Diabetes Mellitus - Heart Disease Prevention Program

Transcript Diabetes Mellitus - Heart Disease Prevention Program

Metabolic Syndrome, Diabetes, and Cardiovascular Disease: Epidemic of Cardiometabolic Risk

Nathan D. Wong, PhD, FACC, FAHA Professor and Director Heart Disease Prevention Program Division of Cardiology University of California, Irvine President, American Society for Preventive Cardiology

Age-adjusted prevalence of obesity in adults 20 – 74 years of age, by sex and survey year (NHES: 1960 –1962; NHANES: 1971–1975, 1976– 1980, 1988 –1994, 1999-2002 and 2003-2006).

35,2 34,0

33,1

28,1 26,0

20,6

16,8 17,1 15,7

12,2 12,8 10,7

10 5 0 1960-62 Men 1971-75 1999-2002 Women 2003-06 1976-80 1988-94

Obesity is defined as a BMI of ≥30.0. Source: Health, United States, 2009 (NCHS).

Roger VL et al. Published online in

Circulation

Dec. 15, 2010

7 6 5 2 1 4 3 0

Diabetes: A Growing Challenge Prevalence in the United States

Percentage of Population Number (Millions) Diagnosed Diabetes 20 18 16 14 12 4 2 0 10 8 6

Centers for Disease Control and Prevention, Division of Diabetes Translation. National Diabetes Surveillance System. Available at http://www.cdc.gov/diabetes/statistics.

Age-Adjusted Prevalence of Type 2 DM: California Adults Aged >18 Including Hispanic and Asian Subgroups 2009 N.D. Wong, California Health Interview Survey (unpublished)

Natural History of Type II Diabetes Mellitus Years from diagnosis -10 -5 Onset 0 Diagnosis 5 10 15 Insulin resistance Insulin secretion Postprandial glucose Fasting glucose Pre-diabetes Ramlo-Halsted BA et al.

Prim Care.

1999;26:771-789 Nathan DM et al.

NEJM

2002;347:1342-1349 Microvascular complications Macrovascular complications Type II diabetes

Diagnostic Criteria for Glycemic Abnormalities FPG Hemoglobin A1C 2-Hour PG on OGTT 126 mg/dL 100 mg/dL Diabetes Mellitus Prediabetes 7.0 mmol/L 6.5% Diabetes Mellitus Prediabetes 5.6 mmol/L 6.0% Normal Normal Diabetes Mellitus 200 mg/dL 140 mg/dL Impaired Glucose Tolerance 11.1 mmol/L 7.8 mmol/L Normal To convert mg/dL to mmol/L multiply mg/dl by 0.055

FPG=Fasting plasma glucose, PG=Plasma glucose, OGTT=Oral glucose tolerance test The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus.

Diabetes Care

American Diabetes Association. Diabetes Care 2010;33:S11-61 2001;24:S5-S20

Diabetes Mellitus: Lifetime Risk Narayan et al.

JAMA

2003;290:1884-1890.

Diabetes and CVD

• Atherosclerotic complications responsible for – 80% of mortality among patients with diabetes – 75% of cases due to coronary artery disease (CAD) – Results in >75% of all hospitalizations for diabetic complications • 50% of patients with type 2 diabetes have preexisting CAD. diabetes.) (This number may be less now that more younger people are diagnosed with • 1/3 of patients presenting with myocardial infarction have undiagnosed diabetes mellitus Lewis GF.

Can J Cardiol

. 1995;11(suppl C):24C-28C Norhammar A, et.al.

Lancet

2002;359;2140-2144

Mechanisms by which Diabetes Mellitus Leads to Coronary Heart Disease Hyperglycemia Insulin Resistance Inflammation   AGE Oxidative stress Infection  IL-6  CRP  SAA  Defense mechanisms  Pathogen burden HTN Endothelial dysfunction Subclinical Atherosclerosis Disease Progression Atherosclerotic Clinical Events Dyslipidemia    LDL TG HDL    PAI-1 TF tPA Thrombosis AGE=Advanced glycation end products, CRP=C-reactive protein, CHD=Coronary heart disease HDL=High density lipoprotein, HTN=Hypertension, IL-6=Interleukin-6, LDL=Low-density lipoprotein, PAI-1=Plasminogen activator inhibitor-1, SAA=Serum amyloid A protein, TF=Tissue factor, TG=Triglycerides, tPA=Tissue plasminogen activator Biondi-Zoccai GGL et al.

