[Thrombocytic hemostasis in hypertensive patients with metabolic syndrome and its correction with lovastatin]

The objective of the study was to evaluate the efficiency of lovastatin correction of dyslipidemia and impaired intravascular platelet activity (IPA) in patients with arterial hypertension (AH) concurrent with metabolic syndrome (MS). Eighteen patients were given lovastatin for a month. The time course of changes in anthropometric parameters, blood lipid spectrum, plasma and lipid peroxidation, antioxidative protectiveness of the liquid blood part and platelets, and IPA were assessed. The results were processed by Student's test and correlation analysis. Lovastin was ascertained to correct dyslipoproteinemia and peroxidation syndrome and to optimize the intrathrombocytic mechanisms responsible for their function regulation in patients with AH + MS. Lovastatin inhibits in vivo increased platelet activity. These effects may be stabilized during its use. Body weight loss and diminished insulin resistance in patients with AH concurrent MS require long use of lovastatin along with low-calorie diet and exercises.

[Metabolic syndrome and latent depression in the population sample]

BACKGROUND

The aim of study was to reveal the relationship between metabolic syndrome and depression in a population sample, based on clinical and metabolic parameters.

METHODS AND RESULTS

We tried to estimate depression (or other psychopathologies) prevalence in a randomly chosen population sample of the Pilsen city, using special questionnaires. Further, we estimated metabolic syndrome of insulin resistance risk factors and we looked for the relationship between these two disorders. Mental state of object was classified according to the questionnaires results, currently evaluated by the psychiatrist. Metabolic syndrome of insulin resistance was diagnosed as a presence of 3 of the 5 following factors: Triglycerides > or = 1.7 mmol/l, HDL cholesterol < 1.0 mmol/l in males or < 1.3 mmol/l in females, blood pressure > or = 130/85 mmHg (and/or antihypertensive medication), fasting plasma glucose > or = 6.1 mmol/l, waist circumference >102 cm in males or > 88 cm in females. Depressive syndrome diagnosed by Zungs scale is present in 31% of the Pilsen population, in 38% females and 31% males (n = 340). In the group of depressive objects, characteristics of metabolic syndrome of insulin resistance were two times higher than in the control group. Differences in resting heart rate, triglycerides level and fasting C-peptid were significantly higher in the depressive subjects. After the corrections considering age, sex and treatment adjustment, the waist to hip ratio was in the depressive subjects statistically higher as well as the 24 hour excretion of urine cortisone. In persons with metabolic syndrome of insulin resistance the prevalence of depression and anxiety was significantly higher.

CONCLUSIONS

Our results show a possible relationship between depressive disorder and risk factors of the syndrome of insulin resistance. The question remains if the depression treatment can correct some of the metabolic syndrome risk factors.

The changing epidemiology and natural history of nonvalvular atrial fibrillation: clinical implications

The growing "epidemic" of non-valvular atrial fibrillation (NVAF) with its associated morbidity and mortality intersects with a number of conditions including aging, thromboembolism, stroke, congestive heart failure, hypertension, and perhaps the metabolic syndrome and inflammation.In the USA approximately 2.3 million people currently have NVAF and estimates based upon the United States census and the aging of the population suggests that this will be 3.3 million by 2020 and 5.6 million by 2050. This may be a serious underestimate since recent data from Rochester, Minnesota have demonstrated an almost threefold increase in the prevalence over the last three decades after adjustment for age. The explanation is probably multifactorial but the socioeconomic implications of this phenomenon are enormous and sobering.Ongoing efforts towards understanding atrial fibrillation are driven, in part, by the concept that atrial fibrillation may in most patients be the consequence of a systemic condition, in which reduced vascular compliance, atherosclerosis, obesity, and inflammation are primary causal factors. These epidemiological investigations need to be carried out in association with studies aimed at defining the molecular genetics of atrial fibrillation which hopefully will provide more insights into the structural and electrical phenotypes resulting from genetic mutations and their interactions with the environment.

Prevalence of metabolic syndrome among hypertensive patients attending a primary care clinic in Kuwait

OBJECTIVE

To determine the prevalence of metabolic syndrome among hypertensive patients using the criteria of the National Cholesterol Education Program's Adult Treatment Panel III in a primary care health center in Kuwait.

SUBJECTS AND METHODS

A population of 250 Kuwaiti hypertensive patients (129 males and 121 females) over the age of 40 were screened for metabolic syndrome by determining body mass index (BMI), waist circumference, levels of fasting plasma glucose and fasting plasma lipids (serum triglycerides, total cholesterol and high-density lipoprotein cholesterol). The study was carried out in the Mishref Family Practice Health Center, Kuwait, from January to July 2001.

RESULTS

The total number of patients who met the criteria for metabolic syndrome was 85 (34%), 55% of them were males and 45% females. Prevalence of the syndrome was 28.2% among 40- to 55-year-olds and 41.9% in those above the age of 55 years. Among the 250 hypertensive patients, type II diabetes mellitus was found in 52.8% (54% males and 46% females), impaired fasting glucose in 8% (70% males and 30% females), high plasma triglycerides in 44.8% (53% males and 47% females) and low high-density lipoprotein cholesterol in 63.2% (54% males and 46% females). Obesity measured as BMI = 30 kg/m(2) was noted in 46% (43% males and 57% females) and increased waist circumference in 58% (44% males and 56% females).

CONCLUSION

The prevalence of metabolic syndrome is high among hypertensives attending primary health care centers in Kuwait.

Should the Insulin Resistance Syndrome be Treated in the Elderly?

