Atherosclerotic Cardiovascular Disease (ASCVD)
The Metabolic syndrome is a cluster of
metabolic risk factors which is strongly associated with the risk for
the development of atherosclerotic cardiovascular disease and Type 2DM.
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.
|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)
Modifiable Risk factors
Lifestyle risk factors
Obesity, especially central or visceral obesity
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 LDL-Cholesterol levels
Elevated blood pressure systolic and/or diastolic,
Elevated plasma glucose,
A prothrombotic state, and
A proinflammatory state.
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.
|"BASIC SCREEN" for risk
1) a comprehensive clinical history and examination for the presence
of coronary heart disease, or cerebrovascular, or peripheral vascular
disease; this includes questions about previous angina. TIAs, intermittent
claudication, established myocardial infarction etc.
2) family history for premature coronary artery disease.
3) A complete physical examination for cardiac function, presence or absence
of peripheral pulses, presence of bruits, evidence of peripheral and /
or cerebral ischemia.
4) Blood pressure recordings.
5) Waist measurements and BMI
6) Lipid profile this profile should include, estimation of serum triglycerides,
serum total cholesterol, HDL-cholesterol and calculated LDL cholesterol
although preferable to do in a fasting state, may be done with a random
sample, and the values confirmed in the fasting stage, if abnormal.
7) Estimation for the presence of microalbuminuria in those who are dipstick
8) History of tobacco use.
9) Standard resting 12 lead ECG; sensitivity of the standard 12 lead resting
ECG is moderate and cannot rule out the possibility of clinically significant
Further investigation would depend on individual circumstances, availability
and degree of clinical suspicion.
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.,
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%).
NOTE: This system does not take diabetes into its point consideration
as all people with diabetes are considered to be in the high risk category.
People with diabetes and ASCVD are always considered to be in the high
|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.
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 risk patients merit intensive management of the risk factors as well
as T2DM if present.
For individuals at high or moderately high 10-year risk, consideration
must be given to specific therapies for the metabolic risk factors. A
person's 10-year risk status will determine the intensity of therapy for
each risk factor and, particularly, whether drug therapy should be employed
in addition to lifestyle management. Factors that favor therapeutic option
are those that can raise individuals to upper range of moderately high
risk: multiple major risk factors, severe and poorly controlled risk factors
(especially continued cigarette smoking), metabolic syndrome, and documented
advanced subclinical atherosclerotic disease (eg, coronary calcium or
carotid intimal-medial thickness >75th percentile for age and sex).
No specific drugs are currently recommended for people with the metabolic
syndrome independent of those agents most appropriate for specific, abnormal
The management of most of the traditional risk factors has been dealt
with in more detail in separate sections.
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
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.