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Cardiometabolic Risk: Evaluation Multiple disease pathways and risk factors are considered to facilitate earlier intervention Early assessment and targeted intervention are needed to treat and prevent all risk factors associated with CVD and diabetes Cardiometabolic Risk Gives a comprehensive picture of a patients health and potential risk for future disease and complications Is inclusive of all risks related to metabolic changes associated with CVD Accommodates emerging risk factors as useful predictive tools Focuses clinical attention to the value of systematic evaluation, education, disease prevention and treatment Supports an integrated approach to care Kahn, et al. The Metabolic Syndrome: Time for a Critical Appraisal: Joint Statement From the American Diabetes Association and the European Association for the Study of Diabetes Diabetes Care. 2005;28 (9)2289-2304. The State of Risk 2 out of 3 Americans are overweight or obese More than 70 million (nearly 1 in 4) Americans have varying degrees of insulin resistance There are an estimated 54 million (more than 1 in 6) Americans with prediabetes Nearly 1 in 4 U.S. adults has high cholesterol 1 in 3 American adults has high blood pressure Direct and Indirect Cost of CVD and Diabetes $296 billion $152 billion $116 billion $58 billion $412 billion $210 billion *Note: these figures may not account for potential overlap. Sources: 2008 statistics from the American Diabetes Association and American Heart Association. Cardiovascular Disease Diabetes TOTAL Estimated Direct Medical Costs Estimated Indirect Costs (disability, work loss, premature mortality) Abnormal Lipid Metabolism LDL ApoB HDL Trigly. Cardiometabolic Risk Global Diabetes / CVD Risk Overweight / Obesity Inflammation Hypercoagulation Hypertension Smoking Physical Inactivity Unhealthy Eating Age, Race, Gender, Family History GlucoseBP Lipids Age Genetics Insulin Resistance ? Insulin Resistance Syndrome Cardiometabolic Risk - Graphic Non-modifiable Age Race/ethnicity Gender Family history Overweight Abnormal lipid metabolism Inflammation, hypercoagulation Hypertension Smoking Physical inactivity Unhealthy diet Insulin resistance Cardiometabolic Risk Factors Modifiable Case - Mr. Martin 47-year-old African American man, hasnt seen doctor in years Works as a truck driver, eats mostly fast food Smokes 1 pack per day At health fair found to have BP = 146/86, total cholesterol = 210 Weight = 230 lbs; BMI = 29 kg/m Family history of HTN and diabetes Whats Mr. Martins Cardiometabolic Risk? Age 47 Race/ethnicity African American Gender Male Family history HTN and diabetes Overweight/obesity BMI = 29 Abnormal lipid metab TC = 210 Hypertension BP = 146/86 Smoking 1 pack per day Physical Inactivity Yes Unhealthy diet Fast food diet Non-Modifiable Risk Factors Number Est. New Diabetes Diagnoses by Age, 2005 Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2005. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2005. 800,000 600,000 400,000 200,000 0 Age Group 20-39 40-59 60+ Cardiovascular Risk Factor Trends Among U.S. Adults Aged 20-74 Centers for Disease Control 14:461-469. Quintiles (pmol) of fasting plasma insulin P20 years of age, cholesterol should be checked every 5 years Ordering a fasting lipid panel is preferred to gauge the patients total cholesterol, LDL-C, HDL-C and triglycerides Treatment priorities Cholesterol Management Category of risk LDL-C Goal 0-1 risk factor* 45 years old; female 55 years old; smoking. Risk of CHD by Triglyceride Level: The Framingham Heart Study Men Women n=5,127 Triglyceride Level, mg/dL 50 100 150 200 250 300 350 400 Relative Risk 0 0.5 1 1.5 2 2.5 3 Castelli WP. Epidemiology of triglycerides: a view from Framingham American Journal of Cardiology. 1992;70:3H-9H. Reaven GM, et al. J Clin Invest. 1993;92:141-146. Association Between Small, Dense LDL and Insulin Resistance Mean Steady State Plasma Glucose (mmol/L)at Identical Plasma Insulin A Larger LDL particle pattern Intermediate pattern B Small LDL particle pattern 0 2 6 10 12 8 4 LDL-Size Phenotype (n=52) (n=19) (n=29) Low HDL-C: Independent Predictor of CHD Risk, Even When LDL-C is Low LDL-C (mg/dL) HDL-C (mg/dL) Risk of CHD . Gordon T, Castelli WP, Hjortland MC, Kannel WB, Dawber TR. High density lipoprotein as a protective factor against coronary heart disease. The Framingham Study. American Journal of Medicine. 1977;62:707-14. Screening for Dyslipidemia Persons without Diabetes Test at least every 5 years, starting at age 20, including adults with low-risk values Persons with Diabetes In adults, test at least annually Lipoproteins: measure at after initial blood glucose control is achieved as hyperglycemia may alter results Preventing Cancer, Cardiovascular Disease, and Diabetes: A Common Agenda for The American Cancer Society, the American Diabetes Association, and the American Heart Association. Circulation. 2004;109:3244-3255. American Diabetes Association. Standards of Medical Care in Diabetes 2007. Available at: /cgi/reprint/30/suppl_1/S4 Healthy Lipid Goals Targets for Patients Without DM or CVD 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); National Cholesterol Education Program, National Heart, Lung, and Blood Institute, National Institutes of Health. NIH Publication No. 01-3670, May 2001 Total 40 men mg/dL 50 women mg/dL Triglycerides 3 mg/L Aspirin and statins reduce CRP levels Unclear whether CRP should be a treatment target Reduce weight Ross R. Atherosclerosis: an inflammatory disease. N Engl J Med.1999;340:115- 126. Ballantyne CH. Pre-Diabetes and Diabetes Prevention Pre-Diabetes Pre-diabetes is an important risk factor for future diabetes and cardiovascular disease Recent studies have shown that lifestyle modification can reduce the rate of progression from pre-diabetes to diabetes American Diabetes Association, Diabetes Care. 2007:30:S4-41 Glucose Tolerance Categories Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 2004; Supplement 1 Fasting Plasma Glucose 126 mg/dL Normal 2-hour Plasma Glucose On OGTT 200 mg/dL 140 mg/dL Diabetes Mellitus Impaired Glucose Tolerance Normal Diabetes Mellitus Any abnormality must be repeated and confirmed on a separate day* * One can also make the diagnosis of diabetes based on unequivocal symptoms and a random glucose 200 mg/dL “Pre-Diabetes” 100 mg/dL Impaired Fasting Glucose ADA Consensus Conference on IFG and IGT: Implications for Diabetes Care October 16-18, 2006 Results: Treat IFG and IGT with aggressive lifestyle modification For certain patients with both IFG and IGT consider metformin Nathan D, et al. Impaired Fasting Glucose and Impaired Glucose Tolerance: Implications for Care. Diabetes Care. 2007 30: 753-759. Cumulative Incidence of Diabetes (%) Years 40 30 20 10 0 0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 Placebo Metformin Lifestyle Knowler WC, et al. NEJM. 2002;346:393-403. Behavior Medication Results of Recent Randomized Trials 58% 58% 31% 25% 55% 45% 61%/NS Metformin Acarbose Troglitazone Orlistat Rosiglitazone/Ramipril IGT IGT Prior GDM IGT IGT US DPP STOP- NIDDM TRIPOD XENDOS DREAM Lifestyle Lifestyle IGT IGT Finnish DPS US DPP Relative Risk Reduction InterventionSubjectsStudy 9 lbs Polycy