The insulin resistance syndrome represents the co-occurrence of hyperglycaemia, hypertension, central and overall obesity, and dyslipidaemia characterised by low high density lipoprotein-cholesterol (HDL-C) and high triglyceride levels. Epidemiologic studies have revealed an increasing prevalence of the insulin resistance syndrome in elderly populations. Indeed, recent data indicate that over 40% of US adults aged > or =60 years meet current criteria for the insulin resistance syndrome. Patients with this syndrome are at increased risk for the development of both cardiovascular disease (CVD) and type 2 diabetes mellitus, two of the most significant health problems among people >65 years of age. Identification and treatment of the insulin resistance syndrome may thus represent an important approach to reducing the overall burden of morbidity and mortality in the elderly. While development of the insulin resistance syndrome is partly determined by modifiable environmental factors, there may be a genetic basis for the syndrome, with high levels of concordance among monozygotic twins. Ongoing research focusing on the pathophysiology of this syndrome has implicated insulin resistance as the central disorder underlying both the development of diabetes as well as the pro-thrombotic endothelial dysfunction characteristic of CVD. Studies aimed at reversing insulin resistance have identified weight loss, exercise and pharmacological treatment with metformin, thiazolidinediones, HMG-CoA reductase inhibitors (statins) and ACE inhibitors as potential therapies to prevent the development of type 2 diabetes. However, although insulin sensitisation may be beneficial for preventing type 2 diabetes, there are no data yet available to show whether this strategy will reduce the incidence of CVD. Increased exercise and other healthy lifestyle changes form the cornerstone of therapy for elderly patients with the insulin resistance syndrome. In addition, active identification and aggressive management of traditional cardiovascular risk factors are the current standard of care. For elderly patients, recent studies have conclusively demonstrated the safety and efficacy of pharmacological management of elevated blood pressure and cholesterol levels.

Pharmacological strategies for kidney function preservation: are there differences by ethnicity?

The prevalence of chronic kidney disease (CKD) is on the rise in all ethnic groups. This is because of the increased prevalence of obesity, diabetes mellitus, the metabolic syndrome, and the inadequate control of elevated blood pressure and other cardiovascular-renal risk factors, especially in ethnic minority populations. The implications of the aforementioned trends in risk factor prevalence and control are profound. Moreover, these trends negatively impact patient quality of life and place an enormous financial burden on the health care system for the provision of care to patients with CKD, end-stage renal disease (ESRD), and/or cardiovascular disease (CVD). Thus, it is of utmost importance to devise strategies that prevent kidney disease and delay progressive loss of kidney function in persons with CKD. Proven strategies include pharmacological interventions that lower blood pressure to less than target levels (<130/80 mm Hg), attainment of optimal glycemic control (Hb A1c <7%), and reducing urinary protein excretion. It is also possible, although yet unproven, that correction of anemia and aggressive treatment of dyslipidemia may forestall the loss of kidney function. In general, ethnic minorities are underrepresented in most large trials. Recently, a few outcome clinical trials in blacks have reinforced the lessons of kidney function preservation already learned in nonblack populations. That is, the reversible risk factors for CKD appear to be virtually identical and, at least in nondiabetic CKD, pharmacological targeting of the renin-angiotensin-aldosterone system (RAAS) with angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers preserves kidney function better than non-RAAS blood pressure-lowering regimens, especially when significant proteinuria exists. Although more CKD studies in ethnic minorities are needed, until they become available, the best available evidence from the existing clinical trial database should be applied to minorities with CKD-even when specific data are not available for a specific racial or ethnic group. Why this approach? First, there are no known unique risk factors for kidney disease in any ethnic group. Second, poor control of reversible risk factors for CKD is universal, particularly in blacks and other ethnic minorities. Thus, it is logical to predict that more efficient use of strategies proven to forestall loss of kidney function will reduce the excess of CKD and ESRD in ethnic minorities relative to non-minority populations. However, medical-based strategies alone are probably not enough. The global epidemic of obesity will fuel the growing population of persons, especially among ethnic minorities, with diabetes, the main cause of CKD, ESRD, and CVD. The obesity and diabetes epidemics are unlikely to abate without innovative and ultimately effective public health approaches.

Hypertensive Renal Damage in Metabolic Syndrome Is Associated with Glucose Metabolism Disturbances

Recent evidence highlights the relationship between metabolic syndrome (MS) and increased risk of cardiovascular (CV) diseases. Mild renal function abnormalities are associated with an enhanced CV risk, considered to be due to the presence of associated risk factors. Hence, MS and renal abnormalities could be linked and contribute to augment CV risk. For estimating the prevalence of diminished creatinine clearance (CC; <60 ml/min per 1.73 m(2)) in hypertensive patients with or without MS and for investigating the factors accompanying this abnormality, 1625 hypertensive patients, aged 18 yr or older, were included. The presence of MS was defined according to the Adult Treatment Panel III criteria. The overall prevalence of MS was 49.4% (n = 802). No significant difference was found for CC between those with and without MS, albeit the presence of MS was accompanied by greater urinary albumin excretion (P = 0.01). The prevalence of a diminished CC was also similar in the two groups. MS-positive patients presented a progressive decay in CC when classified as normoglycemic (n = 319), impaired fasting glucose (n = 237), and diabetic patients (n = 246; 85.9 +/- 30.2, 81.8 +/- 26.8, and 75.2 +/- 25.7 ml/min per 1.73 m(2), respectively; P = 0.0007 linearity test) and the opposite for microalbuminuria (29.5 +/- 45.5, 45.0 +/- 96.6, and 74.1 +/- 146.3 mg/24 h, respectively; P = 0.001 linearity test). In multiple regression analysis, factors related to the finding of a diminished CC in MS and non-MS patients were similar. Hypertensive patients at a relatively young age present with an elevated prevalence of minor abnormalities of renal function that is mostly related to the presence of metabolic alteration of glucose together with age and BP.

[Circadian blood pressure profile in patients with metabolic syndrome and osteoarthrosis during therapy with nonsteroidal anti-inflammatory drugs]

Twenty-three patients with metabolic syndrome (MS) concurrent with ostearthrosis (OA) who had been long taking various nonsteroidal anti-inflammatory drugs (NSAID) (a study group) and 23 patients with MS without locomotor diseases (a control group) were examined. The groups were matched by gender, age, body mass index, and office blood pressure values. All the patients underwent 24-hour blood pressure (BP) monitoring. The mean 24-hour, mean diurnal and nocturnal variables of BP and the proportion of non-dippers were estimated in the study and control groups. In the study group, there were higher levels of the mean 24-hour systolic BP (SBP) (p = 0.044), pulse BP (p = 0.023), mean diurnal and mean nocturnal SBP (p = 0.040 and 0.036, respectively). There was also a predominance of non-dippers in the study group as compared with the control one (p = 0.037). Thus, the use of NSAID in patients with MS and concomitant OA causes negative changes in the 24-hour profile of BP.

