enfermedad cardiovascular Síndrome metabólico y prevención de enfermedad cardiovascular (un diagnóstico en crisis) Josep Vidal Hospital Clínic Universitari Barcelona
Síndrome metabólico 1923 Kylin Asociación hipertensión, hiperglucemia, hiperuricemia
Síndrome metabólico 1923 Kylin Asociación hipertensión, hiperglucemia, hiperuricemia 1955 Vague Obesidad central más elementos RCV que periférica
Síndrome metabólico 1923 Kylin Asociación hipertensión, hiperglucemia, hiperuricemia 1955 Vague Obesidad central más elementos RCV que periférica 1980 Reaven Síndrome X: resistencia a la insulina, alteración tolerancia a la glucosa, hipertrigliceridemia, colesterol HDL bajo, hipertensión
Síndrome metabólico 1923 Kylin Asociación hipertensión, hiperglucemia, hiperuricemia 1955 Vague Obesidad central más elementos RCV que periférica 1980 Reaven Síndrome X: resistencia a la insulina, alteración tolerancia a la glucosa, hipertrigliceridemia, colesterol HDL bajo, hipertensión 1980-1999 Distintos elementos añadidos al concepto Cambios cualitativos lípidos, disfunción endotelial, estado procoagulante, inflamación …
Síndrome metabólico 1923 Kylin Asociación hipertensión, hiperglucemia, hiperuricemia 1955 Vague Obesidad central más elementos RCV que periférica 1980 Reaven Síndrome X: resistencia a la insulina, alteración tolerancia a la glucosa, hipertrigliceridemia, colesterol HDL bajo, hipertensión 1980-1999 Distintos elementos añadidos al concepto Cambios cualitativos lípidos, disfunción endotelial, estado procoagulante, inflamación … 1999-actual Definiciones de SM OMS, ATPIII, EGIR, ACE, IDF
Con 2 ó más de los siguientes: Definición OMS (1999) Resistencia a la insulina (<cuartil inferior de la población control), y/o Glucemia plasmática en ayunas > 110 mg/dl y/o glucèmia a les 2h de una SOG > 140 mg/dl Con 2 ó más de los siguientes: TAS > 140 y/o TAD > 90 mmHg Triglicéridos > 150 mg/dl y/o HDL-colesterol < 35 mg/dl en hombres o < 39 mg/dl en mujeres. WHR>0.9 H o 0.85 M y/o IMC > 30 kg/m2 Microalbuminuria.EUA>20mg/min o cociente alb/crea > 20 mg/g NCEP (2001) Tres o más de los siguientes: Obesidad abdominal Cintura > 102 cm en hombres Cintura > 88 cm en mujeres Glucemia plasmática en ayunas > 110 mg/dl Tensión arterial > 130 / 85 mmHg Triglicéridos > 150 mg/dl HDL-colesterol < 40 mg/dl en hombres < 50 mg/dl en mujeres
Definición IDF (2005) NCEP (2005) Obesidad abdominal* Cintura > 94 cm en hombres Cintura > 80 cm en mujeres Más 2 de los siguientes: Glucemia plasmática en ayunas > 100 mg/dl o tto Tensión arterial > 130/85 mmHg o tto Triglicéridos > 150 mg/dl o tto HDL-colesterol o tto < 40 mg/dl en hombres < 50 mg/dl en mujeres * variable según etnia IDF (2005) NCEP (2005) Tres o más de los siguientes: Obesidad abdominal Cintura > 102 cm en hombres Cintura > 88 cm en mujeres Glucemia plasmática en ayunas > 100 mg/dl o tto Tensión arterial > 130/85 mmHg o tto Triglicéridos > 150 mg/dl o tto* HDL-colesterol < 40 mg/dl en hombres < 50 mg/dl en mujeres * Fibrato o Ac nicotínico
Síndrome metabólico Concepto Mejoría sincrónica FRCV con cambios en estilo de vida Síndrome metabólico LDL-C elevado Obesidad central Glucemia elevada HDL-C bajo Triglic. elevados TAS elevada Metabolic syndrome increases risk for CHD and type 2 diabetes The National Cholesterol Education Program (NCEP) has traditionally focused on high low-density lipoprotein cholesterol (LDL-C) as a risk factor for coronary heart disease (CHD). In the NCEP Adult Treatment Panel III (ATP III) recommendations published in JAMA in 2001, the NCEP suggested that the metabolic syndrome might independently predict the development of both type 2 diabetes and CHD. Note that in most definitions of the metabolic syndrome whether NCEP, WHO or AACE, diabetic subjects are included among those subjects who now have the metabolic syndrome. Most papers examining the relationship of the metabolic syndrome to cardiovascular disease have excluded diabetic subjects with the metabolic syndrome since diabetic subjects are at high risk of cardiovascular disease whether they have the metabolic syndrome or not. Note also that the arrow pointing from the metabolic syndrome to type 2 diabetes refers to non-diabetic metabolic syndrome patients. References: Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285:2486-2497. Enfermedad cardiovascular Edad Tabaco Sexo M Hª fam +