JACC

2003;41:1071-1077.

Most Cardiovascular Patients Have Abnormal Glucose Metabolism

GAMI n = 164 EHS n = 1920 CHS n = 2263

35% 34% 31% 37% 18% 45% 37% 27% 36%

Normoglycemia Prediabetes Type 2 Diabetes GAMI = Glucose Tolerance in Patients with Acute Myocardial Infarction study; EHS = Euro Heart Survey; CHS = China Heart Survey

Anselmino M, et al. Rev Cardiovasc Med. 2008;9:29-38 .

Age-Adjusted CVD Death Rates (MRFIT)

No. of risk factors (total cholesterol, HTN, smoking) CVD=cardiovascular disease MRFIT=multiple risk factor intervention trial

Adapted with permission from Stamler J et al. Diabetes Care. 1993;16:434-444.

Diabetes Mellitus: Survival Following a Myocardial Infarction Minnesota Heart Survey MEN WOMEN 100 No diabetes No diabetes 80 n=1628 n=568 60 Diabetes Diabetes n=228 40 Months Post-MI 0 0 20 40 60 MI=Myocardial infarction Sprafka JM et al.

Diabetes Care

1991;14:537-543.

80 0 n=156 Months Post-MI 20 40 60 80

**Risk of Cardiovascular Events in Patients with Diabetes: Framingham Study**

_________________________________________________________________ Age-adjusted Cardiovascular Event Biennial Rate Age-adjusted Per 1000 Risk Ratio Men Women Men Women Coronary Disease

Stroke 39 21 15 6 Peripheral Artery Dis. 18 18 1.5** 2.2*** 2.9*** 2.6*** 3.4*** 6.4*** Cardiac Failure All CVD Events 23 21 4.4*** 7.8*** 76 65 2.2*** 3.7***

_________________________________________________________________

Subjects 35-64 36-year Follow-up **P<.001,***P<.0001

Diagnostic Criteria for Metabolic Syndrome: Modified NCEP ATP III

≥3 Components Required for Diagnosis Components Defining Level Increased waist circumference Men Women Elevated triglycerides ≥ 40 in ≥ 35 in ≥150 mg/dL (or Medical Rx) Reduced HDL-C Men Women Elevated blood pressure Elevated fasting glucose

AHA/NHLBI Scientific Statement; Circulation 2005; 112:e285-e290.

<40 mg/dL <50 mg/dL (or Medical Rx) ≥130 / ≥85 mm Hg (or Medical Rx) ≥100 mg/dL (or Medical Rx)

IDF Criteria: Abdominal Obesity and Waist Circumference Thresholds

Europid South Asian Chinese Japanese Men ≥ 94 cm (37.0 in) ≥ 90 cm (35.4 in) ≥ 90 cm (35.4 in) ≥ 85 cm (33.5 in) Women ≥ 80 cm (31.5 in) ≥ 80 cm (31.5 in) ≥ 80 cm (31.5 in) ≥ 90 cm (35.4 in) • AHA/NHLBI criteria: ≥ 102 cm (40 in) in men, ≥ 88 cm (35 in) in women • Some US adults of non-Asian origin with marginal increases should benefit from lifestyle changes. Lower cutpoints (≥ 90 cm in men and ≥ 80 cm in women) for Asian Americans >90cm (male) and >80cm (female) recommended for persons of Central and South American ancestry (including US Hispanics) Alberti KGMM et al.

Lancet

2005;366:1059-1062. | Grundy SM et al.

Circulation

2005;112:2735-2752.

Intra-abdominal (Visceral) Fat

The dangerous inner fat!