Role of changes in dietary habits in polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a heterogeneous clinical condition. In most women, especially in the obese, all features of the metabolic syndrome, particularly insulin resistance and associated hyperinsulinaemia, are present. Insulin is a physiological hormone regulating ovarian function, specifically ovarian steroidogenesis and androgen blood transport and/or activity in the target tissues. Hyperinsulinaemia may therefore play a pivotal role in favouring the hyperandrogenic state and related clinical and metabolic alterations. The abdominal obesity phenotype is common, affecting more than half of PCOS women. Menstrual cycles and fertility rate are negatively affected by the presence of insulin resistance, hyperinsulinaemia and obesity. PCOS women with obesity and insulin resistance are the obvious target for lifestyle intervention, such as changes in dietary habits and increased physical activity. Weight loss should therefore represent the first-line approach in the treatment of obese PCOS women, since it significantly improves hormonal and metabolic abnormalities and may favour spontaneous ovulation and improve fertility rate in the majority of patients. Individualized pharmacological support aimed at favouring weight loss and maintenance and improving insulin resistance may play a complementary role to lifestyle intervention.

[Characteristics of immune system in patients with metabolic syndrome]

AIM

To characterize features of immune status in patients with metabolic syndrome (MS).

MATERIAL AND METHODS

41 MS patients entered the study (mean age 55.9 +/- 9.7 years). Blood free triiodthyronine (T3f), thyroxine (T4f), TTH, antibodies to thyroglobulin (abTG), thyroid peroxidase (AbTP) were studied with enzyme immunoassay; levels of CD3+, CD4+, CD8+, CD16+, CD72+ were studied with monoclonal antibodies; IgG, IgA, IgM were measured by radial immunodiffusion in gel by Manchini. The size and the structure of the thyroid were investigated with ultrasound.

RESULTS

Thyroid pathology was in 48.8% patients with MS, chronic infectious diseases (CID)--in 51.2%. MS patients free of thyroid pathology and CID had elevated blood levels of IgG, IgA, dysimmunoglobulinemia and low relative number of CD3+ lymphocytes, close correlations of T3free with the levels of CD3+, CD4+, CD8+, T4free with CD72+ (r = -0.97 to +0.92), T4free with IgA, IgG (r = -0.96, r = -0.90), TTH and IgA (r = -0.89), weak negative correlations of uric acid with the levels of CD3+, CD4+, CD72+ and positive with CD8+, CD16+, immunoglobulins. Combination of MS with thyroid pathology and/or CID was characterized with aggravated defects in T- and B-cell immunity, fall in IgG, IgA and changed direction of correlations of thyroid and immune statuses.

CONCLUSION

Immune status in MS patients was characterized by stimulation of humoral immunity, dysimmunoglobulinemia, T-cell immunity deficiency. This may be related to chronic hyperinsulinemia, dyslipidemia, antigenic stimulation with modified lipoproteins. Thyroid hormones levels positively correlate with concentrations of immunocytes and negatively--with immunoglobulins.

[Inflammatory diseases of the parodontium in patiens with metabolic syndrome]

Comprehensive stomatologic examination of 45 patients with chronic generalized parodontitis (CGP) was combined with parallel determination of immunoreactive insulin (IRI) in blood. In 30 patients CGP developed on the background of metabolic syndrome (MS). Clinical and X-ray examination of periodontal tissues disclosed that CGP in patients with MS was characterized by active and aggressive course. A correlation between CGP severity degree and level of IRI in blood was established.

[Cerebrovascular complications in metabolic syndrome: possible approaches to decrease risk]

AIM

To compare brain perfusion in hypertensive patients with diabetes mellitus type 2 (DM2) or metabolic (MS) syndrome and hypertensive patients without clinicobiochemical signs of DM2 or MS; to study enoxaparin effects on brain perfusion in DM2 and arterial hypertension (AH).

MATERIAL AND METHODS

Seventy patients included in the study were divided into three groups: 30 patients with DM2 and AH (group 1), 30 patients with MS and AH (group 2) and 10 AH patients without manifestations of MS or DM2 (group 3). All the patients have undergone single-photon emission computed tomography (SPECT) of the brain, carbohydrate and lipid metabolism were examined.

RESULTS

Deterioration of brain perfusion was more prominent in DM2 and MS patients with AH than in hypertensive patients with normal metabolism. Stress test with acetasolamide revealed defective autoregulation of cerebral blood flow in hypertensive patients with DM2. A 6-week therapy with enoxaparin significantly improved brain perfusion in hypertensive patients with DM2.

CONCLUSION

Enoxaparin treatment of hypertensive DM2 and MS patients with abnormal perfusion of the brain can be used for prevention of cerebrovascular complications.

[Clinical parameters of the course of metabolic syndrome in advanced age]

The proposed principles of classification of metabolic syndrome are critically considered, as they do not take into account peculiarities of its clinical course in patients of advanced and senile age. Results of examination are presented of two groups of patients of the cardiological profile, who were long observed under conditions of a departmental outpatient clinic. In the first group, evaluated were the incidence and the degree of severity of symptoms characterizing disturbances in systems of carbohydrate and lipid metabolism, peculiar to metabolic syndrome, as well as the incidence and severity of arterial hypertension and obesity. It has been established that these symptoms are more frequent in various combinations as a picture of the "incomplete" syndrome and have different incidence in the older and younger age groups. Among patients with the "complete" set of characters of the metabolic syndrome there also takes place the statistically significant polymorphism of its clinical manifestations, which allows suggesting effects of mechanism of compensation and mutual aggravation. Peculiarities of manifestations of symptoms of the metabolic syndrome in patients of the elderly group make it possible to identify prognostically favorable and unfavorable forms of the course of the syndrome and, accordingly, to optimize the therapeutic and preventive programs.

The Metabolic Syndrome is an independent predictor of cardiovascular disease in Type 2 diabetic subjects. Prospective data from the Verona Diabetes Complications Study

AIMS

To evaluate the cardiovascular risk associated with the presence of the Metabolic Syndrome in Type 2 diabetic subjects.