La prevalencia de SM según criterios utilizados Estados Unidos Rexrode KM, Carey VJ, Hennekens CH et al. Abdominal adiposity and coronary heart disease in women. JAMA 1998;280:1843-8. Edad (años) Varones Mujeres Adams S. Diabetes Care 2005
Síndrome metabólico El problema Olvida otros marcadores de acuerdo con base fisiopatológica LDL-C elevado Su valor como diagnóstico sobrepasa al concepto Metabolic syndrome increases risk for CHD and type 2 diabetes The National Cholesterol Education Program (NCEP) has traditionally focused on high low-density lipoprotein cholesterol (LDL-C) as a risk factor for coronary heart disease (CHD). In the NCEP Adult Treatment Panel III (ATP III) recommendations published in JAMA in 2001, the NCEP suggested that the metabolic syndrome might independently predict the development of both type 2 diabetes and CHD. Note that in most definitions of the metabolic syndrome whether NCEP, WHO or AACE, diabetic subjects are included among those subjects who now have the metabolic syndrome. Most papers examining the relationship of the metabolic syndrome to cardiovascular disease have excluded diabetic subjects with the metabolic syndrome since diabetic subjects are at high risk of cardiovascular disease whether they have the metabolic syndrome or not. Note also that the arrow pointing from the metabolic syndrome to type 2 diabetes refers to non-diabetic metabolic syndrome patients. References: Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285:2486-2497. Enfermedad cardiovascular Edad Tabaco Sexo M Hª fam +
The Metab. Syndrome: Riquescat in Pace En contra: Diabetes Care, septiembre 2005 The Metab. Syndrome: Riquescat in Pace Reaven, Clin Chemistry 2005 A favor: Circulation, 25 octubre 2005 The Metabolic Syndrome Still Lives Grundy, Clin Chemistry 2005
Síndrome metabólico Relación con enfermedad cardiovascular Prevención 1aria En ausencia DM 2 En presencia DM 2 Enfermedad cardiovascular Metabolic syndrome increases risk for CHD and type 2 diabetes The National Cholesterol Education Program (NCEP) has traditionally focused on high low-density lipoprotein cholesterol (LDL-C) as a risk factor for coronary heart disease (CHD). In the NCEP Adult Treatment Panel III (ATP III) recommendations published in JAMA in 2001, the NCEP suggested that the metabolic syndrome might independently predict the development of both type 2 diabetes and CHD. Note that in most definitions of the metabolic syndrome whether NCEP, WHO or AACE, diabetic subjects are included among those subjects who now have the metabolic syndrome. Most papers examining the relationship of the metabolic syndrome to cardiovascular disease have excluded diabetic subjects with the metabolic syndrome since diabetic subjects are at high risk of cardiovascular disease whether they have the metabolic syndrome or not. Note also that the arrow pointing from the metabolic syndrome to type 2 diabetes refers to non-diabetic metabolic syndrome patients. References: Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285:2486-2497. Prevención 2aria
Hoorn Study n=615 H y 749 mujeres, no DM ni ECV en 1989-90 Relación: SM NCEP-ATPIII Eventos CV ocurridos antes de 1-1-200 Hombres Mujeres Prevención 1aria Dekker JM, Circulation 2005
Hoorn Study SM y tipo de eventos Hombres Mujeres Prevención 1aria Dekker JM, Circulation 2005
Estudio Botnia Prevalencia Enf coronaria según tolerancia a glucosa Si SM No SM Criterios OMS Risk factors occur in isolation only 30% of the time, and clustering of three or more factors occurs 17% of the time in both genders N=3928 N=1808 N=685 N=1430 Prevención 1aria Isomaa B et al. Diabetes Care. 2001.
