(July 31, 2008 - Insidermedicine) Welcome to Insidermedicine's If I Had, where we get a chance to ask an expert what they would do if they had a medical condition.
On a recent trip to Atlanta, we caught up with Dr. Larry Sperling, MD, a Cardiologist and the Director of Emory University's Center for Heart Disease Prevention.
What is metabolic syndrome?
Metabolic syndrome is a constellation of cardiovascular risk factors. If we were to define it on paper, it’s having three out of five factors. Including central obesity, which can be defined either by waist circumference, or BMI, your Body Mass Index. Low HDL cholesterol, that’s the good cholesterol. Moderate elevations of the triglycerides, circulating fats in the blood. High blood pressure, or evidence of insulin resistance. That means just slightly elevated blood sugar levels, but not full-blown diabetes.
What are the keys to preventing the disease?
In regards to metabolic syndrome certainly one of the keys to primary prevention of heart disease is just the detection of this syndrome. Although it is very prevalent, about a quarter of all adults Americans have this syndrome by definition; about forty-two percent of individuals over the age if sixty. It often goes undiagnosed. I would have to say one of the keys to primary prevention is diagnosis of this clustering of risk factors. We know that once identified we can do a lot about these individuals risks. The initial approach, often depending on the age of this person and whether the have any other manifestations of overt heart or blood vessel disease, might be a lifestyle approach. Its been well studied, in a study called The Diabetes Prevention Program, in several thousand people with this pre-diabetic state who were randomized to a lifestyle program, versus a medicine typically used for diabetes. And actually the lifestyle program of walking for thirty five minutes five days per week, losing five to seven percent of their bodyweight, and improving their diet, reduced the development of diabetes by fifty eight percent. Even better than any of the medicines we have available.
What are methods of secondary prevention for metabolic syndrome?
I think it’s important for the audience to also understand the difference between primary and secondary prevention in terms of heart disease, or heart disease risk. In primary prevention our patients are people who have risk factors. Our job as doctors and patients are to prevent hard events, like a heart attack, or a stroke, or needing a by-pass, or an angioplasty. Secondary prevention; these are people who have already had clinical manifestations of blood vessel disease. They’ve had a heart attack, they’ve been hospitalized with chest pain; angina, chest pain from the heart. Had a stroke, heart attack, had identified blood vessel disease. In this category of individuals with metabolic syndrome the cat is out of the bag. We really approach this population ultra-aggressively. We call these people “heart risk equivalents”, even before they have had an event if they have full-blown diabetes. But after their event we treat them as the highest of the high risk patients. Our targets and goals for treating them both with medical therapy and aggressive behavioral therapy are really getting tougher and tougher. We are pushing harder and harder to get their cholesterol levels down, their blood pressure down. And certainly to affect things like quitting smoking, walking, losing weight.
What is the evidence for the use of statins in primary prevention of metabolic syndrome?
If we look at statins, which is the most commonly used medication for high cholesterol, in people who have risk or risk factors the evidence is pretty compelling if we select the right individuals. If we look at some of the studies that have looked at this in particular there was a study of average Americans, if was called the AFCAPS/TexCAPS Trial. These average Americans actually had lower than average heart risk. But they had low good cholesterol levels, the HDL. When randomized to a statin, actually the oldest statin on the market, its been used now for twenty years versus a placebo. There was about a thirty five percent reduction in hard end points related to the heart. Again heart attack, dying of heart disease, and need for heart procedures. If we look at other primary prevention trials in individuals with higher heart risk who had high cholesterol, there again was pretty compelling and consistent evidence. In making decisions about who to treat with medications, a statin for primary prevention, what we need to focus on in that individual’s risk, via the Framingham risk score. Whether there is any evidence of occult blood vessel disease, and this is something we can do sometimes at the bedside by listening to the arteries in the neck, examining somebody very closely. And sometimes by trying to further stratify these individuals using measures of subclinical atherosclerosis. And this just means that can we detect disease before it explodes.
If I had a family member with metabolic syndrome…
First and foremost I would want to be aware of it. I’d want it to be brought to my attention that these clustering of heart risk factors that often are genetically imparted in us. What can flip the switch and change our genes are sometime modest changes in our behavior, by gaining a little bit of weight on our abdomen, by becoming sedentary, we can change our whole metabolic pathways and begin a state of inflammation in our blood. Why I would want to be aware of this early or why my family member should be aware of this early is that there is a concept know as the “ticking clock hypothesis”, and this just means that by the time somebody is diagnosed with diabetes, full-blown diabetes, this state of pre-diabetes of inflammation has been going on for several decades. If we are unaware of this we greatly increase our risk of building up plaque in our blood vessels, and for early heart and blood vessel disease. I think awareness would be the key. I would want to be aware that there are very well thought of therapies and the initial therapies would be modest lifestyle and behavioral approaches. An individual with this syndrome who have evidence of high blood pressure or significant cholesterol abnormalities, or even early blood vessel disease, we do have excellent medical therapy that can prevent heart and blood vessel problems as well.