Front Visceral AT Subcutaneous AT Back

Pericardial Fat Predicts CVD Risk

MACE patient (CABG): 58-year-old woman with BMI 32.8 and CCS = 0, PFV = 187 cm 3 and TFV 315 cm 3 After adjustment for Framingham risk score (FRS), CCS, and body mass index, PFV and TFV were significantly associated with MACE (odds ratio [OR]: 1.74, 95% confidence interval [CI]: 1.03 to 2.95 for each doubling of PFV; OR: 1.78, 95% CI: 1.01 to 3.14 for TFV).

Cheng et al. JACC Img 2010;3:352-60

Abdominal Adiposity Is Associated With Increased Risk of Diabetes

25 20 15 10 5 0 P value for trend <0.001

<28 >28-29 30-31 32-33 34-35 36-37 ≥38 Waist Circumference (in)

Carey VJ, et al. Am J Epidemiol. 1997;145:614-619

Metabolic Syndrome and Diabetes in Relation to CHD, CVD, and Total Mortality: U.S. Men and Women Ages 30-74

(Risk-factor Adjusted Cox Regression) NHANES II Follow-up (n=6255)

***

None 4 MetS

*** ***

Diabetes

***

* **

CVD

*** ***

1 CVD+Diabetes 0 CHD Mortality CVD Mortality Malik and Wong, et al., Circulation 2004.

Total Mortality

* p<.05, ** p<.01, **** p<.0001 compared to none

Annual CHD Event Rates (in %) by Calcium Score Events by CAC Categories in Subjects with DM, MetS, or Neither Disease (Malik and Wong et al., Diabetes Care 2011) Coronary Heart Disease

4 Annual CHD Event Rate 4 3.5

3 2.5

2 1.5

1 0.5

0 0 0.4

0.1

0.2

0.4

0.8

1.5

1.3

2.1

1.9

2.2

3.5

DM MetS Neither MetS/DM 1-99 100-399 400+

Coronary Artery Calcium Score

•

ACCF/AHA 2010 Guideline: CAC Scoring for CV risk assessment in asymptomatic adults aged 40 and over with diabetes (Class IIa-B)

A B C D E F

Summary of Care: ABC's for Providers

A1c Target Aspirin Daily Blood Pressure Control Cholesterol Management Cigarette Smoking Cessation Diabetes and Pre-Diabetes Management Exercise Food Choices

Under-Treatment of Cardiovascular Risk Factors Among U.S. Adults with Diabetes

– NHANES Survey 2001-2002, 532 (projected to 15.2 million) or 7.3% of adults aged >/=18 years had diabetes – 50.2% not at HbA1c goal <7% – 64.6% not at LDL-C goal <100 mg/dl – 52.3% not at recommended HDL-C >/=40 (M), >/=50 (F) – 48.6% not at recommended triglycerides <150 mg/dl – 53% not at BP goal of <130/80 mg/dl – Overall, only 5% of men and 12% of women at goal for HbA1c, BP, and LDL-C simultaneously Malik S, Wong ND et al. Diab Res Clin Pract 2007;77:126-33.

Summary of Care: ABC's for Providers A A1c Target Aspirin Daily

B C D E F Blood Pressure Control Cholesterol Management Cigarette Smoking Cessation Diabetes and Pre-Diabetes Management Exercise Food Choices

A1c Target Aspirin Therapy

• •

A1c Target

: In persons with diabetes, glucose lowering to achieve normal to near normal plasma glucose, as defined by the HbA1c<7% also consider measurement of HbA1c for CVD risk assessment in asymptomatic adults w/o DM (ACCF/AHA 2010)

Aspirin Daily

: Patients with type 2 DM >40 years of age or with prevalent CVD, OR those with metabolic syndrome without DM who are at intermediate or higher risk (e.g., >=10% 10-year risk of CHD)