Estudio PROCAM Importancia de la concurrencia de FRCV (n= 19 Estudio PROCAM Importancia de la concurrencia de FRCV (n= 19.700, mediana edad) Criterios ATPIII modificados TA TA HDL HDL Tg Tg Risk factors occur in isolation only 30% of the time, and clustering of three or more factors occurs 17% of the time in both genders Prevención 1aria Assmann G. End Metab Clin N Am 2004
GISSI Prevenzione Trial n=11 GISSI Prevenzione Trial n=11.323 pacientes, IAM<3 m, seguimiento 3,5 años Criterios ATPIII No diabéticos Diabéticos Prevención 2aria Levantesi G, Am J Cardiol 2005
Población austríaca n=750, coronarogria por EC establecida o sospecha Seguimiento 2,3 0,4 años Criterios ATPIII Riesgo relativo por SM SM no Todos Mujeres Hombres No Diabetes Diabetes 0.1 10 100 RR 5,03 RR 2.45 RR 2.37 RR 4.51 RR 2,74 SM si Prevención 2aria Saely, J Clin Endocrinol Metab 2005
Síndrome metabólico Relación con enfermedad cardiovascular Prevención 1aria En ausencia DM 2 En presencia DM 2 Enfermedad cardiovascular Metabolic syndrome increases risk for CHD and type 2 diabetes The National Cholesterol Education Program (NCEP) has traditionally focused on high low-density lipoprotein cholesterol (LDL-C) as a risk factor for coronary heart disease (CHD). In the NCEP Adult Treatment Panel III (ATP III) recommendations published in JAMA in 2001, the NCEP suggested that the metabolic syndrome might independently predict the development of both type 2 diabetes and CHD. Note that in most definitions of the metabolic syndrome whether NCEP, WHO or AACE, diabetic subjects are included among those subjects who now have the metabolic syndrome. Most papers examining the relationship of the metabolic syndrome to cardiovascular disease have excluded diabetic subjects with the metabolic syndrome since diabetic subjects are at high risk of cardiovascular disease whether they have the metabolic syndrome or not. Note also that the arrow pointing from the metabolic syndrome to type 2 diabetes refers to non-diabetic metabolic syndrome patients. References: Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285:2486-2497. Prevención 2aria
Síndrome metabólico Relación con enfermedad cardiovascular Riesgo relativo Prevención 1aria Síndrome metabólico Prevención 1aria En ausencia DM 2 En presencia DM 2 DM >SM Enfermedad cardiovascular Metabolic syndrome increases risk for CHD and type 2 diabetes The National Cholesterol Education Program (NCEP) has traditionally focused on high low-density lipoprotein cholesterol (LDL-C) as a risk factor for coronary heart disease (CHD). In the NCEP Adult Treatment Panel III (ATP III) recommendations published in JAMA in 2001, the NCEP suggested that the metabolic syndrome might independently predict the development of both type 2 diabetes and CHD. Note that in most definitions of the metabolic syndrome whether NCEP, WHO or AACE, diabetic subjects are included among those subjects who now have the metabolic syndrome. Most papers examining the relationship of the metabolic syndrome to cardiovascular disease have excluded diabetic subjects with the metabolic syndrome since diabetic subjects are at high risk of cardiovascular disease whether they have the metabolic syndrome or not. Note also that the arrow pointing from the metabolic syndrome to type 2 diabetes refers to non-diabetic metabolic syndrome patients. References: Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285:2486-2497. Prevención 2aria Estudio HOORN Dekker JM, Circulation 2005
Síndrome metabólico Relación con enfermedad cardiovascular Prevención 2aria Síndrome metabólico no DM/noSM SM Prevención 1aria En ausencia DM 2 En presencia DM 2 DM DM >SM Enfermedad cardiovascular Metabolic syndrome increases risk for CHD and type 2 diabetes The National Cholesterol Education Program (NCEP) has traditionally focused on high low-density lipoprotein cholesterol (LDL-C) as a risk factor for coronary heart disease (CHD). In the NCEP Adult Treatment Panel III (ATP III) recommendations published in JAMA in 2001, the NCEP suggested that the metabolic syndrome might independently predict the development of both type 2 diabetes and CHD. Note that in most