METHODS

Subjects with the Metabolic Syndrome, defined by WHO criteria, were identified in a large sample of non-insulin-treated Type 2 diabetic patients examined within the Verona Diabetes Complications Study (n = 946). At baseline and after a mean of 4.5 years follow-up, cardiovascular disease (CVD) was assessed by medical history, physical examination, electrocardiogram (ECG) and echo-duplex of carotid and lower limb arteries. Death certificates and medical records of subjects who died during the follow-up were scrutinized in order to identify CVD deaths. In statistical analyses, CVD was considered as an aggregate end-point, including fatal and non-fatal coronary, cerebrovascular and peripheral vascular disease as well as ischaemic ECG abnormalities and vascular lesions at the echo-duplex.

RESULTS

The proportion of subjects with the Metabolic Syndrome was very high (92.3%). At the baseline, 31.7% of subjects were coded positive for CVD, which was more prevalent in subjects with the Metabolic Syndrome (32.9 vs. 17.8%, P = 0.005). Among subjects free of CVD at the baseline (n = 559), CVD events during the follow-up were significantly increased in patients with the Metabolic Syndrome as compared with those without it (19.9% vs. 3.9%, P < 0.001). Multiple logistic regression analysis showed that, along with sex, age, smoking and HbA1c, the presence of the Metabolic Syndrome independently predicted prevalent (OR 2.01, P = 0.045) and incident CVD (OR 4.89, P = 0.031).

CONCLUSIONS

In Type 2 diabetes, the presence of the Metabolic Syndrome is associated with an almost 5-fold increase in CVD risk.

[Arterial hypertension in adolescents with different physical constitution including those with signs of metabolic syndrome]

AIM

Detection of clinico-paraclinical features of arterial hypertension (AH) in adolescents with different physical constitution including signs of metabolic syndrome (MS).

MATERIAL AND METHODS

Blood levels of uric acid, cholesterol, triglycerides (TG), high and low density lipoproteins were examined and glucose tolerance test was made in 108 adolescents with arterial hypertension (AH) and different physical constitution (normal, with overweight and obese). Waist and hip distribution of fat was assessed. The control group consisted of 108 healthy adolescents.

RESULTS

Most of the hypertensive children had hyperuricemia (HU), some of the patients combined HU with changes in glycemic profile of blood. The above abnormalities were especially evident in patients with MS who were characterized by abdominal obesity, higher blood pressure, subnormal high density lipoproteins, higher triglycerides and total cholesterol in blood, more severe HU and defects in glycemic profile of blood.

CONCLUSION

MS in adolescents may be of genetic origin as well as constitutional HU and insulin resistance may be mutually dependent signs combination of which with other factors presents the whole spectrum of clinical and paraclinical manifestations of MS. Detection of HU and insulin resistance with their correction in a preclinical disease stage (in children and adolescents) may represent a new line in prevention of AH and MS in adults.

Metabolic syndrome

This paper reviews current diagnostic criteria for Metabolic Syndrome, and provides in-depth discussion of the component abnormalities. A cluster of abnormalities defines Metabolic Syndrome including insulin resistance, hypertension, obesity, hypertriglyceridemia, and low HDL cholesterol. Evidence that inflammation is another component of Metabolic Syndrome raises the possibility that this is an additional process that links Metabolic Syndrome to cardiovascular disease (CVD) risk. Population studies strongly suggest the existence of a relationship between the metabolic abnormalities associated with Metabolic Syndrome and the development of diabetes and cardiovascular disease. It appears that lifestyle modifications can contribute to the prevention of progression to diabetes and the reduction of individual CVD risk factors. Whether use of insulin sensitizing drugs can significantly delay or prevent the progression to diabetes is under investigation. Because of its contribution to the growing prevalence of type 2 diabetes, and the associated increased CVD risk, the recognition of Metabolic Syndrome and its consequences are critical in the course of morbidity and mortality risk assessment.

The epidemic of diabetes mellitus and the metabolic syndrome in African Americans

The metabolic syndrome and type 2 diabetes mellitus are increasingly associated with cardiovascular disease morbidity and mortality in African Americans. African Americans are specifically prone to the negative effects of hypertension and risk factor clustering associated with the metabolic syndrome and diabetes. Data demonstrate a decrease in cardiovascular events in diabetic patients with secondary prevention and, most recently, primary prevention with lipid-lowering therapy. African Americans should benefit from intense risk factor control, including antihypertensive therapy and lipid lowering, to prevent cardiovascular disease. Appropriate lifestyle modification programs, glucose control, and cardiovascular risk reduction therapy will reduce the excessive morbidity and mortality in this population.

Cardiovascular risk in Cushing's syndrome

Chronic cortisol hypersecretion causes central obesity, hypertension, insulin resistance, dyslipidemia, protrombotic state, manifestations which form a metabolic syndrome in all patients with Cushing's syndrome. These associated abnormalities determine an increased cardiovascular risk not only during the active phase of the disease but also long after the "biomedical remission". Clinical management of these patients should be particularly careful in identifying global cardiovascular risk. Considering that remission from hypercortisolism is often difficult to achieve care and control of all cardiovascular risk factors should be one of the primary goals during the follow up of these patients. Extending the indications of the recent consensus on Cushing's syndrome, we suggest to carry out an OGTT to avoid underestimation of diabetes mellitus, an echocardiography and Doppler ultrasonography of the epiaortic vessels in all patients at diagnosis and during follow-up.

The metabolic syndrome: pathophysiology, clinical relevance, and use of niacin

OBJECTIVE

To review the pathophysiology and clinical relevance for using niacin to treat the metabolic syndrome.

DATA SOURCES

Primary articles were identified through a MEDLINE search (1966-January 2003), and recommendations for treatment were obtained from the National Cholesterol Education Program Adult Treatment Panel (NCEP-ATP) III guidelines.

STUDY SELECTION AND DATA EXTRACTION

Published studies showing the effects of the metabolic syndrome, atherogenic dyslipidemia, and niacin were evaluated and reviewed.

