The metabolic syndrome
- •
The term ‘metabolic syndrome’ refers to the combination of several factors that tend to cluster together central obesity – hypertension, low
Guidelines and Expert Consensus Documents summarize and evaluate all currently available evidence on a particular issue with the aim to assist physicians in selecting the best management strategies for a typical patient, suffering from a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines are not substitutes for textbooks. The legal implications of medical guidelines have been discussed
CVDs were the direct cause of >4 million deaths in Europe around the year 2000 (1.9 million in the EU), accounting for 43% of all deaths of all ages in men and for 55% in women (Table 1 from www.ehnheart.org [6]) [7]. CVDs were also the major cause of hospital discharges, with an average rate of 2557 per 100 000 population around the year 2002. Out of these, 695 per 100 000 were caused by CHD and 375 per 100 000 by stroke, but more than half were due to other forms of chronic heart disease. The
Three strategies for the prevention of CVD can be distinguished: population, high-risk and secondary prevention. The three strategies are necessary and complement each other. The population strategy in particular is critical to reducing the overall incidence of CVD since it aims to reduce risk factors at population level through lifestyle and environmental changes that affect the whole population without requiring the medical examination of individuals. This type of strategy is mostly achieved
Evidence-based medicine (EBM) has been defined as the integration of individual clinical expertise with the best available clinical evidence from systematic research. It involves asking answerable questions, searching for the best evidence, critically appraising the evidence, applying the evidence to individual patient care, and evaluating the process [29]. Despite over a decade of educational effort, it is rare for clinicians to practise EBM as intended, with many considering that the major
Physicians and other health professionals in the primary and out-patient care setting are in a unique position to contribute significantly to the improved prevention and management of CVD. Physicians are generally perceived by the general public as the most reliable and credible source of information on health and advice. Patients usually want to receive as much information as possible from physicians, and often prefer to receive assistance from them in order to change behaviours such as
There is overwhelming evidence for an adverse effect of smoking on health [47]. This adverse effect of smoking is related to the amount of tobacco-smoked daily and to the duration of smoking. The effects of smoking on CVD interact synergistically in the presence of other CVD risk factors such as age, gender, arterial hypertension, and diabetes.
Passive smoking has been shown to increase the risk of CHD and other smoking-related diseases [48].
The benefits of smoking cessation have been
Fatty acids regulate cholesterol homeostasis and concentrations of blood lipoproteins, and affect the levels of other cardiovascular risk factors, such as BP, haemostasis, and body weight, through various mechanisms. There are strong, consistent, and graded relationships between saturated fat intake, blood cholesterol levels, and the mass occurrence of CVD. The relationships are accepted as causal. n-3 fatty acids, in contrast, showed protective effects on fatal events in patients who had
As societies develop a higher standard of living, cardiovascular mortality initially increases. This is followed by a reduction in both major risk factors such as blood cholesterol and high BP which, together with improvements in therapy, translate into reduced cardiovascular mortality. The exceptions to these trends are body weight and diabetes which tend to increase as other risk factors decline. Obesity is becoming a worldwide epidemic in both children and adults [52]. Currently it is
A lack of regular physical activity may contribute to the early onset and progression of CVD.
Almost any increase in physical activity will result in health benefits.
Assessment of physical activity is a key element of risk evaluation.
Physical inactivity is a significant public health problem in Europe: children have become less physically active and only in a few countries do children have access to the recommended daily dose of physical activity. More than half of adolescents become physically
Elevated heart rate has been shown to be associated with increased risk of all-cause mortality, CVD mortality, and development of CVD in the general population, hypertensives, diabetics, and those with pre-existing coronary artery disease [82], [83]. The relationship is also seen in animal models. Levine demonstrated the semi-logarithmic inverse relationship between heart rate and life expectancy in mammalian species [84]. A reduction in the development of atherosclerosis has been demonstrated
Elevated BP is a risk factor for CHD [91], heart failure, CVD, peripheral vascular disease, and renal failure in both men and women [91], [92], [93], [94]. BP levels correlate inversely with cognitive function, and hypertension is associated with an increased incidence of dementia [95]. CHD and stroke mortality increase progressively and linearly from BP levels as low as 115 mmHg systolic and 75 mmHg diastolic upward [96].