definitions of the metabolic syndrome whether NCEP, WHO or AACE, diabetic subjects are included among those subjects who now have the metabolic syndrome. Most papers examining the relationship of the metabolic syndrome to cardiovascular disease have excluded diabetic subjects with the metabolic syndrome since diabetic subjects are at high risk of cardiovascular disease whether they have the metabolic syndrome or not. Note also that the arrow pointing from the metabolic syndrome to type 2 diabetes refers to non-diabetic metabolic syndrome patients. References: Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285:2486-2497. Prevención 2aria DM >SM Estudio WISE Marroquin, Circulation 2004
Síndrome metabólico Relación con enfermedad cardiovascular Problemas Síndrome metabólico Olvida otros marcadores de acuerdo con base fisiopatológica Prevención 1aria En ausencia DM 2 En presencia DM 2 Proteína C reactiva Su valor como diagnóstico sobrepasa al concepto ¿Mejor predicción ECV que con ecuación Framingham? Enfermedad cardiovascular Metabolic syndrome increases risk for CHD and type 2 diabetes The National Cholesterol Education Program (NCEP) has traditionally focused on high low-density lipoprotein cholesterol (LDL-C) as a risk factor for coronary heart disease (CHD). In the NCEP Adult Treatment Panel III (ATP III) recommendations published in JAMA in 2001, the NCEP suggested that the metabolic syndrome might independently predict the development of both type 2 diabetes and CHD. Note that in most definitions of the metabolic syndrome whether NCEP, WHO or AACE, diabetic subjects are included among those subjects who now have the metabolic syndrome. Most papers examining the relationship of the metabolic syndrome to cardiovascular disease have excluded diabetic subjects with the metabolic syndrome since diabetic subjects are at high risk of cardiovascular disease whether they have the metabolic syndrome or not. Note also that the arrow pointing from the metabolic syndrome to type 2 diabetes refers to non-diabetic metabolic syndrome patients. References: Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285:2486-2497. Prevención 2aria
sobre la relación SM-ECV (Prevención 1aria) Efecto valorar PCR sobre la relación SM-ECV (Prevención 1aria) Proteína C reactiva Ridker PM. Circulation, June 04
¿Mejor predicción ECV que con ecuación Framingham? San Antonio Heart Study, n= 2570, follow up 7.5 y Sensibilidad Falsos positivos Sd. Metabólico 67,3% 34,2% Framingham fijado a 34,2% 81,4% Framingham fijado a 67,3% 20,0% Sd Metabólico Obesidad Tensión arterial Triglicéridos Colesterol HDL Glucemia en ayunas Ecua. Framingham Edad Género Colesterol total Tabaquismo Tensión arterial sistólica Diabetes (0-1) Dicotómico Ponderado Stern MP, Diabetes Care 2004
Distribución grasa corporal (circumferencia cintura elevado) Tratamiento Distribución grasa corporal G. visceral G. subcutánea Fenotípico Obesidad central (circumferencia cintura elevado) Molecular Resistencia a insulina Inflamación No hoy por hoy No tto selectivo
Tratamiento Sd. Metabólico Mejoría sincrónica FRCV con cambios en estilo de vida Síndrome metabólico LDL-C elevado Obesidad central Glucemia elevada HDL-C bajo Triglic. elevados TAS elevada Metabolic syndrome increases risk for CHD and type 2 diabetes The National Cholesterol Education Program (NCEP) has traditionally focused on high low-density lipoprotein cholesterol (LDL-C) as a risk factor for coronary heart disease (CHD). In the NCEP Adult Treatment Panel III (ATP III) recommendations published in JAMA in 2001, the NCEP suggested that the metabolic syndrome might independently predict the development of both type 2 diabetes and CHD. Note that in most definitions of the metabolic syndrome whether NCEP, WHO or AACE, diabetic subjects are included among those subjects who now have the metabolic syndrome. Most papers examining the relationship of the metabolic syndrome to cardiovascular disease have excluded diabetic subjects with the metabolic syndrome since diabetic subjects are at high risk of cardiovascular disease whether they have the metabolic syndrome or not. Note also that the arrow pointing from the metabolic syndrome to type 2 diabetes refers to non-diabetic metabolic syndrome patients. References: Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285:2486-2497. Enfermedad cardiovascular Edad Tabaco Sexo M Hª fam +