DATA SYNTHESIS

The metabolic syndrome is a highly prevalent condition that affects 24% of American adults and significantly increases the risk of coronary heart disease (CHD). Most patients with metabolic syndrome have atherogenic dyslipidemia characterized by elevated triglycerides, low high-density-lipoprotein cholesterol (HDL-C), and small, dense low-density-lipoprotein cholesterol (LDL-C) particles. The NCEP-ATP III identifies patients with the metabolic syndrome as candidates for intensified therapy. Lifestyle modifications and drug therapy are recommended. Niacin represents a good option for treating the triad of lipid abnormalities seen in the metabolic syndrome because it raises HDL-C, lowers triglycerides, and increases LDL-C particle size.

CONCLUSIONS

Treatment of the metabolic syndrome is recommended by NCEP-ATP III to further reduce CHD risk after the LDL-C target has been met. Prospective clinical studies are needed to define the impact of niacin and other lipid-modifying agents on CHD morbidity and mortality in patients with the metabolic syndrome.

[Influence of various diets on lipid exchange in patients with obesity and metabolic syndrome]

The investigation of influence the diets with different rations carbohydrate and lipid components on the status of lipid spectrum of patients, suffering of metabolic syndrome, these were be used during 4 mounts, was the aim of present researches. The 84 male in the age of 30-65 years were examination Effective decrease body mass, atherogenic parameters of lipid metabolism (hypertrigleciridemia, LDL) and also the levels of arterial hypertension were founded in patients? Using low carbohydrate and low fatty diets.

Association of the metabolic syndrome with history of myocardial infarction and stroke in the Third National Health and Nutrition Examination Survey

BACKGROUND

The combination of cardiovascular risk factors known as the metabolic syndrome is receiving increased attention from physicians, but data on the syndrome's association with morbidity are limited.

METHODS AND RESULTS

Applying National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) criteria, we evaluated 10 357 NHANES III subjects for the 5 component conditions of the metabolic syndrome: insulin resistance, abdominal obesity based on waist circumference, hypertriglyceridemia, low HDL cholesterol (HDL-C), and hypertension, as well as the full syndrome, defined as at least 3 of the 5 conditions. Logistic regression was used to estimate the cross-sectional association of the syndrome and each of its 5 component conditions separately with history of myocardial infarction (MI), stroke, and either MI or stroke (MI/stroke). Models were adjusted for age, sex, race, and cigarette smoking. The metabolic syndrome was significantly related in multivariate analysis to MI (OR, 2.01; 95% CI, 1.53 to 2.64), stroke (OR, 2.16; 95% CI, 1.48 to 3.16), and MI/stroke (OR, 2.05; 95% CI, 1.64 to 2.57). The syndrome was significantly associated with MI/stroke in both women and men. Among the component conditions, insulin resistance (OR, 1.30; 95% CI, 1.03 to 1.66), low HDL-C (OR, 1.35; 95% CI, 1.05 to 1.74), hypertension (OR, 1.44; 95% CI, 1.00 to 2.08), and hypertriglyceridemia (OR, 1.66; 95% CI=1.20 to 2.30) were independently and significantly related to MI/stroke.

CONCLUSIONS

These results indicate a strong, consistent relationship of the metabolic syndrome with prevalent MI and stroke.

Dyslipidemia in the metabolic syndrome and type 2 diabetes mellitus

Patients with type 2 diabetes mellitus or the metabolic syndrome have a unique dyslipidemia characterized by hypertriglyceridemia; elevated blood levels of apolipoprotein B; small, dense low-density lipoprotein (LDL) cholesterol; and low levels of high-density lipoprotein (HDL) cholesterol, in particular HDL(2)-C. Treatment of the dyslipidemia associated with these disorders should focus on correcting the abnormal lipoprotein levels as well as LDL and HDL heterogeneity. Statins and fibrates are useful for treating elevated LDL in patients with and without diabetes or the metabolic syndrome. In addition, thiazolidinediones or niacin in combination with a statin show promise for correcting defects in LDL and HDL heterogeneity. The ultimate goal of treatment in this patient population is to prevent the development and progression of coronary artery disease.

Serum uric acid levels in obese children and adolescents: linkage to testosterone levels and pre-metabolic syndrome

Hyperuricemia is part of the "metabolic syndrome". The aim of this study was to investigate the regulation and role of serum uric acid in the cardiovascular risk factor profile of obese children and adolescents. Serum levels of uric acid and selected risk factors and hormones were determined in 269 children aged 10.0-15.9 years with a BMI >90th percentile (mean 24.0 kg/m2, SD 5.43). Stepwise regression adjusted for age and sex revealed that testosterone (p < 0.0001), BMI (p < 0.0001), systolic blood pressure (p < 0.0017), triglycerides (p < 0.0345) and cholesterol/HDL ratio (p < 0.0393) were positively correlated with serum uric acid and accounted for 42.1% of the variance. Additional regression models with the same set of variables indicated that uric acid contributed significantly to levels of cholesterol/HDL, total cholesterol, BMI and systolic blood pressure, respectively. These results suggest a not yet described impact of androgens in the regulation of serum uric acid in obese children and adolescents. Furthermore, they show that uric acid is a reliable indicator for the "pre-metabolic syndrome" in obese youths.

The metabolic syndrome: mechanisms, epidemiology, and clinical implications

This article reviews the definition, mechanisms, epidemiology, and clinical sequelae of the metabolic syndrome and explores potential relationships between the metabolic syndrome, type 2 diabetes, and cardiovascular disease. Definitions for the metabolic syndrome proposed by the World Health Organization and the National Cholesterol Education Program of the National Heart Lung and Blood Institute, as well as proposed criteria for defining the syndrome in adolescents, are presented. Mechanisms that may be involved in the development of the metabolic syndrome--the role of obesity and visceral fat, insulin resistance, lipid abnormalities, chronic inflammation, and genetic factors--are discussed. Information on the epidemiology of the metabolic syndrome is reviewed, although the reported prevalence has varied widely due to the lack of a single accepted definition. This article also provides guidance concerning the evaluation and treatment of the metabolic syndrome, including the appropriate role of drug therapy in reducing the risk of diabetes and cardiovascular disease.

Metabolic syndrome

The metabolic syndrome is characterized by diabetes mellitus, obesity, hypertension, hyperlipidaemia and polycystic ovary syndrome. The lipid profiles of patient with metabolic syndrome is often characterized by the appearance of hypertrygliceridaemia and small, dense LDL-cholesterol, together with low HDL-cholesterol. Patients with these abnormalities are at an increased risk for premature coronary artery disease. Treatment is a multifactorial process and includes modification of lifestyle factors such as diet and physical activity, weight reduction, correction of dyslipidemia, meticulous blood pressure and glycemic control. The case of a 36-year-old woman who develops metabolic syndrome is discussed.

