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Syndrome X & Cardiac Effects Do You Know Everything You Should? Julia Garrison RN, MSN, CCRN, PCCN Code 266 Proceedings Book pg. 641

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  • Syndrome X & Cardiac EffectsDo You Know Everything You Should?Julia Garrison RN, MSN, CCRN, PCCNCode 266Proceedings Book pg. 641

  • Statistics 24% of the adult population have Metabolic Syndrome X (Met Syn X) and the prevalence reaches 50-60% over age 50 years.

  • StatisticsSoon metabolic syndrome will overtake cigarette smoking as the number one risk factor for heart disease among the US population.

  • JAMA 287:356, 2002

  • Statistics 50% of hypertensive pts and 10% of those with normal blood pressure having evidence of hyperinsulinemia.

  • Statistics In Framingham, the metabolic syndrome alone predicted approximately 25% of all new onset CVD.

  • Prediction The epidemic of insulin resistance syndrome will prevent our ability to improve rates of CVD, which currently accounts for half of deaths among men and one-third of deaths among women.

  • Risk FactorsFor WomenAndroid Appearance Alopecia Hirsutism Central obesity

    History Amenorrhea Infertility Gestational diabetes Birth of baby > 9 lbsFor Men & WomenPhysical Assessment Acanthosis Nigricans Skin Tags

  • Are you one of the Lucky ones?PCOS (Polycystic Ovary Syndrome) The most common endocrinopathy of women, present in 4-7% of womenYounger persons with CHD Metabolic syndrome is particularly likely to be presentNot Diabetic? Approximately one in five nondiabetic persons will develop the metabolic syndrome over the next 5 years

  • Why Do We Care? Insulin resistance will lead to type 2 diabetes and subsequent CHD

  • Does This Person Sound Familiar? E.C. - a 53 year old postmenopausal female -referred for tx of hypertension, with a family hx of T2D, hypertension, and CHD. She has felt well, postmenopausal symptoms had responded to hormone replacemnt tx. BP was too high during routine physical exam. BMI 23.7kg/m2, BP145/95. Lab results revealed a normal blood count and urinalysis, with glucose 102, triglycerides 238, LDL 147, HDL 40

  • How do we define it?The syndrome was first identified in 1988

    ICD 9 diagnostic code 277.7

  • Major Characteristics of Met Syn Xinsulin resistance/ glucose intoleranceabdominal obesityelevated blood pressurelipid abnormalities (elevated levels of triglycerides and low levels of high density lipoprotein HDL)Proinflammatory stateprothrombotic state

  • Metabolic Syndrome Effects of Insulin ResistanceCardio protectionPro-apoptotic stateAtherosclerosisAnti-fibrinolytic statePro-thrombotic StateChronic Pro-Inflammatory StateROS generationOxidative stressPlatelet HyperaggregabilityTonic vasoconstrictionAbnormal vascular reactivityVascular flow reserveHyperinsulinemiaSodium retention

  • Diagnostic Criteria

  • ATP III Clinical Manifestations- Abdominal ObesityMen>102 cm (>40in)Women>88 cm (>35in)- Triglycerides> 150 mg/dl- HDL CholesterolMen< 40 mg/dlWomen< 50 mg/dl- Blood Pressure>130/>85 mmHg- Fasting Glucose>110 mg/dlJAMA 285:2486, 2001.

  • WHO Clinical CriteriaInsulin Resistance, identified by 1 of the following:Type II diabetesImpaired fasting glucoseImpaired glucose toleranceOr for those with normal fasting glucose levels(140 mmHg systolic or >90 mmHg diastolic)Plasma triglycerides >150 mg/dl HDL cholesterol 0.9 in men,>0.85 in womenUrinary albumin excretion rate >20mcg/min or albumin:creatinine ratio >30mg/g

  • AACE Clinical Criteria- Overweight/obesityBMI >25kg/m2- Elevated Triglycerides>150 mg/dl (1.69mmol/L)- Low HDL CholesterolMen< 40 mg/dl (1.04 mmol/L)Women< 50 mg/dl (1.29 mmol/L)- Elevated Blood Pressure > 130/85 mmHg- 2 hr post glucose challenge > 140 mg/dl- Fasting GlucoseBetween 110 and 126 mg/dl- Other risk factors- Family history of type 2 diabetes, hypertension, or CVD - Polycystic ovary syndrome - Sedentary lifestyle - Advancing age - Ethic groups having high risk for type 2 diabetes or CVD

  • Other Useful MeasuresTriglyceride-to-HDL Cholesterol RatioSmall LDL particlesImpaired glucose tolerance (IGT)Variation in coagulation factors plasminogen activator inhibitor (PAI-1) fibrinogen

  • CRPThere is a correlation between C-reactive protein (CRP) level and the number of syndrome components.