Diabetes Mellitus: Effect of Aspirin 25 p<0.002

p=NS No ASA ASA 20 p < 0.001

p=.04

15 p<0.05

10 p=NS 5 p=NS 0 PHS ETDRS APT BIP PPP POPADAD JPAD n= 533 3711 4502 2368 1031 1276 2539 Endpoint 5 yr MI 7 yr MI 1 yr MCE 5 yr CV Death 4 yr MCE 7yr MCE 4 yr MCE # Events 26 vs 11 283 vs 241 502 vs 415 183 vs 133 20 vs 22 117 vs 116 86 vs 68 NS=Not Significant 1. Steering Committee of the Physicians' Health Study Research Group. NEJM 1989;321:129-35 2. ETDRS Investigators. JAMA 1992;268:1292 3. Antiplatelet Trialists' Collaboration. BMJ 1994; 308:81 4. Harpaz D et al. Am J Med 1998;105:494 3. Sacco M et al. Diabetes Care 2003;26:3264 4. Belch J et al. BMJ 2008; 337:a1840 5. Ogawa H et al. JAMA 2008; 300: 2134

Diabetes Mellitus: Impact of Glycemic Control on CV Risk United Kingdom Prospective Diabetes Study (UKPDS) 35 60 50 40 30 20 10 0 Myocardial Infarction Microvascular Disease 5.5% 6.5% 7.5% 8.5% 9.5% 10.5% CHD=Coronary heart disease, HbA 1C =Glycated hemoglobin Stratton IM et al. BMJ 2000;321:405-12

Diabetes Mellitus (Type II): Effect of Intensive Glycemic Control United Kingdom Prospective Diabetes Study (UKPDS) 3,867 patients with DM randomized to intensive therapy with a sulphonylurea or insulin (mean HbA 0 1C 7.0%) or conventional therapy (mean HbA 1C 7.9%) -10 -20 -25 P<0.01

-21 P=0.02

-16 P=0.05

-12 P=0.03

-30 -33 P<0.01

-40 Microalbuminuria at 12 years Retinopathy Microvascular complications Myocardial infarction Any DM endpoint -50 Intensive glycemic control in DM reduces the risk of microvascular complications DM=Diabetes mellitus, HbA 1C =Glycosylated hemoglobin UKPDS Group.

Lancet

1998;352:837-853

5 20

UKPDS Metformin Sub-Study: CHD Events

Myocardial Infarction p=0.01

10 Coronary Deaths p=0.02

NS 8 15 39% Reduction 50% Reduction 6 10 4 2 0 n= #Events Conventional Diet Insulin SU’s 411 73

UKPDS 34, Lancet 352: 854, 1998

951 139 Metformin 342 39 0 Conventional Diet 411 36 Metformin 342 16

Recent Trials Show No Reduction in CV Events with More Intensive Glycemic Control

ACCORD: Primary Outcome 25 20 15 10 Intensive therapy Standard therapy 5 0 0 1 2 3 4 5 6 Years 25 ADVANCE: Primary Outcome 20 15 10 Intensive therapy Standard therapy 5 0 0 12 24 36 48 60 Months of follow-up Number at Risk Intensive 5128 4843 4390 2839 1337 475 448 Standard 5123 4827 4262 2702 1186 440 395 Number at Risk Intensive 5570 5369 5100 4867 4599 1883 Standard 5569 5342 5065 4808 4545 1921

1 ACCORD Study Group.

N Engl J Med.

2008;358:2545-2559.

2 ADVANCE Collaborative Group.

N Engl J Med.

2008;358:2560-2572.

Was Intensive Glycemic Control Harmful? A closer look at ACCORD AND ADVANCE • ACCORD was discontinued early due to increased total and CVD mortality in the intensive arm. • VA Diabetes Trial showed severe hypoglycemia to be a powerful predictor of CVD events.

• A recent analysis of ACCORD (Diabetes Care, May 2010) showed deaths related to unsuccessful intensive therapy where A1c remained high .

• But in both ACCORD AND ADVANCE, those

without macrovascular disease at baseline had an actual benefit in the primary endpoint.

Diabetes Mellitus (Type I): Effect of Intensive Glycemic Control Diabetes Control and Complications Trial (DCCT) and Epidemiology of Diabetes Interventions and Complications (EDIC) 12% Conventional Intensive 0.12

42% risk reduction

=0.02

0.10

10% Conventional 0.08

8% 0.06

0.04

0.02

Intensive 6%

< 0.001

DCCT End of Randomized Treatment

< 0.001

EDIC Year 1

= 0.61

EDIC Year 7 0.00

0 2 4 6 8 10 12 14 16 18 20 Years Since Entry* Any cardiovascular outcome Intensive glycemic control in DM reduces long-term CV risk DCCT/EDIC Research Group.