Unilateral adrenalectomy improves insulin resistance and diabetes mellitus in a patient with ACTH-independent macronodular adrenal hyperplasia

ACTH-independent macronodular adrenal hyperplasia (AIMAH) is a rare cause of Cushing's syndrome. Bilateral adrenalectomy is considered to be a standard therapy for AIMAH, although lifetime replacement of glucocorticoids is necessary after the procedure. This paper describes a subject with AIMAH who underwent unilateral adrenalectomy of the predominantly enlarged gland and subsequently displayed an improvement in insulin resistance and diabetes mellitus, the cardinal symptoms before the operation, concomitant with alleviation of abnormal cortisol secretion. The patient was a 61-year-old man with a body mass index of 25.6 kg/m2. He was diagnosed as having diabetes mellitus, hypertension, and hyperlipidemia at 50 years of age. Eight years after diagnosis, bilateral enlargement of the adrenal glands was revealed by chance upon computed tomography of the abdomen. Typical manifestations of Cushing's syndrome were not demonstrated. Basal levels of serum and urinary cortisol had not increased, although the serum cortisol level displayed no circadian rhythm and no response to the administration of dexamethasone. Despite sulfonylurea treatment, the patient's HbA1C level was as high as 7.6% (normal range 4.3-5.8%). Fasting insulin concentration was increased to 42.6 microU/ml, and the homeostasis model insulin resistance index (HOMA-R) was calculated to be 15.5 (with a normal range of less than 2.5), indicating severe insulin resistance. Unilateral adrenalectomy of the predominantly enlarged gland revealed that the resected gland consisted of multiple nodules of various sizes. Based on endocrinological, radiological, and pathological findings, a diagnosis of AIMAH was made. Ten months after the unilateral adrenalectomy, cortisol circadian rhythms were restored, and serum cortisol concentration was suppressed in response to the administration of low doses of dexamethasone, suggesting an improvement in the cortisol secretory pattern. Levels of HbA1C, fasting insulin, and HOMA-R decreased to 5.7%, 12.7 microU/ml, and 2.2, respectively. An improvement in hyperlipidemia was also observed. Insulin resistance and glucose intolerance are recognized as features of mild hypercortisolism. In the present case, unilateral adrenalectomy was effective in ameliorating insulin resistance and improving glycemic control. Unilateral adrenalectomy might be an alternative therapy for improvement of glucose and lipid metabolism in subjects with AIMAH.

[Correction of insulin resistance syndrome does not cause normalisation of hyperferritinaemia]

The consequences of iron overload from dysmetabolic hyper-ferritinaemia are a strong motivation for an active medical care program. Venesection therapy is known to be effective in controlling iron overload parameters although no study has evaluated the impact of the normalization of metabolic dysfunction on iron overload.

AIMS

To evaluate the impact of normalization of metabolic dysfunction on iron overload.

METHODS

Sixty consecutive patients with dysmetabolic hepatosiderosis were included in a prospective study. Patients with hyper-ferritinaemia above 1000 microg/l were excluded. Multidisciplinary care was offered to all patients to normalize metabolic disorders (body mass index, arterial hypertension, fasting and postprandial hyperglycemia, hyperuricemia, hypercholesterolemia and hypertriglyceridemia) every three months. All patients were followed for one year. At clinical examinations, ferritinaemia concentrations were measured and all dysmetabolic parameters evaluated. MRI was performed at the beginning of the study and at the one year follow-up, to measure hepatic iron load.

RESULTS

Despite efficient medical care of insulin resistance syndrome, ferritinaemia remained stable. In two thirds of the study population, hyper-ferritinaemia reached at least one and a half times the baseline value, although the dysmetabolic disorders of 40% of the patients were strictly normalized. In this group of 44 patients with strict normalization of metabolic functions, 24 (54%) had hyper-ferritinaemia at one year follow-up whereas 16 other (36%) normalized this parameter. Only 4 patients who had a ferritinaemia below 450 microg/l at baseline, normalized this value at one year. Intra-hepatic iron overload, evaluated by MRI imaging remained stable except for 2 patients who normalized ferritinaemia.

CONCLUSION

Although efficient handling of dysmetabolic disorders is essential, it is not sufficient to normalize dysmetabolic hyper-ferritinaemia. Only patients with a ferritinaemia value below a baseline of 450 microg/l had normalization of iron overload. Therefore venesection must be offered to all patients with a hyper-ferritinaemia above this value.

Cardiovascular disease with diabetes or the metabolic syndrome: should statins or fibrates be first line lipid therapy?

PURPOSE OF REVIEW

Subgroups with diabetes or with features of the metabolic syndrome have been increasingly highlighted in large clinical endpoint trials with lipid therapy. This review will focus on the results of trials with statins or fibrates and examine the strength of the evidence for major cardiovascular event reduction with each kind of therapy in these high-risk subgroups that typically have low-to-moderate levels of LDL cholesterol.

RECENT FINDINGS

Of six statin trials in populations with moderately increased LDL cholesterol only one, the Heart Protection Study, has shown that statin therapy will significantly reduce the major coronary heart disease events of non-fatal myocardial infarction or coronary heart disease death in diabetes. None of these trials has shown that statins have a particular predilection for reducing cardiovascular events in individuals with higher levels of body weight or other features of the metabolic syndrome. There are far fewer trial data with fibrates than with statins. However, the Veterans Affairs High Density Lipoprotein Intervention Trial has shown that a fibrate can significantly reduce major cardiovascular events, most particularly coronary heart disease death, in those with diabetes as well as those without diabetes who have insulin resistance. Indeed, all fibrate trials show that this therapy appears to selectively benefit the individual with obesity and features of the metabolic syndrome.

SUMMARY

Based principally on evidence from the Veterans Affairs High Density Lipoprotein Intervention Trial and the cumulative experience with statins, trial data would thus far suggest that the patient with a modest increase in LDL cholesterol who has diabetes or features of the metabolic syndrome might be likely to achieve more substantial cardiovascular benefit from fibrate than from statin therapy.

