Introduction, Integration of CM risk factors, Targeting obesity, Management of hypertension, Management of dyslipidemia, Antiplatelet therapy, Management of microalbuminuria, CB1 blockade

1. METABOLIC SYNDROME
Dr. Md.Toufiqur Rahman
MBBS, FCPS, MD, FACC, FESC, FRCPE, FSCAI,
FAPSC, FAPSIC, FAHA, FCCP, FRCPG
Associate Professor of Cardiology
National Institute of Cardiovascular Diseases(NICVD),
Sher-e-Bangla Nagar, Dhaka-1207
Consultant, Medinova, Malibagh branch
Honorary Consultant, Apollo Hospitals, Dhaka and
STS Life Care Centre, Dhanmondi
drtoufiq19711@yahoo.com

2.  Introduction
 Integration of CM risk factors
 Targeting obesity
 Management of hypertension
 Management of dyslipidemia
 Antiplatelet therapy
 Management of microalbuminuria
 CB1 blockade
 Conclusion
METABOLIC SYNDROME

3. METABOLIC SYNDROME
Heart disease and stroke are the most
common life-threatening consequences of
diabetes mellitus, with mortality rates up
to two to four times higher for persons
with diabetes vs. those without.
JAMA.2002;288:2709-2716

4. INTRODUCTION
Type-2 diabetes is associated with
clustering of multiple cardiometabolic
risk factors such as
Obesity,
Hypertension,
Dyslipidaemia,
Microalbuminuria,
Prothombotic state.
Proinflammatory state

5. METABOLIC SYNDROME (MS)
 Cluster of cardiovascular risk factors occurring in
association with insulin resistance and obesity.
 Obesity, insulin resistance/hyperglycemia and
dyslipidemias (high TG and low HDL) are common
components in all definitions of MS.
 In patients with the metabolic syndrome, relative risk for
ASCVD ranges form 1.5 to 3.0
 Once diabetes develops, cardiovascular risk increases
even more.
 ASCVD risk in MS is greater than the sum of its measured
risk factors and the risk rises geometrically instead of
linearly (Grundy 2006).

6. INTEGRATION OF MULTIPLE CARDIOMETABOLIC RISK
FACTORS

7. TARGETING OBESITY

8. TARGETING OBESITY
• Measures of obesity- body mass index (BMI) as a
measure of overall obesity and waist circumference
(WC) as a measure of abdominal obesity.
• WHO 1999 - BMI > 30 kg/m2 or Waist-to-hip ratio>0.9
(male) or >0.85 (female)
 Waist circumference
NCEP ATP III - ≥102 cm (male), ≥88 cm (female)
IDF 2005 (South Asian) - ≥90 cm (male),
≥80 cm (female)

10. THERAPEUTIC GOALS AND RECOMMENDATIONS
WEIGHT MANAGEMENT
Goals:
 Reduce body weight by 7% to 10% during
year 1 of therapy.
 BMI - 18.5-24.9 kg/m2
 Waist circumference:
<90 cm in male <80 cm in female

11. RECOMMENDATIONS -- WEIGHT MANAGEMENT
 Balance of physical activity, caloric intake,
and formal behavior-modification programs.
 Decrease caloric intake by 500 to 1000
calories per day for over weight or obese or
metabolic syndrome.

12. Lake of Physical Activity

13. How much active we are?

14. THERAPEUTIC GOALS AND RECOMMENDATIONS
PHYSICAL INACTIVITY
 Goals
Regular moderate-intensity physical activity; at
least 30 min of continuous or intermittent (and
preferably 60 min) 5 d/wk, but preferably daily
 Recommendations
For general public (without any risk factors) > 30
mins brisk walking at least 5 days of the week,
preferably daily.
Those with obesity or metabolic syndrome
sixty minutes or more of continuous or
intermittent aerobic activity, preferably
done every day, will promote weight loss
or weight-loss maintenance

15. RECOMMENDATIONS
 Preference is given to 60 minutes of moderate intensity
brisk walking to be supplemented by other activities
including :
multiple short (10- to 15-minute) bouts of activity
(walking breaks at work, gardening, or
household work),
using simple exercise equipment (e.g., treadmills),
jogging, swimming,
biking, golfing, team sports, and
engaging in resistance training
avoiding common sedentary activities in leisure
time (television watching and computer
games)

16. Lack of
vegetables
& fruits
Excess alcohol/soft drinks
Excess salty sugary fatty food
Recipe for Unhealthy Diet

17. THERAPEUTIC GOALS AND RECOMMENDATIONS -- DIET
 Goals:
 Ample intake of fresh fruits and vegetables,
 Low salt intake
 Reduced intakes of saturated fats, trans fats and
cholesterol
 Recommendations:
 At least 5 portions of fresh fruits and vegetables per day
(one large apple, guava or tomato or 2 teaspoonful
cooked vegetables is equal to one portion)
 Whole grains and fish intake should be encouraged
 Fiber intake (20-35g/d) including 2g/d plant stanol
/sterols and > 10g/d viscous fiber
 Encourage omega-3 fatty acid in the form of fish or in
capsule form (1g/d)

18. RECOMMENDATIONS -DIET (CONT’D):
 Saturated fat ,<7% of total calories;
 Reduce trans fat;
 Dietary cholesterol < 200 mg daily;
 Total fat 25–35% of total calories;
 Most dietary fat should be unsaturated;
 Carbohydrates- 50-60 % of total calories
 Proteins 15 % of total calories
 Simple sugars should be limited.
 Moderation of alcohol intake; overweight patients
should avoid alcohol.

