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Management of Patients with Metabolic Syndrome

The World Health Organization in 1998 suggested using the term "metabolic syndrome" to describe the combination of atherosclerotic risk factors that includes insulin resistance, microalbuminuria, hypercoagulability, dyslipidemia, obesity, and hypertension. Recognition of the increased risk for coronary disease and stroke makes intervention essential in patients with these risk factors. Scott reviewed the management of patients with the metabolic syndrome.

Treatment Goals for Patients with Metabolic Syndrome Blood pressure <125/75 mm Hg LDL cholesterol level <100 mg per dL (2.60 mmol per L) Triglyceride level <150 mg per dL (1.70 mmol per L) HDL cholesterol level:    Men: >40 mg per dL (1.04 mmol per L)    Women: >50 mg per dL (1.30 mmol per L) LDL = low-density lipoprotein; HDL = high-density lipoprotein.

The compensatory hyperinsulinism occurring in insulin-resistant patients stimulates the sympathetic nervous system and causes hypertension. The visceral obesity in patients with metabolic syndrome is associated with dyslipidemia. Increased circulating free fatty acids and macrovascular damage caused by insulin resistance causes endothelial dysfunction and accelerates atherosclerosis. Microalbuminuria, a strong independent risk factor for cardiovascular events, results from endothelial dysfunction and oxidative stress.

The treatment goal for patients with metabolic syndrome is prevention of type 2 diabetes and cardiovascular events. To accomplish this goal, treatment must address each component of the syndrome (see accompanying table). Treatment should begin with lifestyle changes, including dietary instruction and moderate daily exercise. Pharmacotherapy with statins, fibrates, angiotensin-converting enzyme (ACE) inhibitors, and thiazolidinediones may be necessary. Although statins do not alter insulin resistance, they may prevent the onset of type 2 diabetes. Statin therapy also decreases cardiovascular event risk by decreasing high-sensitivity C-reactive protein levels and stabilizing atherosclerotic plaques. Fibrate therapy reverses dyslipidemia and redistributes small, dense low-density lipoprotein particles to larger, less atherogenic particles. ACE inhibitors (especially ramipril) reduce the risk of developing diabetes. Thiazolidinediones (insulin sensitizers) decrease hyperglycemia by improving glucose uptake in muscles and adipose tissue and reducing glucose production. Thiazolidinediones also decrease triglyceride levels, increase high-density lipoprotein cholesterol levels, and help reduce microalbuminuria and blood pressure. Other potentially useful pharmacologic agents include nicotinic acid, alpha blockers, estrogen, and alcohol.

The author concludes that early detection of insulin resistance and initiation of treatments to correct all of the components of metabolic syndrome will decrease morbidity and mortality in patients with this condition.

RICHARD SADOVSKY, M.D.

Scott CL. Diagnosis, prevention, and intervention for the metabolic syndrome. Am J Cardiol July 3, 2003;92(2 suppl):35i-42i.

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