《代謝綜合癥：臨床設(shè)置的第一時(shí)間準(zhǔn)備》由會(huì)員分享，可在線閱讀，更多相關(guān)《代謝綜合癥：臨床設(shè)置的第一時(shí)間準(zhǔn)備（28頁珍藏版）》請(qǐng)?jiān)谘b配圖網(wǎng)上搜索。

1、The Metabolic Syndrome: Ready for Prime Time in Clinical Settings?Yuling Hong, MD, PhD, FAHA*Director, Biostatistics and EpidemiologySenior Science and Medicine AdvisorAmerican Heart AssociationThe presentation does not necessarily represent the official position of the American Heart Association Ou

2、tline Evolution of the the Metabolic Syndrome( MetS).Clinical definitions and the implications. Major health consequences of the MetS.Is the metabolic syndrome a useful marker of CHD above and beyond the risk associated with its individual components and other major CVD risk factors? Underlying mech

3、anisms behind the MetS and factors associated with it. Management of the MetS? Future research directions Syndrome X PlusDiabesity, the Big 4, the Deadly Quartet, the, the Reaven Syndrome, is a term for constellation of endogenous risk factors that increase the risk of developing both atherosclerost

4、ic vascular disease (ASCVD) and type 2 diabetes mellitus. 1923: Kylin described clustering of hypertension, gout, and hyperglycemia1988: Reavens Banting lecture at ADA Annual Conference described the term of Syndrome X. 1998: World Health Organization first defined the MetS for clinicians and resear

5、chers.2001: US NCEP ATP III definition for the MetS was released2005: IDF and AHA/NHLBI definition of the MetS for worldwide use was releasedEvolution of the MetS WHO (1998)Insulin resistance DM / IGT / IFG2 or more of1)ObesityW/H ratio:0.9(m), 0.85(w);BMI: 302)DyslipidemiaTG 150; HDL-c35(m)/39(w)3)

6、Blood pressure 140/904)High glucose5)Microalbuminura EGIR (1999)Insulin resistance2 or more of1) ObesityWC:94(m)/80(w) 2) DyslipidemiaTG 150;HDL-c393) Blood pressure 140/90 or RX4) High glucoseIGT or IFG (but notDM) ATP III (2001)3 or more of1)ObesityWC102(m)/88(w)2)High TG1503)Low HDL-C110 includin

7、g DM AACE (2003)IGT / IFG1 or more of1)ObesityBMI: 302)DyslipidemiaTG 150; HDL-c40(m)/45(w)3)Blood pressure 130/854)High glucose5)Other features of Insulin resistance IDF (2005)Increase WC(population specific)2 or more of1) TG 150 or Rx 2) HDL-c40(m)/50(w) or RX3) Blood pressure 130(S) or 85(D) or R

8、x4) High glucose 100 including DM AHA/NHLBI(2005)3 or more of1)ObesityWC102(m)/88(w)*2)High TG150 or Rx3)Low HDL-C100 or Rx*90/80 for Asician A Prevalence of Components of the MetS* *US adults age 20 and over (1988-1994) Ford ES, et al. JAMA. 2002:287:356-359. Age-Adjusted Prevalence of the MetS: Re

9、sults from the NHANES III Survey* *Criteria based on ATP III; diabetics were included in diagnosis; overall unadjusted prevalence was 21.8%.Prevalence , % 24.8 16.4 28.322.8 25.7 35.60510152025303540 White 25.7% differenceAfrican American Mexican American MenWomen 56.7%difference Ford ES, et al. JAM

10、A. 2002;287:356-359. 05101520253035404550 20-70+ 20-29 30-39 40-49 50-59 60-69 70Men WomenAge (years)Ford E et al. JAMA. 2002;287:356(%) Number of publication of the MetS in Medical Literatures Year of publication Number of PublicationsAnyway in the Citation In the title only1970 70 131980 79 301988

11、 203 841990 260 911995 649 2782000 1097 4662004 2381 1180 How is the MetS used by clinicians? On May 11, 2000, The US ICD-9-CM Coordinating and Maintenance Committee created a new ICD code for the MetS. The official name is Dysmetabolic Syndrome In October 2001, the code of 277.7 became available. H

12、ow is the MetS is used by clinicians? Sixteen and 11 records of the MetS in the 2002 and 2003 NHDS database (327254 and 319530 records) Of 16 records in 2002 3: third-listed Dx 2 each: fourth- and fifth-listed Dx 6: sixth-listed Dx 3: seventh-listed Dx Of 11 records in 2003 1: First-listed Dx 2 each

13、: third- through seventh- listed Dx Ford E. Diabetes Care 2005;28:1808 Major Health Consequences of the MetSSummary of evidence from 15 prospective studiesRelative Risk for ATP III MetS definition For all-cause mortality1.27 (95%CI: 0.90-1.78) For CVD1.65 (95%CI:1.38-1.99) For DM 2.99 (95%CI:1.96-4.