JAMA

. 2002;287:2563-2569 Nathan DM, et al.

N Engl J Med

. 2005;353:2643-2653

Diabetes Mellitus (Type II): Effect of Intensive Glycemic Control United Kingdom Prospective Diabetes Study (UKPDS) 10-Year Follow-Up Sulphonylurea vs. Conventional Therapy Insulin vs. Conventional Therapy Intensive glycemic control in DM reduces the long-term risk of myocardial infarction Holman RR et al. NEJM 2008;359:1577-89

2009 ADA/AHA/ACC Statement Recommendations

• Goal of A1c<7% remains reasonable – for uncomplicated patients • • • •

ACC/AHA Class I (A)

– and for those with macrovascular disease

ADA Level B; ACC/AHA Class IIb (A)

• Incremental microvascular benefit may be obtained from even lower goals

ADA Level B; ACC/AHA Class IIa (C)

• Less stringent goals may be appropriate for those with labile glucose control or with advanced micro- or macrovascular disease

ADA Level C; ACC/AHA Class IIa (C)

Circulation 2009; 119: 351-357

Summary of Care: ABC's for Providers

A A1c Target Aspirin Daily

B Blood Pressure Control

C D E F Cholesterol Management Cigarette Smoking Cessation Diabetes and Pre-Diabetes Management Exercise Food Choices

UKPDS: Effects of Tight vs. Less-Tight Blood Pressure Control

UK Prospective Diabetes Study Group.

BMJ.

1998; 317:703-713.

Diabetes Mellitus: Effect of Blood Pressure Control Action to Control Cardiovascular Risk in Diabetes (ACCORD) Blood Pressure Trial 4,733 diabetic patients randomized to intensive BP control (target SBP <120 mm Hg) or standard BP control (target SBP <140 mm Hg) for 4.7 years 20 20 HR=0.88

95% CI (0.73-1.06) HR=0.59

95% CI (0.39-0.89) 15 15 10 5 10 5 0 0 1 2 3 4 5 6 7

Years Post-Randomization

8 0 0 1 2 3 4 5 6 7

Years Post-Randomization

8 Intensive BP control in DM does not reduce a composite of adverse CV events, but does reduce the rate of stroke BP=Blood pressure, DM=Diabetes mellitus, HR=Hazard ratio, SBP=Systolic blood pressure ACCORD study group. NEJM 2010

Scientific Statements: Diabetes, CV Disease and Hypertension

• JNC VII Report on Diabetic Hypertension – BP goal (<130/80 mm Hg) • Commonly requiring combinations of ≥2 drugs – ACEIs, CCBs, Thiazide-diuretics,  -blockers, and ARBs shown to reduce CVD/CVA risk – ACEIs/ARBs reduce progression of diabetic nephropathy and reduce albuminuria – ARBS reduce progression of macroalbuminuria Grundy SM, et al.

Circulation

. 1999;100:1134-1146. Chobanian AV, et al.

JAMA

. 2003;289:2560-2572.

Summary of Care: ABC's for Providers

A B A1c Target Aspirin Daily Blood Pressure Control

C Cholesterol Management

Cigarette Smoking Cessation D E F Diabetes and Pre-Diabetes Management Exercise Food Choices

Diabetes Mellitus: Effect of an HMG-CoA Reductase Inhibitor Meta-analysis of 18,686 patients with DM randomized to treatment with a HMG-CoA Reductase Inhibitor Statins reduce CV events 21% in diabetics (similar to non-diabetics) Cholesterol Treatment Trialists’ (CTT) Collaborators. Lancet 2008;37:117-25

ACCORD Lipid Study Results (NEJM 2010; 362: 1563-74)

• • 5518 patients with type 2 DM treated with open label simvastatin randomly assigned to fenofibrate or placebo and followed for 4.7 years.

