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Atherosclerotic Cardiovascular Disease (ASCVD)

The presence of the metabolic syndrome raises the lifetime risk for both ASCVD and type 2 diabetes (T2DM). Average relative risks are increased about twofold for ASCVD and fivefold for T2DM compared with those for individuals without the metabolic syndrome. The risk for ASCVD is significantly more in those people with the metabolic syndrome who already have T2DM.

At the same time, the metabolic factors utilized in making the diagnosis of the metabolic syndrome do not take into account all the known risk factors leading especially to ASCVD.


Table


The risk factors for premature atherosclerotic cardiovascular disease (ASCVD) are:

Non-Modifiable Risk factors

Genetic factors (family history of premature CAD in first degree relative: male < 55years and female <65 years old) The closeness of the relationships (eg, CHD in a sibling or parent confers greater risk than CHD in an uncle)

Age of the patient ( >45 years in men and > 55 years in women)

Male Sex
Modifiable Risk factors

Lifestyle risk factors

Obesity, especially central or visceral obesity

Atherogenic diet

Physical inactivity

Smoking
Metabolic Risk Factors

Atherogenic dyslipidemia (elevations of lipoproteins containing apolipoprotein B, elevated triglycerides, increased small particles of LDL, and low levels of high- density lipoproteins (HDL), Elevated lipoprotein(a)

Elevated LDL-Cholesterol levels

Elevated blood pressure systolic and/or diastolic,

Elevated plasma glucose,

A prothrombotic state, and

A proinflammatory state: Markers of inflammation, such as hs-CRP

Elevated homocysteine.

"BASIC SCREEN" for risk factors is practically the same as one would undertake for a person with diabetes.

Further investigation would depend on individual circumstances, availability and degree of clinical suspicion.

Management

The metabolic syndrome is a simple clinical tool to identify people with a particular set of risk factors who are at higher life time risk for both ASCVD and type 2 diabetes.

All patients with the metabolic syndrome must be offered

1) lifestyle intervention (weight loss, increased physical activity, and a healthy diet) and
2) more detailed, short-term risk assessment (e.g., Framingham scoring).

For management of long-term as well as short-term risk, lifestyle therapies are first-line interventions to reduce the metabolic risk factors. The major lifestyle interventions include weight loss in overweight or obese subjects, increased physical activity, and modification of an atherogenic diet. These changes will produce a reduction in all of the metabolic risk factors simultaneously. In the long run, the greatest benefit for those with the metabolic syndrome will be derived from effective lifestyle intervention.

For metabolic syndrome patients without ASCVD or diabetes, Framingham risk (or similar validated risk) scoring should be performed to estimate 10-year risk for coronary heart disease (CHD). This assessment triages patients into 3 risk categories based on 10-year risk for CHD: high risk (10-year risk >20%), moderately high risk(10-year risk 10% to 20%), or lower to moderate risk (10-year risk <10%).

For the Framingham Point Score Tables see Appendix 16a

Framingham Point Scores

People with diabetes and ASCVD are always considered to be in the high risk category.

CHD risk is also higher than indicated in the charts for:

Those with a family history of premature CHD (male first degree relatives aged <55 years and female first degree relatives aged <65 years) which increases the risk by a factor of approximately 1.5

Those with raised triglyceride levels and other dyslipidemias.

Women with premature menopause.

Those who are not yet diabetic, but have IFG or IGT, or both.

Patients with Type 1 diabetes.

Patients with type 2 diabetes

Moreover, in ethnic minorities the risk charts should be used with caution because they have not been validated in these populations. For example, in people originating from the Indian subcontinent it is safest to assume that the risk is higher than predicted from the charts.


Management

High-risk patients have established atherosclerotic CVD, diabetes, or 10-year risk for CHD >20%. For cerebrovascular disease, high-risk conditions include TIA or stroke of carotid origin or >50% carotid stenosis.

All high and moderately high 10 year risk patients merit intensive and specific management of all metabolic risk factors as well as T2DM if present.

No specific drugs are currently recommended for people with the metabolic syndrome independent of those agents most appropriate for specific, abnormal risk factors.

The management of most of the traditional risk factors has been dealt with in more detail in separate sections.

Prothrombotic State

In metabolic syndrome patients who are at high or moderately high risk for ASCVD events, aspirin prophylaxis is an attractive therapeutic option to lower vascular events.
Dosage recommendations range from 75 mg to 325 mg per day. The principal risks of aspirin therapy include gastric mucosal injury and gastrointestinal hemorrhage. Minor bleeding episodes may occur at low dosages. Contraindications to aspirin include allergy, tendency for bleeding, anticoagulant therapy, recent gastrointestinal bleeding and clinically active hepatic disease. Ticlopidine and recently clopidogrel have also been used either by themselves or with aspirin. But most studies still maintain the primacy of aspirin usage.

Proinflammatory State

Although several drugs used to treat other metabolic risk factors have been reported to reduce CRP levels (eg, statins, nicotinic acid, fibrates, ACE inhibitors, thiazolidinediones), presently, these drugs cannot be recommended specifically to reduce a proinflammatory state independent of their indications for other risk factors.



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