14、57) Relative Risk for WHOMetS definition For all-cause mortality1.37 (95%CI: 1.09-1.74) For CVD1.93 (95%CI:1.39-2.67) For DM 2.60 (95%CI:1.55-4.38) Ford E. Diabetes Care 2005;28:1769 Major Health Consequences of the MetSSummary of evidence from 15 prospective studiesPopulation-attributable fraction

15、for the MetS: 6-7% for all-cause mortality12-17% for cardiovascular disease30-52% for diabetes mellitus Ford E. Diabetes Care 2005;28:1769 Major Health Consequences of the MetSSummary of evidence from 15 prospective studiesAdjustment scheme None: 3 studies Age only: 4 studies Age, sex: 1 study Age,

16、sex, race: 1 study Age, sex, race, and other major CVD risk factor: 6 studies Age, sex, race, and all major CVD risk factor (ie,Family history, smoking, HBP, high cholesterol,Obesity, physical inactivity, diabetes): none Ford E. Diabetes Care 2005;28:1769 Major Health Consequences of the MetSSummary

17、 of results from 11 prospective studies in non-diabetic European men and womenOverall hazard ratios for all-cause mortality* 1.44 (95% CI: 1.17-1.84) in men 1.38 (95% CI: 1.02-1.87) in womenOverall hazard ratios for cardiovascular mortality* 2.26 (95% CI: 1.61-3.17) in men 2.78 (95% CI: 1.57-4.94) i

18、n women*After adjustment for age, BP, cholesterol and smoking Hu G, et al. Arch Int Med 2004;164:1066 How does obesity relate to the MetS? Genetics of the MetS Common genetic for all the component of the MetS BMI IR TG HDL SBPG EG G GE E E EGenetic and Environmental Architecture of IRSHong Y et al.

19、AJHG 1997;60:143 Goals and Recommendations for Clinical Management of the MetS No specific drugs for the MetS use only Refer AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke, AHA/ACC Guidelines for Prevention Heart Attack and Death in Patients with Atherosclerotic Cardiovas

20、cular Disease, the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7), and the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adu

21、lts (ATP III) in the US Additional measures reported to be associated with the MetS and in need of more researchAbnormal fat distribution General fat distribution Central fat distribution Biomarkers Liver fat contents Myocellular fatAtheogenic dyslipidemia Apolipoprotein B Small LDL particles Trigly

22、cerides/HDL-c ratioDysglycemia Fasting glucose OGTT Hoemonal factors Corticosteroid axis Polycystic ovary syndrome Insulin resitanceFasting insulin/proinsulin HOMA-IR IR by Bergman MIMOD Elevated fasting or OGTT FFA Vascular Dysregulation Endothelial dysfuction Microalluminua Chronic renal diseasePr

23、oinflammatory state C-reactive protein Inflammatory cytokinesProthrombotic state Fibrinolytic factors (PAI-1, etc) Clotting factor (fibrinogen, etc)Grundy et al. Circulation 2005,112, Modified Add Future research Assess whether all components of the MetS are equally important and whether some combin

24、ations have great risk Need more evidence-based analysis to assess the rationale and value of adding or (replacing) other CVD risk factors (eg, age, CRP, family hx, a direct measure of insulin resistance Require additional basic and clinical research to better understand Pathophysiology from the sta

25、ndpoint of genetics molecular biology and cellular signaling Establish a standard method to measure blood insulin level Conduct clinical trials to conform ASCVD risk reduction from decreasing insulin resistance per see Improve strategies to achieve and sustain long-term weight reduction and increase

26、d physical activities Evaluate the cost-effectiveness of various drugs, both alone and in combination therapies Reference Group=No MetS componentsHBP = Elevated BPHG = Elevated fasting glucoseTG = Elevated triglyceridesHDL = Low HDL-Cholesterol levelWC = Elevated Waist circumferenceAll 16 possible c

27、lusters of MetS components were entered into the models and compared to individuals without any of MetS components (reference group). All models were adjusted for age, race, and sex. Personal communication with Dr. D Liao Conclusions 1. MetS is highly prevalent in our society 2. It has not been well

28、 recognized and diagnosed by clinicians despite of extensive research and publications3. The syndrome is not a discrete entity known to be caused by a single factor. Moreover, it shows considerable variation in the components among different individuals. This variation is even greater among differen

29、t racial and ethnic groups.4. MetS is a secondary target for reducing CV events. Smoking cessation, lowering the levels of LDL-c, and blood pressure management are primary target for risk reduction Conclusions 5. Lifestyle interventions are the initial therapies recommended for treatment of the MetS

30、. If lifestyle change is not sufficient, the drug therapies for abnormalities in the individual risk factors may be indicated.6. To date, there is insufficient evidence for primary use of drugs that target the underlying causes of the MetS7. Considerable additional research is needed to better refine the most appropriate therapies for individuals with the MetS