• Annual rate of primary outcome of nonfatal MI, stroke or CVD death 2.2% in fenofibrate group vs. 1.6% in placebo group (HR=0.91, p=0.33).

• Pre-specified subgroup analyses showed a benefit in men vs. women and those with high triglycerides and low HDL-C.

Results support statin therapy alone to reduce CVD risk in high risk type 2 DM patients.

Lipid Goals for Persons with Metabolic Syndrome and DM (Grundy et al., 2005) LDL-C targets, ATP III guidelines

– High Risk: CHD, CHD risk equivalents (

incl. DM or >20% 10-year risk

): <100 mg/dL (option <70 mg/dl if CVD present) – Moderately High Risk (10-20%) 2 RF: <130 mg/dL, option <100 mg/dL – Moderate Risk (2+ RF, <10%) <130 mg/dL -- Low Risk: 0-1 RF: <160 mg/dL

HDL-C:

>40 mg/dL (men) >50 mg/dL (women)

TG:

<150 mg/dL

Specific Dyslipidemias: Elevated Triglycerides

Non-HDL: Secondary Target

• Non-HDL = TC – HDL • Non-HDL: secondary target of therapy when serum triglycerides are  200 mg/dL (esp. 200-499 mg/dl) • Non-HDL goal: LDL goal + 30 mg/dL

Summary of Care: ABC's for Providers

A B

C

D E F A1c Target Aspirin Daily Blood Pressure Control Cholesterol Management

Cigarette Smoking Cessation

Diabetes and Pre-Diabetes Management Exercise Food Choices

Cigarette Smoking Cessation Recommendations Goals Complete cessation No environmental tobacco smoke exposure

I I II II

Recommendations Ask about tobacco use at every visit In a clear, strong, and personalized manner, advise the patient to stop smoking Urge avoidance of exposure to second-hand smoke at work and home Assess patient’s willingness to quit smoking Develop a plan for smoking cessation and arrange follow-up Provide counseling, pharmacologic therapy, and referral to a formal cessation program Smith SC Jr. et al.

JACC

2006;47:2130-9

The 5 “A’s” for Effective Smoking Intervention

1. ASK

about smoking

2. ADVISE

to quit

3. ASSESS

willingness to make a quit attempt

4. ASSIST

if ready - offer therapy and consultation for quit plan and if not, then offer help when ready

5. ARRANGE

follow up visits

Summary of Care: ABC's for Providers

A B C A1c Target Aspirin Daily Blood Pressure Control Cholesterol Management Cigarette Smoking Cessation

D Diabetes and Pre-Diabetes Management

E F Exercise Food Choices

iabetes

revention

rogram: Reduction in Diabetes Incidence

Pre-diabetic Conditions: Benefit of a Thiazolidinedione Actos Now Study for the Prevention of Diabetes (ACT NOW) 602 patients with impaired glucose tolerance + impaired fasting glucose randomized to pioglitazone (45 mg) or placebo for up to 4 years 81% RRR 9 6.8

6 3 1.5

P<0.00001

0 Placebo Pioglitazone A thiazolidinedione reduces the risk of DM *Defined as a fasting glucose measurement >126 mg/dL or a glucose level of >200 mg/dL following an OGTT with repeat OGTT for confirmation DM=Diabetes mellitus, OGTT=Oral glucose tolerance test, RRR=Relative risk reduction DeFronzo RA et al. Presented at the 68 th 6, 2008, San Francisco, CA Annual Scientific Sessions of the American Diabetes Association, June

Risk of Developing Diabetes Mellitus Among Different Antihypertensive Agents Systematic review of 22 clinical trials evaluating 143,153 patients without DM randomized to an antihypertensive agent Treatment with an ARB or ACE inhibitor carries the lowest risk of developing DM, whereas treatment with a diuretic or  -blocker carries the highest risk ACE=Angiotensin converting enzyme, ARB=Angiotensin receptor blocker, DM=Diabetes mellitus Elliott WJ et al. Lancet 2007;369:201-7