    CVD and CRP

    Waist circumference and CRP

  • Circulation 107:391, 2003

  • Additional Tools to Help Make the DiagnosisInsulin resistance score (HOMA-IR) fasting plasma glucoses (mmol/L) X fasting serum insulin (mIU/ml) / 22.5.

    Obtain lipid levels when most appropriate

  • Screening QuestionsDo you have difficulty losing weight despite exercising regularly?Do you have a close relative who has had heart disease, high blood pressure, T2D, polycystic ovarian syndrome, infertility problems, or obesity?Do you experience frequent cravings for sugars or other high carbohydrate foods?4. Do you often feel tired after a meal?5. Do you eat meals that consist of pasta, rice, potatoes, and corn more than 2-3 times per week?6. Do you awaken at night 2 or more times to urinate?Have you either gained or lost more than 5 lbs in the last 3 months?For women: Do you feel that you have more facial hair than other women in your family, racial, and/or ethnic group?

  • The Metabolic Syndrome and Its Relationship to Type 2 Diabetes and Cardiovascular DiseaseExcess Energy IntakeOver Expenditure

    Genetic Predispostion Truncal Obesity Muscular Inactivity

    Acquired or GeneticInsulin Resistance Metabolic Syndrome Unbalanced Diet

    Hypertension Acquired or Genetic Beta Cell Defect

    Cardiovascular Disease Type 2 Diabetes

  • Pathophysiology 3 potential etiologic categories:1-obesity and disorders of adipose tissue2-insulin resistance3-constellation of independent factors the mediate specific components of the syndrome.

  • InsulinProperties:Vasodilation

    Anti-inflammatory Sodium retention

  • Insulin Resistance Aging is the most important environmental factor in causing insulin resistance.

    Physical fitness is as powerful as obesity in predicting insulin sensitivity

  • HyperinsulinemiaResults in:Increased CHD riskReactive hypoglycemiaHigh triglyceridesLow HDLHypercholesteremiaHypertensionHypofibrinolysisPolycystic ovaries

  • PCOSThe most common endocrinopathy among young womenAffects 6-10% of women of childbearing age Accounts for 50-60% of female infertility 82% of women with T2D have polycystic ovaries.

  • Why fat?The Real Question Is:

    Where Are The Famines?

  • Adipose TissueAn important source of hormones, the best known of which is Leptin.Decrease in Insulin Sensitivity Increased hepatic triglyceride production and higher free fatty acid FFA level.Elevated Angiotensin II levels

  • Adipose TissueAdipose tissue also plays a central role in insulin resistance because it synthesizes and secretes: - Cortisol - Adiponectin- nonesterified fatty acids (NEFA)- interleukin-6- plasminogen activator inhibitor-1 (PAI-1)- tumor necrosis factor- proinflammatory cytokines (C-reactive protein)

  • LeptinLeptin increases sympathetic activity and may increase sodium reabsorption and heart rate.

    When insufficient levels, there is a marked increase in tissue fat, increased triglycerides,

    Insulin increases Leptin production

  • InflammationResult of excessive caloric intake

  • Organ Involvement - RenalUric acid clearance is also correlated with insulin sensitivity. RAS cross talk between angiotensin II and insulin signaling contributes to the pathophysiology

  • Organ Involvement - LungAbnormal lung function and sleep apnea may be related to diabetes

    2hr insulin levels show a progressive rise with increased frequency of sleep apnea.

  • Organ Involvement - LiverThe liver is the major organ involved in lipid and glucose homeostasis.

    Similar to alcoholic liver disease, there is a spectrum of abnormalities, progressing to nonalcoholic steatohepatits (NASH)

  • DyslipidemiasHDL LDL TriglyceridesHDL & LDL VLDL

  • Cardiovascular SystemHypertensionSomatostatin Sodium retention and angiotensin II Hypertension and lipid metabolism Increased vascular resistanceabnormal vascular smooth muscle function

  • Other Important ModifiersPhysical inactivity promotes the development of obesity and modifies muscle insulin sensitivity. Aging is commonly accompanied by a loss of muscle mass and by an increase in body fat particularly accumulation of fat in the abdomen, both changes can increase insulin resistance.

  • Management of the Metabolic SyndromeConsists primarily of 2 strategies: modification or reversal of the root causes, including weight reduction and increased physical activitydirect treatment of the metabolic risk factors, including atherogenic dyslipidemia, elevated blood pressure, the prothromboti

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