代謝綜合癥：臨床設(shè)置的第一時間準(zhǔn)備ppt課件

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 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

4、first defined the MetS for clinicians and researchers.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 MetSWHO (1998)Insulin resistance DM / IGT / IFG2 or more of1)ObesityW/H ratio:0.9(m), 0.85(w);

5、BMI: 302)DyslipidemiaTG 150; HDL-c35(m)/39(w)3)Blood pressure 140/904)High glucose5)MicroalbuminuraEGIR (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)ObesityWC10

6、2(m)/88(w)2)High TG1503)Low HDL-C110 including DMAACE (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 resistanceIDF (2005)Increase WC(population specific)2 or more of1) TG 150 or Rx 2) HDL-c40(m)/50(w)

7、or RX3) Blood pressure 130(S) or 85(D) or Rx4) High glucose 100 including DMAHA/NHLBI(2005)3 or more of1)ObesityWC102(m)/88(w)*2)High TG150 or Rx3)Low HDL-C100 or Rx*90/80 for Asician APrevalence of Components of the MetS*US adults age 20 and over (1988-1994)Ford ES, et al. JAMA. 2002:287:356-359.*C

8、riteria based on ATP III; diabetics were included in diagnosis; overall unadjusted prevalence was 21.8%.Prevalence, %24.816.428.322.825.735.60510152025303540White25.7% differenceAfrican AmericanMexican American MenWomen56.7%differenceFord ES, et al. JAMA. 2002;287:356-359.0510152025303540455020-70+2

9、0-2930-3940-4950-5960-6970MenWomenAge (years)Ford E et al. JAMA. 2002;287:356(%)Number of publication of the MetS in Medical LiteraturesYear of publicationNumber of PublicationsAnyway in the CitationIn the title only1970701319807930198820384199026091199564927820001097466200423811180How is the MetS u

10、sed 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.How is the MetS is used by clinicians? Sixteen and 11 records of the MetS in

11、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: third- through seventh- listed DxFord E. Diabetes Care 2005;28:1808Major H

12、ealth 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:1.96-4.57)Relative Risk for WHOMetS definition For all-cause mortality1.37 (95%CI: 1.

13、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;28:1769Major Health Consequences of the MetSSummary of evidence from 15 prospective studiesPopulation-attributable fraction for the MetS: 6-7% for all-cause mortality12-17% for cardiovascular disease30-52%

14、 for diabetes mellitusFord E. Diabetes Care 2005;28:1769Major Health Consequences of the MetSSummary of evidence from 15 prospective studiesAdjustment scheme None: 3 studies Age only: 4 studies Age, sex: 1 study Age, sex, race: 1 study Age, sex, race, and other major CVD risk factor: 6 studies Age,

15、sex, race, and all major CVD risk factor (ie,Family history, smoking, HBP, high cholesterol,Obesity, physical inactivity, diabetes): noneFord E. Diabetes Care 2005;28:1769Major Health Consequences of the MetSSummary of results from 11 prospective studies in non-diabetic European men and womenOverall

16、 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) in women*After adjustment for age, BP, cholesterol and smokingHu G, et al. Arch Int Me

17、d 2004;164:1066How does obesity relate to the MetS?Genetics of the MetSBMIIRTGHDLSBPG EGGGEEEEGenetic and Environmental Architecture of IRSHong Y et al. AJHG 1997;60:143Goals and Recommendations for Clinical Management of the MetS No specific drugs for the MetS use only Refer AHA Guidelines for Prim

18、ary Prevention of Cardiovascular Disease and Stroke, AHA/ACC Guidelines for Prevention Heart Attack and Death in Patients with Atherosclerotic Cardiovascular Disease, the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7),

19、 and the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (ATP III) in the USAdditional measures reported to be associated with the MetS and in need of more researchAbnormal fat distribution General fat

20、 distribution Central fat distribution Biomarkers Liver fat contents Myocellular fatAtheogenic dyslipidemia Apolipoprotein B Small LDL particles Triglycerides/HDL-c ratioDysglycemia Fasting glucose OGTT Hoemonal factors Corticosteroid axis Polycystic ovary syndromeInsulin resitanceFasting insulin/pr

21、oinsulin HOMA-IR IR by Bergman MIMOD Elevated fasting or OGTT FFA Vascular Dysregulation Endothelial dysfuction Microalluminua Chronic renal diseaseProinflammatory state C-reactive protein Inflammatory cytokinesProthrombotic state Fibrinolytic factors (PAI-1, etc) Clotting factor (fibrinogen, etc)Gr

22、undy et al. Circulation 2005,112, Modified AddFuture research Assess whether all components of the MetS are equally important and whether some combinations have great risk Need more evidence-based analysis to assess the rationale and value of adding or (replacing) other CVD risk factors (eg, age, CR

23、P, family hx, a direct measure of insulin resistance Require additional basic and clinical research to better understand Pathophysiology from the standpoint of genetics molecular biology and cellular signaling Establish a standard method to measure blood insulin level Conduct clinical trials to conf

24、orm ASCVD risk reduction from decreasing insulin resistance per see Improve strategies to achieve and sustain long-term weight reduction and increased physical activities Evaluate the cost-effectiveness of various drugs, both alone and in combination therapies ReferenceGroup=NoMetScomponentsHBP=Elev

25、atedBPHG=ElevatedfastingglucoseTG=ElevatedtriglyceridesHDL=LowHDL-CholesterollevelWC=ElevatedWaistcircumferenceAll16possibleclustersofMetScomponentswereenteredintothemodelsandcomparedtoindividualswithoutanyofMetScomponents(referencegroup).Allmodelswereadjustedforage,race,andsex.Personal communication with Dr. D Liao Conclusions MetS is highly prevalent in our society It has not been well recognized and diagnosed by clinicians despite of extensive research and publications3. The syndrome is n