In addition, longitudinal data obtained from the Framingham Heart Study
The relationship between a raised plasma cholesterol and atherosclerotic vascular disease fulfils all of the criteria for causality. The evidence that reducing plasma cholesterol reduces risk is equally unequivocal. The higher the risk, the greater the benefit. A 10% reduction in plasma total cholesterol is followed by a 25% reduction in incidence of coronary artery disease after 5 years, and a reduction of LDL cholesterol of 1 mmol/L (∼40 mg/dL) is accompanied by a 20% reduction in CHD events
The extensive literature on diabetes and its precursor stages and CVD has been thoroughly reviewed in the recent guidelines on diabetes, pre-diabetes and cardiovascular disease created by the Joint Task Force of the ESC and the European Association for the Study of Diabetes. In addition to the full text of the present guidelines, the readers are referred to that document [5].
In subjects with impaired glucose tolerance, it has been demonstrated that progression to diabetes can be prevented or
The metabolic syndrome describes the clustering of cardiovascular risk factors in individuals with obesity or insulin resistance. It identifies individuals with increased risk of developing CVD in accordance with the clustering of risk factors, but does not indicate risk of CVD over and above the effect of the risk factors involved.
The metabolic syndrome The term ‘metabolic syndrome’ refers to the combination of several factors that tend to cluster together central obesity – hypertension, low
There is increasing scientific evidence that psychosocial factors contribute independently to the risk of CHD even after statistical control for the effects of standard risk factors [159]. In addition to increasing the risk of a first event and worsening the prognosis in CHD, these factors may act as barriers to treatment adherence and efforts to improve lifestyle, as well as to promote health and well-being in patients and populations.
The following psychosocial risk factors have been shown to
Risk factors may be classed into several hierarchical categories as follows: classical, established, emerging, and putative, and also as risk markers. The highest level of classification achieved thus far by the heterogeneous group of factors discussed in these guidelines is ‘emerging’, but many are under active investigation in clinical and epidemiological studies. These factors are associated with many different biological systems such as those regulating platelets, coagulation, fibrinolysis,
Genetic information is divided into three categories: family history, phenotypes, and genotypes.
One of the major objectives of a CVD detection programme should be to identify those apparently healthy individuals who have asymptomatic arterial disease in order to slow the progression of atherosclerotic disease, to induce regression, and in particular to reduce the risk of clinical manifestations. The revolution in technology has clearly influenced the decision making of cardiovascular patients, and this can be clearly applied to the early detection of the disease even in asymptomatic
More women than men die from CVD, although they do so at an older age. CHD is slightly more common as a cause of death in women, and stroke markedly more common. In contrast, breast cancer accounts for only 3% of all deaths in women. CVD risk in women is deferred by 10 years compared with that of men. A 55-year-old woman is identical in terms of risk to a 45-year-old man. The decline in CVD mortality in recent years has been greater in men than in women, and CVD incidence has actually increased
Renal impairment and cardiovascular risk Risk of CVD rises progressively from microalbuminuria with preserved GFR to end-stage renal disease, when it is 20–30× that of the general population. Applies to apparently healthy people and to those with hypertension, CVD, and heart failure. Associated with high blood pressure, hyperlipidaemia, metabolic syndrome, uric acid, homocysteine, and anaemia. Particularly vigorous risk factor control needed.
The use of prophylactic drugs which have been shown to reduce morbidity and mortality in clinical trials should be considered, in addition to drugs used for treatment of elevated blood pressure, lipids, and glucose.
Several studies have been carried out to evaluate the effect of different implementation strategies of guidelines on clinical practice.
EUROASPIRE I (1995/96) [39] and II (2000/01) [38] surveys both showed a high prevalence of unhealthy lifestyles, modifiable risk factors, and inadequate use of drug therapies to achieve BP and lipid goals in patients with established CHD, with wide variations in medical practice between countries.
Many surveys have shown similar results, some also showing great
The ESC Guidelines represent the views of the ESC and were arrived at after careful consideration of the available evidence at the time they were written. Health professionals are encouraged to take them fully into account when exercising their clinical judgement. The guidelines do not, however, over-ride the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patients, in consultation with that patient, and, where appropriate
The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the ESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request to Oxford University Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC.
European Society of Cardiology (ESC) including European Association for Cardiovascular Prevention and Rehabilitation (EACPR) and Council on Cardiovascular Nursing.
European Association for the Study of Diabetes (EASD).
International Diabetes Federation Europe (IDF-Europe).
European Stroke Initiative (EUSI).
International Society of Behavioural Medicine (ISBM).
European Society of Hypertension (ESH).
European Society of General Practice/Family Medicine (ESGP/FM/WONCA).
European Heart Network (EHN).
European Atherosclerosis Society (EAS).