation of interrelated conditions, including obesity, impaired glucose metabolism, hypertension, and lipid disorders. Read our overview article, “A complex constellation of interrelated conditions,” which describes these components of cardiometabolic disorders in more detail. For a complete list of articles in the series, please see “Series Content” below the References.
References
1. National, Heart, Lung, and Blood Institute Diseases and Conditions Index. Metabolic syndrome. www.nhlbi.nih.gov/health/dci/Diseases/ms/ms_whoisatrisk.html. Accessed July 29, 2009.
2. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III).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) final report. Circulation. 2002;106(25):3143–3421.
3. Soni A. Agency for Healthcare Research and Quality. Medical Expenditure Panel Survey. Statistical Brief #232. The top five therapeutic classes of outpatient prescription drugs ranked by total expense for adults age 18 and older in the US civilian noninstitutionalized population, 2006. http://www.meps.ahrq.gov/mepsweb/data_files/publications/st232/stat232.pdf. Accessed July 29, 2009.
4. Grundy SM, Cleeman JI, Merz CN, et al; National Heart, Lung, and Blood Institute; American College of Cardiology Foundation; American Heart Association. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 2004;110(2):227–239.
5. Alberti KG, Zimmet PZ. Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus provisional report of a WHO consultation. Diabet Med 1998;15(7):539–553.
6. Alberti KG, Zimmet P. Shaw J; IDF Epidemiology Task Force Consensus Group. The metabolic syndrome—a new worldwide definition. Lancet. 2005;366(9491):1059–1062.
7. Balkau B, Charles MA. Comment on the provisional report from the WHO consultation. European Group for the Study of Insulin Resistance (EGIR). Diabet Med. 1999;16(5):442–443.
8. Kahn R, Buse J, Ferrannini E, Stern M; American Diabetes Association; European Association for the Study of Diabetes. The metabolic syndrome: time for a critical appraisal: joint statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2005;28(9):2289–2304.
9. Chobanian AV, Bakris GL, Black HR, et al; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC7 report. JAMA. 2003;289(19):2560–2572.
10. American Diabetes Association. Standards of medical care in diabetes—2009. Diabetes Care.2009;32(suppl 1):S13–S61.
SERIES CONTENT
Clinical Pharmacy
P&T considerations in fashioning a knowledge base, action plan for cardiometabolic disorders and weight
The P&T committee is uniquely positioned to provide knowledge and strategies to improve the treatment of patients with cardiometabolic disorders.
Community Pharmacy
Cardiometabolic disorders: The pharmacist’s role
With an estimated 47 million Americans facing increased risk of heart disease because of atherosclerotic cardiovascular disease and type 2 diabetes conditions, management of patients’ cardiometabolic disorders is a priority for pharmacists.
Dermatology
All systems go: Association between psoriasis, metabolic syndrome is strong
The evidence linking psoriasis to metabolic syndrome and cardiovascular disease is overwhelming, classifying psoriasis as a systemic disease and not simply a disease of the skin.
Geriatrics
Cardiovascular medication adherence among the elderly
A review of the current evidence describing the etiology, diagnosis, and treatment of poor adherence to cardiovascular medications among the elderly.
Opinion: Baby Boomers court metabolic syndrome
Many bulging Baby Boomers already have the “metabolic syndrome,” and if clinicians don’t do anything about it, their patients are 3 to 5 times more likely to develop type 2 diabetes and twice as likely to develop cardiovascular heart disease.
Managed Care
Cardiometabolic care links
Address the risks
Nursing
Diabetes: The tipping point to a metabolic meltdown
Follow the treatment and education of a newly diagnosed type 2 diabetes patient: taking a case history, making a diagnosis, and teaching the patient how to monitor and control blood sugar.
Lipids: A nursing action plan for improving patients’ lipoprotein levels
Use our sample patient with high blood lipids as a guide for diagnosing hyperlipidemia, interpreting blood tests, and educating your own patients.
[Audio icon] Motivating the diabetic patient
To help you manage your patients’ cardiometabolic disorders more effectively, listen to Rebecca Abernathy, an RN in San Diego, as she discusses how her practice is handling these increasingly prevalent disorders.
Pediatrics
New tools for children with Type 1 diabetes
Normalization of blood glucose levels is the ultimate goal of diabetes treatment, but this goal must be balanced against the risk of hypoglycemia. In recent years, new technologies have helped us improve glycemic control while simultaneously decreasing the risk of hypoglycemia.
CP Links: Pediatric obesity resources
A collection of web resources about pediatric obesity.
Pharmaceutical Industry
Obesity: The last remaining categories with mega-blockbuster potential
This article looks at what’s next in the pipeline and whether it will be enough to improve obesity rates.
Primary Care
Clinical Centers of Excellence: Cardiometabolic Disorders & Weight
More than two-thirds of US adults and one-third of children and adolescents are overweight or obese, according to the National Center for Health Statistics.
CCE: Cardiometabolic disorders management strategies
Each patient with a cardiometabolic disorder is likely to have an additional related disorder.
Cardiometabolic Disorders & Weight: Action for Outcomes
For the first time, 17 of Advanstar Communications’ Life Sciences publications and its web portal, ModernMedicine.com, are collaborating in a coordinated, interdisciplinary initiative to address a major public health issue: cardiometabolic disorders and weight.
A complex constellation of interrelated conditions
An estimated 47 million Americans have double the average risk of heart disease because they are affected by a complex constellation of interrelated conditions, including obesity, impaired glucose metabolism, hypertension, and lipid disorders.
Improve your management of cardiometabolic disorders
The art of medicine can be as pivotal as the science of medicine when it comes to managing the treatment regimens of patients with cardiometabolic disorders.
Sidebar: When to refer a nonadherent patient to a mental health specialist
Consider a referral to a mental health provider for patients who remain nonadherent to therapy or lifestyle changes even after extensive patient education efforts.
Sidebar: Getting reimbursed for patient education
Insurers are also signing on to support new chronic care patient education delivery systems that incorporate web-based and electronic technologies.
Researchers develop computer model to help doctors with statin therapy
A new tool to help treat cardiometabolic conditions with greater certainty is ready to be tested in a practice environment.
Viewpoint: Help your patients make a difference in their own lives
Beginning this issue and continuing through November, Medical Economics will deliver “Cardiometabolic Disorders & eight: Action for Outcomes,” a series of in-depth coverage designed to help you manage your patients’ disorders more effectively.
[Audio icon] Helping Patients Manage Cardiometabolic Disorders & Weight
Listen to Drs. Mike Hagaman and David Spees as they discuss how they are helping their patients tackle cardiometabolic disorders and weight problems head-on
Obesity/Gynecology & Women’s Health
Cardiometabolic disorders and weight: A special report on metabolic syndrome
The first in a series of articles on the disorder outlines the major editorial initiative being launched by Advanstar Communications’ journals and ModermMedicine.com.
Urology
Research links cardiometabolic disorders, urologic disease
As research reveals more associations between cardiometabolic disorders and urologic disease, experts are emphasizing the importance of the urologist in detecting cardiometabolic risk factors in patients.
[Audio icon] Cardiometabolic disorders and ED
Dr. Daniel H. Williams IV and Dr. Ajay Nangia discuss cardiometabolic disorders and urologic disease in aging men with Urology Times’ Ben Saylor
Cardiometabolic Disorders: Do They Matter?
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