Benefit of Comprehensive, Intensive Management: STENO 2 Study

Primary End Point=CV events (%) 60

• Treatment Goals: – Intensive TLC – HgbA1c <6.5% – Cholesterol <175 – Triglycerides <150 – BP <130/80

50 40 30 20 10 0 0 Conventional Therapy Intensive Therapy n =80 n =80 12 24 36 48 60 Months of Follow Up 72 84 96

Gaede, P. et al, NEJM 2003;348:390-393

Summary of Care: ABC's for Providers

A B C D A1c Target Aspirin Daily Blood Pressure Control Cholesterol Management Cigarette Smoking Cessation Diabetes and Pre-Diabetes Management

E Exercise

F Food Choices

AHA Diabetes Mellitus Recommendations

I II I II I II I II I II I II

Goals Recommendations Intensive lifestyle modification to prevent the development of DM (especially in those with the metabolic syndrome) Vigorous modification of other CV risk factors (e.g. physical activity, weight management, blood pressure control, and cholesterol management) Initiate lifestyle and pharmacotherapy to achieve near-normal HBA 1C Coordination of diabetic care with the patient’s primary physician and/or endocrinologist CV=Cardiovascular, DM=Diabetes mellitus, HbA 1C =Glycosylated hemoglobin Smith SC Jr. et al.

JACC

2006;47:2130-9

RCT Trial Assessment of Pedometer Interventions

N=277; 8 Trials Pedometer increased steps by 2500/day

Bravata, DM et al. JAMA 2007; 298:2296-2304

Summary of Care: ABC's for Providers

A B C D E A1c Target Aspirin Daily Blood Pressure Control Cholesterol Management Cigarette Smoking Cessation Diabetes and Pre-Diabetes Management Exercise

F Food Choices

Effect of Mediterranean-Style Diet in the Metabolic Syndrome

• 180 pts with metabolic syndrome randomized to Mediterranean-style vs. prudent diet for 2 years • Those in intervention group lost more weight (-4kg) than those in the control group (+0.6kg) (p<0.01), and significant reductions in CRP and Il-6 Esposito K et al. JAMA 2004; 292(12): 1440-6.

Therapeutic Lifestyle Changes Nutrient Composition of TLC Diet

Nutrient

• Saturated fat • Polyunsaturated fat • Monounsaturated fat • Total fat • Carbohydrate • Fiber • Protein • Cholesterol • Total calories (energy)

Recommended Intake

Less than 7% of total calories Up to 10% of total calories Up to 20% of total calories 25 –35% of total calories 50 –60% of total calories 20 –30 grams per day Approximately 15% of total calories Less than 200 mg/day Balance energy intake and expenditure to maintain desirable body weight/ prevent weight gain Sodium intake should be <1500 mg/day (AHA 2011)

My Life Check Assessment

My Life Check Assessment

Age-standardized prevalence estimates for poor, intermediate and ideal cardiovascular health for each of the seven metrics of cardiovascular health in the AHA 2020 goals, among US adults >20 years of age, NHANES 2005-2006 (baseline available data as of January 1, 2010).

100.0

22.9

33.2

80.0

45.2

46.6

41.7

61.4

72.2

60.0

40.0

20.0

0.0

32.9

23.2

76.8

41.2

38.4

3.2

30.4

33.8

31.7

24.5

15.0

17.1

8.2

Current Smoking Body Mass Index Physical Activity

Poor

Healthy Total Diet Score Cholesterol Blood Pressure

Intermediate Ideal

Roger VL et al. Published online in

Circulation

Dec. 15, 2010

Conclusions

• Metabolic syndrome and diabetes are associated with increased levels of atherosclerosis and cardiovascular disease event risk • Lifestyle measures focusing on weight reduction, dietary, and physical activity guidance are crucial in initial management.

Conclusions (cont.)

• Clinical management emphasizes achievement of BP and lipid goals, glycemic control, and antiplatelet therapy.

• Multidisciplinary programs including primary care physicians, specialists (endocrinologists and cardiologists), dietitians, and exercise specialists are key for the successful management of these conditions.

Braunwald’s Preventive Cardiology Now Available www.heart.uci.edu

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