Tratamiento Sd. Metabólico Mejoría sincrónica FRCV con cambios en estilo de vida Síndrome metabólico LDL-C elevado 5-10% peso corporal Obesidad central Glucemia elevada HDL-C bajo Triglic. elevados TAS elevada Metabolic syndrome increases risk for CHD and type 2 diabetes The National Cholesterol Education Program (NCEP) has traditionally focused on high low-density lipoprotein cholesterol (LDL-C) as a risk factor for coronary heart disease (CHD). In the NCEP Adult Treatment Panel III (ATP III) recommendations published in JAMA in 2001, the NCEP suggested that the metabolic syndrome might independently predict the development of both type 2 diabetes and CHD. Note that in most definitions of the metabolic syndrome whether NCEP, WHO or AACE, diabetic subjects are included among those subjects who now have the metabolic syndrome. Most papers examining the relationship of the metabolic syndrome to cardiovascular disease have excluded diabetic subjects with the metabolic syndrome since diabetic subjects are at high risk of cardiovascular disease whether they have the metabolic syndrome or not. Note also that the arrow pointing from the metabolic syndrome to type 2 diabetes refers to non-diabetic metabolic syndrome patients. References: Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285:2486-2497. Enfermedad cardiovascular Edad Tabaco Sexo M Hª fam +
Estilo de vida y Sd. Metabólico Diabetes Prevention Program Sujetos con TDG, 3 años seguimiento -2 -4 -6 -8 Cambio de peso (kg) 6 18 30 12 42 24 36 48 Tiempo (meses) Knowler et al, N Eng J Med 2002;346:393-403 Placebo Metformina Estilo de vida Cambio peso corporal
Estilo de vida y Sd. Metabólico Diabetes Prevention Program Resolución SM por grupo tto Pérdida moderada de peso: DM2 IRI HDL-Colest. LDL-Colest. Trigliceridos TAS TAD P<0.001 DPP Study Group, Ann Int Med 2005
Fàrmacos tratamiento obesidad Sibutramina Señales centrales Ingesta Rimonabant Gasto energético Orlistat Señales periféricas Leptina Insulina Balance Energético
Fármacos obesidad y Sindrome Metabolico Rimonabant - tras 12 m de tratamiento- ITT Estudio 1 Estudio 2 Estudio 3 - 7.9% - 10 - 21% - 21% - 20 - 39% p<0.001 Reduction in metabolic syndrome (%) - 30 - 40 - 51% p<0.001 - 53% p<0.001 - 50 - 60 Placebo Rimonabant 20 mg
Tratamiento Sd. Metabólico Síndrome metabólico LDL-C elevado 5-10% peso corporal Obesidad Glucemia elevada HDL-C bajo Triglic. elevados TAS elevada Metabolic syndrome increases risk for CHD and type 2 diabetes The National Cholesterol Education Program (NCEP) has traditionally focused on high low-density lipoprotein cholesterol (LDL-C) as a risk factor for coronary heart disease (CHD). In the NCEP Adult Treatment Panel III (ATP III) recommendations published in JAMA in 2001, the NCEP suggested that the metabolic syndrome might independently predict the development of both type 2 diabetes and CHD. Note that in most definitions of the metabolic syndrome whether NCEP, WHO or AACE, diabetic subjects are included among those subjects who now have the metabolic syndrome. Most papers examining the relationship of the metabolic syndrome to cardiovascular disease have excluded diabetic subjects with the metabolic syndrome since diabetic subjects are at high risk of cardiovascular disease whether they have the metabolic syndrome or not. Note also that the arrow pointing from the metabolic syndrome to type 2 diabetes refers to non-diabetic metabolic syndrome patients. References: Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285:2486-2497. ? Enfermedad cardiovascular Edad Tabaco Sexo M Hª fam +
