CasePresentation

Moderator:SharonLiu,DOAssociateInternalMedicineChief

AustinRegionalClinicAustin,Texas

Izzy(2006)• 51y/oHispanicwomanwithahistoryofdiabetesandobesity.• Herdiabeteshasnotbeenwell-controlledasshecravessweet

candy,carbohydratesandprocessedfoods.• Shedrinkssocially,onaverage6drinksaweek,smokes½pack

ofcigarettesaday.Shedeniesdruguse.Shehas2tattoos,obtainedintheearly1980s.

• PMHispositiveforHTN,hypothyroidismandhyperlipidemia.• BMIis32;waistcircumferenceis36.5inches.• Worksasadministrativeassistantforadoctorintown.• Marriedandhas2adultchildren.

Izzy• Substernalburningpainforthepast6weeksforwhichherPCPprescribedaPPI.SymptomspersisteddespitePPI.

• ReturnedtoPCP.• Labs– CMP:LFTsweremildlyelevated,otherwisenormal– CBCnormal– Fastinglipidpanel:LDL170,HDL32,triglycerides352– HgA1c9.4

• BP:140/90• ReferredtoDr.Dlabal

CardiovascularComplicationsofMetabolicSyndrome

PaulW.Dlabal,M.D.

Austin,Texas

MetabolicSyndrome: DefinitionsofNCEP,WHO,EGIRandACE

JACC Vol. 59,No.72012- February 14,2012; 665-72

Circulation. 2005;112:666-673

PrevalenceofIndividualMetS Abnormalities

Circulation. 2004;110:1245-1250

MetabolicSyndrome:Definitions/HazardRatios/Risk

Circulation. 2005;112:666-673

NumberofMetabolicSyndromeAbnormalitiesbyNCEP

Circulation. 2005;112:666-673

UnadjustedKaplan-MeierHazardCurves

JAMA December 4, 2002– Vol 288,No.21(Reprinted)

AgeandGenderAdjustedCHD,CVD,andTotalMortalityRates

Circulation. 2004;110:1245-1250

MetabolicSyndromeandAge-adjustedRisk

Circulation. 2005;112:3066-3072

MetabolicSyndrome/AgeAdjustedRisk

Circulation. 2005;112:666-673

Four-yearKaplan-MeierPlotsofSurvival

Circulation. 2004;109:714-721

WomenWithoutSignificantCAD

Circulation. 2004;109:714-721

WomenWithSignificantCAD

Circulation. 2004;109:714-721

IncidenceRateofMajorCVEvents

Circulation. 2010;121; 230-236; originally published December 28, 2009

RisksinOverweightorObesePatients:With/WithoutMetabolicSyndrome

Circulation. 2010;121; 230-236; originally published December 28, 2009R

ISTHEREHOPE?

• TheproblemconsistsofMODIFIABLE riskfactorsforCAD/CHD/CVMortality

• ThesolutionistoMODIFYtheserisks:–WeightLoss– IncreasedCardiorespiratoryFitness–DirectIntervention

Correlations BetweenChangesinFitnessorFatness

JACC Vol. 59,No.72012- February 14,2012; 665-72

HRsofIncidentCardiovascularDiseaseRisk(1)

JACC Vol. 59,No.72012- February 14,2012; 665-72

HRsofIncidentCardiovascularDiseaseRisk(2)

JACC Vol.59,No.72012- February 14,2012; 665-72

HRsofIncidentCardiovascularDiseaseRisk(3)

JACC Vol.59,No.72012- February 14,2012; 665-72

Summary

• TheprevalenceofmetabolicsyndromeintheUSandotherindustrializedcountriesissubstantial,andcontributesgreatlytotheburdenofCVD.– Affects:Upto25%oftheUSpopulation.– CVRisk:Increasesupto2fold.– Diabetes&MetS increasetheriskupto4fold.– CV&MetS syndromeincreasetheriskmorethan4fold.

– Improvementinfitness&fatnessconfersexpectedbenefit.