19. HYPERTENSION
 Blood pressure should be
measured at every routine
diabetes visit.
 Goals:
Patient of diabetes should
be treated to a SBP <130
mmHG and DBP <80 mmHG.

20. HYPERTENSION
 SBP 130-139 mmHG & DBP 80-89 mmHG :
Lifestyle and behavioral therapy for a maximum
of 3 months. If target are not achieved treat with
pharmacological agent.
 SBP≥140 mmHG & DBP ≥90 mmHG:
Start with drug therapy in addition to
lifestyle and behavioral therapy.

21. HYPERTENSION
 Multiple drug therapy (Two or more agents
at proper doses) is required to achieve
blood pressure target.
 All patient with diabetes and hypertension
should be treated with a regimen that
includes either an ACE inhibitor or an ARB.
 If ACEi, ARBs or diuretics is used, monitor
renal function and serum potassium level.

22. MANAGEMENT OF DIABETIC DYSLIPIDEMIA

23. THE CHANGING LANDSCAPE OF CARDIOMETABOLIC RISK
Past burden : High LDL
Coming burden :
Dyslipidaemia ( low HDL, high
TG & small, dense LDL)

24. HDL WITH NEW DIMENTIONS
 Numerous prospective epidemiological studies have shown
a strong inverse relationship between HDL cholesterol
(HDL-C) levels and coronary heart disease (CHD).
 Many controlled clinical trials demonstrate that treating
patients with low HDL-C with lipid modifying therapies, can
reduce major coronary events.
 Even in patients treated to aggressive LDL-C goals,
coronary events still occur, and low HDL-C is a major risk
factor in this group.

25. CURRENT APPROACHES TO PATIENTS
WITH LOW HDL-C
 Therapeutic lifestyle changes:
Smoking cessation Aerobic exercise
Weight reduction Diet
 Pharmacological therapy: Increases HDL by-
Statins ---5-10%
Fibrates ---- 5-20%
Niacin ------ 15-30%
Pioglitazone ----5-15%

26. P.J. Barter, Editorial, Arterioscler Thromb Vasc Biol. 2005;25:1305-1306

27. NEW APPROACHES TO
THERAPEUTIC TARGETING OF HDL
 New Approaches are based on current
understanding of M/A of HDL.
 An important concept is that simply raising HDL-
C levels may not necessarily be the optimal
target for the development of new therapies
targeted toward HDL.
 Function of HDL is more important than its
concentration and that therapies that improve
HDL “function,” even if they do not increase
HDL-C levels, may have important
antiatherogenic and vascular protective effects.

28. THE TARGET AREAS FOR THERAPY
 Apolipoprotein A-I–Directed Therapies
-Recombinant Apo A-I Milano and synthetic HDL-C
-Apo A-I mimetic peptide
 Therapies Directed to Promotion of Macrophage
Cholesterol Efflux and RCT
-Increase expression of ABCAI receptor
 Therapies Intended to Alter HDL and ApoA-I Metabolism
to Raise Their Levels in Plasma
-CETP inhibitors : Torcetrapib, JTT-705

29. LOWERING TG
 Goal: Lower TG to<150mg/dl
 Lifestyle interventions:
Weight loss
Increased physical activity
Restricted intake of saturated fat
Increased monounsaturated fat
Reduction of carbohydrate intake
Reduction of alcohol consumption.

30. LOWERING TG
 Improved glycaemic control
 Fibric acid derivatives (gemfibrozil, fenofibrate)
 Niacin
 High dose statins (in those who also have high LDL
cholesterol)

31. ANTIPLATELET AGENT
Aspirin therapy (75-162mg/day) is recommended
in all patients with 10 years risk of CHD
≥10%,CHD patients, and coronary risk
equivalents including diabetes.

32. MANAGEMENT OF MICROALBUMINURIA
Screening:
Annually in all type-2 diabetic patients
starting at diagnosis and during
pregnancy.
Treatment:
In the treatment of both micro and
macroalbuminuria, either ACEi or ARBs
should be used except during
pregnancy.

33. ATTACKING MULTIPLE RISK FACTORS BY SINGLE AGENT –
RIMONABANT (CB1 BLOCKER)
Central blockade
(hypothalamus)
Decreased food intake
(decrease weight)
Peripheral blockade
(adipose tissue)
Decreased abdominal fat
(waist circumference)
Adiponectin
 Triglycerides
 High-density lipoprotein
 Small, dense low-density
lipprotein
C-reactive protein
 Insulin resistance

36. THANK YOUdrtoufiq19711@yahoo.com
Asia Pacific Congress of
Hypertension, 2014, February
Cebu city,
Phillipines
Seminar on Management
of Hypertension,
Gulshan, Dhaka