[The metabolic syndrome]

Metabolic syndrome represents a cluster of clinical, biochemical and humoral abnormalities associated with impaired insulin action in glucose metabolism. In the literature also the term syndrome of insulin resistance, dysmetabolic syndrome X, Reaven syndrome or Kaplans dead quartet can be found. Hyperinsulinaemia, central obesity, essential hypertension, dyslipidaemia, impaired glucose homeostasis or type 2 diabetes, hyperuricaemia, hypercoagulable state, endothelial dysfunction and increased markers of inflammation such as C-reactive protein, selectines, adhesion molecules, pro-inflammatory cytokines are the typical components of metabolic syndrome increasing the risk of cardiovascular complications. List of currently recognized clinical and biochemical manifestations continues to expand and include also non-alcoholic steatohepatitis, polycystic ovaric syndrome (PCOS), hyperhomocysteinaemia and others. No standard definition of metabolic syndrome has been routinely used. The WHO initially proposed a definition of metabolic syndrome in 1998, and more recently NCEP-ATP III provided a new working definition in 2001, which is more suitable for clinical practice. Prevalence of metabolic syndrome is very high, about 25-30% in Caucasians, depending on diagnostic criteria used. The clinical significance of metabolic syndrome is augmented by its association with increased and accelerated atherosclerosis. Whether IR predicts cardiovascular disease (CVD) independently of diabetes and other CVD risk factors is still a matter of controversy. Recently there is a growing evidence that metabolic syndrome increases also the risk of all-cause mortality and risk of certain tumors.

[Diabetes and multimetabolic syndrome]

The metabolic syndrome is associated with increased morbility and mortality for cardiovascular disease. This syndrome is determined not only by metabolic alterations such as hyperglycemia, and hyperlipidemia but also by a chronic proinflammatory state. Another culprit in the formation and progression of vascular disease is the so-called endothelial dysfunction which is linked to insulin resistance itself. The common denominator of the metabolic syndrome is insulin resistance. The most convincing evidence for the existence of a syndrome comes from the cluster analysis which outlines four main factors: the "metabolic factor", the "pressor factor", the "lipid factor", and the "obesity factor". It is clear that the presence of the metabolic syndrome appears to identify a substantial additional cardiovascular risk above the individual risk factors. The studies available in the literature have pointed out the beneficial effects, in terms of cardiovascular mortality, of the treatment with inhibitors of the 3-hydroxy-3-methylglutaryl coenzyme A reductase (statins): this risk reduction has been observed despite the fact that high triglyceride and low HDL cholesterol levels, but not hypercholesterolemia, are the main features of the dyslipidemia observed in patients with this syndrome. Yet, despite a normal LDL cholesterol level, patients with this syndrome are at high risk for future cardiovascular events: for this reason treatment with statins is mandatory.

[Dyslipidemia and the metabolic syndrome]

Dyslipoproteinemia is the common part of metabolic syndrome, it appears probably due tu high level of free fatty acids. The typical lipid disorders are: high trigylcerides concentration, low HDL-cholesterol level, elevation of small dense LDLs particles and elevation of apolipoprotein B100 and non-HDL cholesterol. LDL-cholesterol concentration is usually normal. This type of dyslipoproteinemia is very aterogenic. Weight reduction, diet and regular physical activity is the most effective way how to treat this type of dyslipoproteinemia. When non-pharmacologic treatment is not successful, treatment with hypolipidemic drugs is necessary to prevent atherosclerotic complications. Fibrates are recommended in typical dyslipidemia to lower high triglycerides level and to elevated low HDL-cholesterol concentration. But when high LDL-cholesterol is present, statins are needed. In some patients with combined hyperlipidemia treating with fibrate and statin together is needed to reach target lipid levels.

Potential contribution of metformin to the management of cardiovascular disease risk in patients with abdominal obesity, the metabolic syndrome and type 2 diabetes

With an evolving landscape of a growing number of obese and/or type 2 diabetic patients in our affluent population, the metabolic syndrome has become a major issue because of its impact on cardiovascular disease risk. In this regard, although it is appropriate to aim at a better glycaemic control in type 2 diabetic patients, hyperglycaemia does not appear to be the main culprit responsible for the markedly increased cardiovascular disease risk in this population. Rather, studies have suggested that a cluster of metabolic abnormalities, which includes an atherogenic dyslipidaemic state, an impaired glucose/insulin homeostasis, and a pro-thrombotic and inflammatory profile, substantially increases the risk of coronary heart disease in type 2 diabetic patients in a manner which is partly independent of glycaemic control. These results imply that in order to reduce the risk of atherosclerotic macrovascular disease in type 2 diabetic patients, physicians need not only to focus on a better glycaemic control but also to improve the features of the metabolic syndrome. As a consequence, in order to evaluate the clinical benefits of pharmacotherapy in type 2 diabetic patients, we need to quantify the impact of any pharmacological intervention beyond glucose control. In this context, metformin has been shown to not only contribute to a better glycaemic control but also to induce some weight loss (especially in the visceral depot) which may contribute to the improvement of the features of the metabolic syndrome. Thus, metformin treatment may represent a relevant element of an integrated lifestyle modification-pharmacotherapy to prevent not only type 2 diabetes but also cardiovascular disease.

Increased incidence of coronary atherosclerosis in type 2 diabetes mellitus: mechanisms and management

Type 2 diabetes mellitus is a metabolic disease of carbohydrate metabolism. However, it should also be considered a vascular disease because diabetic patients have a strong predilection for atherosclerosis. With the increasing prevalence and earlier age at onset of diabetes, the projected effect of diabetes on cardiovascular health and resource utilization is sobering. The mechanisms of the high rate of atherosclerosis are multifactorial and give clinicians and researchers insights into potential preventive therapies. Effective pharmacologic and lifestyle interventions are available for primary and secondary prevention of cardiovascular complications. However, data show that these interventions continue to be underutilized. Treatment of patients with type 2 diabetes and coronary artery disease is similar to that of patients with coronary artery disease alone. However, patients with diabetes benefit more from treatments that reduce coronary artery disease risk.