BacktoDr.Liu

Izzy• Acardiacstresstestwasorderedanditwaspositive.Sheunderwentaleftcardiaccath andwasfoundtohave1vesseldisease,thiswasstented.

• Treatmentplan– StartedonPlavix

• Hersubsternalpainresolvedandshefeltmuchbetter.• Labs:LDL145,HDL35,TG230• UltrasoundwasorderedsinceLFTsremainedelevated.• Dr.Dlabal,howwillyoumanageherhyperlipidemia?

LipidManagementinMetabolicSyndrome

PaulW.Dlabal,M.D.

Austin,Texas

MetabolicSyndrome:ConstellationofReversibleRiskFactorsforCAD

• ReducedHDL• ElevatedTG• ElevatedBPandFBS• Weightgain

CriteriaforClinicalDiagnosis

Grundy “RiskAssessment” NCBIBookshelf, 2015

SecondaryCausesofHyperlipidemiaMostCommonlyEncountered

AHA

ParadigmforSubtypingMetS

JACC VOL.66,NO.9,2015 SEPTEMBER1,2015:1050–67

Step-by-stepProcessofReviewofEvidenceintheGuideline

JACC Vol. 59,No.72012- February 14,2012; 665-72

Cholesterol-ASCVDRelationship:TwoTypesofMeta-Analysis

JACC Vol. 59,No.72012- February 14,2012; 665-72

SummaryofStatinInitiationRecommendations

Professional Heart.org,AHA

FourTreatmentBenefitGroups

• ASCVD• LDL>190mg/dL• Diabetes• LDL<190mg/dL with10-yearrisk>5%

JACC Vol. 59,No.72012- February 14,2012; 665-72

DefinitionofTreatmentIntensity

Step-by-stepProcessofReviewofEvidenceintheGuideline

JACC Vol.59,No.72012- February 14,2012; 665-72

JACC Vol. 59,No.72012- February 14,2012; 665-72

Step-by-stepProcessofReviewofEvidenceintheGuideline

JACC Vol. 59,No.72012- February 14,2012; 665-72

Step-by-stepProcessofReviewofEvidenceintheGuideline

InitiatingStatinsinIndividualswithClinicalASCVD

AHA

AHA

InitiatingStatinsinIndividualsWithoutClinicalASCVD

RiskCalculators

• http://my.americanheart.org/cvriskcalculator• http://www.cardiosource.org/en/Science-And-Quality/Practice-Guidelines-and-Quality-Standards/2013-Prevention-Guideline-Tools.aspx

• http://tools.acc.org/ASCVD-Risk-Estimator/

ASCVDRiskEstimator

ACCandAHA2014

TheAbsoluteCVDRisk/BenefitCalculator

AHA2014

CriteriaforClinicalDiagnosisbyCAC

Grundy “RiskAssessment” NCBIBookshelf, 2015

CholesterolLoweringDrugs

Grundy “RiskAssessment” NCBIBookshelf, 2015

Patient1

Patient1

SecondaryCausesofHypertriglyceridemia

Tamrock “Risk Assessment forTG”NCBI2000

CholesterolLoweringDrugs/AlsoGoodforTG

Grundy “RiskAssessment” NCBIBookshelf, 2015

StatinRxvsLiverDamageinNASH

Nascimbeni Fetal.,BMJOpenGastro2016:3:e000075. doi:10.1136/bmjgast-2015-000075

Summary:TreatmentofHyperlipidemiaisComplex!

• AfterDx,thendietandlifestylechange.• AssessriskgroupandneedforRxaswellasintensityofRx.

• SinceMetS doublesCVriskoveranybaseline,initiatestatintherapywhereindicated.

• MonitorresultsfornecessitytoaugmentRx.• AssessTGlevel,Dx andneedforRx.• Wherenecessary,obtainlipidparticlesizeandnumbertooptimizeRx.

Izzy

• StartedonLipitor.• Shewasgivenastrictlowcholesteroldiettofollow.– Sinceshecutbackoneatingfattyfoods,shestartedeatingmoresweets.

• Labs:HgA1c10.5• ShewasthenreferredtoDr.Musi.