Tratamiento Sd. Metabólico Los problemas Pudiera obviarse cambio EV en quien también precisa Síndrome metabólico LDL-C elevado Puede llevar a no tratar adecuadamente FRCV muy importantes ¿Los cambios en EV no eran ya parte del tratamiento de FRCV? Metabolic syndrome increases risk for CHD and type 2 diabetes The National Cholesterol Education Program (NCEP) has traditionally focused on high low-density lipoprotein cholesterol (LDL-C) as a risk factor for coronary heart disease (CHD). In the NCEP Adult Treatment Panel III (ATP III) recommendations published in JAMA in 2001, the NCEP suggested that the metabolic syndrome might independently predict the development of both type 2 diabetes and CHD. Note that in most definitions of the metabolic syndrome whether NCEP, WHO or AACE, diabetic subjects are included among those subjects who now have the metabolic syndrome. Most papers examining the relationship of the metabolic syndrome to cardiovascular disease have excluded diabetic subjects with the metabolic syndrome since diabetic subjects are at high risk of cardiovascular disease whether they have the metabolic syndrome or not. Note also that the arrow pointing from the metabolic syndrome to type 2 diabetes refers to non-diabetic metabolic syndrome patients. References: Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285:2486-2497. Enfermedad cardiovascular Edad Tabaco Sexo M Hª fam +
Recomendaciones AHA 05’ The metabolic syndrome: Modify root causes, Síndrome metabólico Cambios estilo de vida Calcular riesgo ecuación Framingham Bajo riesgo (<10% a 10 a) Riesgo Medio (10 a 20%) Alto riesgo (>20% a 10 a) The metabolic syndrome: Modify root causes, Treat risk factors Objetivos de tto según riesgo calculado HTA TAS/TAD >130/85 Tg>150 HDL<40 Diabetes tipo 2 Gluc >100 LDL-C elevado Tabaco
Distribución grasa corporal (circumferencia cintura elevado) Tratamiento Distribución grasa corporal G. visceral G. subcutánea Fenotípico Obesidad central (circumferencia cintura elevado) Molecular Resistencia a insulina Inflamación No hoy por hoy No tto selectivo No hoy por hoy
(circumferencia cintura elevado) Tratamiento Fenotípico Obesidad central (circumferencia cintura elevado)
(circumferencia cintura elevado) Tratamiento Diabetes tipo 2 HTA Gluc >100 TAS/TAD >130/85 Tg>150 HDL<40 Fenotípico Obesidad central (circumferencia cintura elevado) + otros FRCV
Tratamiento Sd. Metabólico Los problemas LDL-C elevado Edad Tabaco Sexo M Hª fam + Enfermedad cardiovascular Síndrome metabólico Pudiera obviarse cambio EV en quien también precisa Puede llevar a no tratar adecuadamente FRCV muy importantes ¿Los cambios en EV no eran ya parte del tratamiento de FRCV? Metabolic syndrome increases risk for CHD and type 2 diabetes The National Cholesterol Education Program (NCEP) has traditionally focused on high low-density lipoprotein cholesterol (LDL-C) as a risk factor for coronary heart disease (CHD). In the NCEP Adult Treatment Panel III (ATP III) recommendations published in JAMA in 2001, the NCEP suggested that the metabolic syndrome might independently predict the development of both type 2 diabetes and CHD. Note that in most definitions of the metabolic syndrome whether NCEP, WHO or AACE, diabetic subjects are included among those subjects who now have the metabolic syndrome. Most papers examining the relationship of the metabolic syndrome to cardiovascular disease have excluded diabetic subjects with the metabolic syndrome since diabetic subjects are at high risk of cardiovascular disease whether they have the metabolic syndrome or not. Note also that the arrow pointing from the metabolic syndrome to type 2 diabetes refers to non-diabetic metabolic syndrome patients. References: Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285:2486-2497. Parecería que hay margen para mejorar la tasa de recomendaciones sobre cambios en EV
Resumen El concepto de Sd. Metabólico es útil para la identificación de pacientes con riesgo CV y para subrayar la importancia del estilo de vida (especialmente en relación con la obesidad central) en la prevención y tratamiento de la ECV
Resumen A pesar de ello no debe sobrevalorarse el diagnóstico: Es necesaria una mejor definición del SM Equilibrando facilidad en el diagnóstico con utilidad clínica No debe considerarse un equivalente de ECV ni sustituir a otras escalas de estimación de RCV No debe hacernos olvidar de que el tratamiento farmacológico de los FRCV establecidos es una prioridad.
Gracias por su atención