[Metabolic syndrome and pancreas. Status of exocrine and incretory function of the pancreas in various types of hyperlipoproteinemia in patients with metabolic syndrome]

We studied the frequency of the main types of hyperlipoproteinemia (HLP) by Fredrickson (1971) and the functional state of the pancreas in 53 patients with metabolic syndromes without any clinical signs of the digestive apparatus pathology and pancreatic diabetes. It was established that IIb [symbol: see text] IV types of the disease were observed in 26 and 13 cases (49 and 24.5%, respectively), type IIa was recorded in 9 cases (17%), and type V was recorded in 5 patients (9.5% of all cases). Functional pancreas disorders were recorded more often in cases of HLP of IIa, IV and V types. Excretory disorders were characterized mainly by insufficient production of lipase, bicarbonates and the liquid secretion fraction, while insular disorders were characterized by apparent disorders of glucose tolerance and pre-clinical pancreatic diabetes of type II.

Clustered features of the metabolic syndrome and the risk for increased aortic pulse wave velocity in middle-aged Japanese men

The association between different features of the metabolic syndrome (MS) (obesity, hypertension, hypercholesterolemia, low high-density lipoprotein cholesterol level, hypertriglyceridemia, high fasting plasma glucose level, and hyperuricemia) and the risk for increased aortic pulse wave velocity (PWV) of > or = 8.0 m/sec was examined in 2431 Japanese men aged 35 to 54 years who were not taking antihypertensive medication. After controlling for age, cigarette smoking, and alcohol intake, the odds ratios for increased aortic PWV in subjects with 1, 2, 3, and > or = 4 features of the MS, compared with those without features of the MS, were 1.35 (95% CI, 0.86 to 2.11), 1.90 (95% CI, 1.18 to 3.06), 1.57 (95% CI, 0.89 to 2.76), and 2.38 (95% CI, 1.26 to 4.49), respectively (p for trend = 0.003). A 9-year longitudinal study was also performed to prospectively examine the association between clustered features of the MS and the development of increased aortic PWV in 2073 men without aortic stiffness with a PWV < 8.0 m/sec and without antihypertensive medication during the follow-up period. The multivariate-adjusted hazard ratios for the incidence of increased aortic PWV in subjects with 1, 2, 3, and > or = 4 features of the MS, compared with those without features of the MS, were 1.39 (95% CI, 1.10 to 1.77), 1.46 (95% CI, 1.1 1 to 1.92), 1.75 (95% CI, 1.27 to 2.40), and 2.22 (95% CI, 1.52 to 3.25), respectively (p for trend < 0.001). These results suggest that clustered features of the MS are closely associated with the risk for increased aortic PWV in middle-aged Japanese men.

[The metabolic syndrome in postmenopausal women. Clinical implications]

Cardiovascular diseases (CVD) remain the major cause of death in postmenopausal women. Before menopause, women are relatively protected from ischemic heart disease and thromboembolism by their circulating estrogens, but this protection is lost after menopause. Following menopause, adverse lipid changes occur and the levels of several coagulation factor increase. One of the major predisposing factors for CVD is the metabolic syndrome, including myriad risk biomarkers: abdominal girth, blood pressure, fasting glucose, triglycerides, lipids. In many ways, the metabolic syndrome is a precursor to the development of abnormalities of insulin action and diabetes. In parallel, there are effects upon blood coagulation and fibrinolysis. Common preventive therapies require rigorous evaluation. Hormone replacement therapy (HRT) has not produced the expected reduction in CVD and the ideal HRT is probably unobtainable. For long-term HRT users, the risk of thromboembolism needs to be weighed against probable benefits. With respect to the effects of HRT, oral estrogen is associated with elevation in C-reactive protein and varied effects on IL-6, but transdermal estradiol has no significant effect on these parameters. Despite the varied effects of HRT on inflammatory biomarkers, there is no definitive evidence that change in these markers results in modification of cardiovascular risk.

Recommendations for special populations: diabetes mellitus and the metabolic syndrome

Cardiovascular diseases (CVD) are the major causes of mortality in persons with diabetes, and many factors, including hypertension, contribute to this high prevalence of CVD. The incidence of hypertension in patients with diabetes is approximately twofold higher than in age-matched subjects without the disease, and conversely, individuals with hypertension are at increased risk of developing diabetes compared with normotensive persons. Furthermore, because up to 75% of cases of CVD in patients with diabetes can be attributed to hypertension, aggressive management of elevated blood pressure (BP) (ie, to <130/85 mm Hg) in these patients is essential for reduction in cardiovascular morbidity and mortality. The renin-angiotensin system is an important regulator of both BP and obesity, and its pharmacologic modulation may thus translate into significant cardiovascular benefits. Apart from hypertension and obesity, the important risk factors for CVD in patients with diabetes include atherosclerosis, dyslipidemia, microalbuminuria, endothelial dysfunction, platelet hyperaggregability, and coagulation abnormalities. Therefore, effective prevention of major cardiovascular events in patients with diabetes requires combination therapy with agents that target key factors contributing to cardiovascular morbidity and mortality. The antiplatelet and anti-inflammatory effects of aspirin, the lipid-lowering activity of statins, as well as the antihypertensive effects of various agents (eg, diuretics, beta-blockers, calcium channel blockers, angiotensin-converting enzyme inhibitors, and angiotensin-II receptor blockers) have all been demonstrated to provide substantial reductions in cardiovascular events.

Lipid overload and overflow: metabolic trauma and the metabolic syndrome

Approximately two-thirds of the US population are overweight, which means that insulin resistance is probably the most common metabolic abnormality in the USA. I propose three novel concepts concerning the causes and consequences of insulin resistance that challenge current thinking. First, there is the evidence that resistance to insulin-stimulated glucose metabolism is not a primary event in obesity, but is secondary to lipid accumulation resulting from full responsiveness to insulin-stimulated lipogenic activity. Second, resistance to insulin-stimulated glucose metabolism, now considered detrimental to health, might be a protective mechanism that reduces lipid-induced damage to tissue by excluding glucose from cells, thus decreasing glucose-derived lipogenesis. Third, I suggest that lipid-induced insulin resistance and the accompanying metabolic syndrome are secondary to leptin resistance, resulting in breakdown in the normal partitioning of surplus lipids in the adipocyte compartment.