งานนำเสนอเรื่อง: "Hypertension & Diabetes Mellitus in the Elderly"— ใบสำเนางานนำเสนอ:
1Hypertension & Diabetes Mellitus in the Elderly รศ.นพ. ประเสริฐ อัสสันตชัยเวชศาสตร์ผู้สูงอายุ ภาควิชาเวชศาสตร์ป้องกันและสังคมคณะแพทยศาสตร์ศิริราชพยาบาล
2Prevalence of chronic diseases among the Thai elderly Health System Research Institute 1998 age group60-6970-7980-89> 90Knee arthralgia22.926.120.8Low back pain16.517.917.710.4Hypertension14.915.014.66.2Vision problem10.214.416.7Diabetes mellitus10.07.03.12.1Ischemic heart dis.2.04.74.2Stroke184.108.40.206Dementia220.127.116.11
3Conditions related to hypertension in the Thai elderly Conditions related to hypertension in the Thai elderly Health System Research Institute 1999HT(%)Normalp valueDementia4.12.8< 0.05Long term disability24.916.2< 0.001Barthel Activity of daily living2.632.27
4Chronic diseases influenced long term disability Chronic diseases influenced long term disability Health System Research Institute 1998Odds ratioAR*Pop.AR**Accident--421217.2Stroke16.89788190.7Eye disease1.93152182.9Knee pain1.8176179.9Hypertension1.50112166.0* AR: attributable risk , ** Pop.AR : population attributable risk
560-74 yr. > 75 yr. rate YLL* Circulatory dis. 574 452567 1936 Mortality rate of diseases among the Thai Elderly (per 105) Health Policy and Planning Institute 200060-74 yr.> 75 yr.rateYLL*Circulatory dis.5744525671936376946Cancer56446188889789321Diabetes mellitus21317898434856542COPD209159142920162844GI diseases1149467430157937YLL : year of life lost – number of years lost due to premature death
6A Worldwide Challenge for the 21st Century Atherosclerosis:A Worldwide Challenge for the 21st Century“Cardiovascular disease accounts for 14.8 million deaths per year worldwide” W.H.O. report 1998Atherosclerotic plaque ruptureLocalised myocardial infarction
8Atherothrombosis: Main Cause of Major Ischemic (Vascular) Events Atherothrombosis is characterized by a sudden (unpredictable) atherosclerotic plaque disruption (rupture or erosion) leading to platelet activation and thrombus formationAtherothrombosis is the underlying condition that results in events leading to myocardial infarction, ischemic stroke, and vascular death• Atherothrombosis is characterized by an unpredictable, sudden disruption (rupture or erosion/fissure) of an atherosclerotic plaque, which leads to platelet activation and thrombus formation.• The left hand image illustrates the rapid progression of atherothrombosis, showing a disrupted coronary plaque with occlusive thrombosis superimposed.1• The right hand image shows plaque erosion with an acute coronary thrombosis.2• Atherothrombosis is the underlying condition that results in events leading to myocardial infarction, ischemic stroke, and vascular death. Cardiovascular, cerebrovascular and peripheral vascular disease (also known as peripheral arterial disease) are part of a continuum of diseases with the common underlying pathophysiology of atherothrombosis.References1. Falk E et al. Circulation 1995; 92: 657–671.2. Arbustini E et al. Heart 1999; 82: 269–272.Plaque rupture1Plaque erosion21. Falk E et al. Circulation 1995; 92: 657– Arbustini E et al. Heart 1999; 82: 269–272
9Increasing Worldwide* Prevalence of Atherothrombotic Manifestations1 Populations aged > 50 year old205.0 million(5.1% since 1997)222.2 million(13.9% since 1997)9.1 million(12.8% since 1997)Myocardial infarction10.7 million(32.7% since 1997)The burden of atherothrombosis is growing. Prevalence of myocardial infarction and ischemic stroke is estimated to rise by approximately one third from 1997–2005.The increases in prevalence of these conditions is growing faster than the elderly population and therefore cannot be entirely explained by changing population demographics. Increased survival after a first event and secondary prevention contribute to this increase in prevalence.Ischemic stroke7.1 million(11.8% since 1997)8.4 million(31.6% since 1997)*Projected populations of people aged over 50 years, and estimated prevalence of myocardial infarction and ischemic stroke cumulated in 14 countries: Belgium, Canada, Denmark, Finland, France, Germany, Italy, Netherlands, Norway, Spain, Sweden, Switzerland, UK, USA1. Guillot F, Moulard O. Circulation 1998; 98(abstr suppl 1): 1421.Reference:1. Guillot F, Moulard O. Circulation 1998; 98(abstr suppl 1): 1421.
10Atherothrombosis* is the Leading Cause of Death Worldwide†1 52%Cancer24%Infectious Disease19%Pulmonary disease14%Violent death12%AIDS5%Atherothrombosis is the leading cause of death worldwide – accounting for 52% of deaths. An estimated 55,694,000 people worldwide died from atherothrombotic disease in 2000 (manifested as cardiovascular disease, ischemic heart disease and cerebrovascular disease). Other main causes of death were:AIDS (5%)Violent death (12%)Pulmonary disease (14%)Infectious diseases (19%)Cancer (24%).Reference1. World Health Organization. The World Health Report Geneva: WHO; 2001.102030405060Mortality (%)*Cardiovascular disease, ischemic heart disease and cerebrovascular disease†Worldwide defined as Member States by WHO Region (African, Americas, EasternMediterranean, European, South-East Asia and Western Pacific).1. World Health Organization. The World Health Report Geneva: WHO; 2001.
11Atherothrombosis Will Remain the Leading Cause of Disease Burden The ten leading causes of disease burden in developed countries 1990–20201990 disease or injury1Rank order2020 disease or injury2Ischemic heart disease1Ischemic heart diseaseCerebrovascular disease2Cerebrovascular diseaseRoad traffic accidents3Unipolar major depressionBronchus and lung cancers4Trachea bronchus & lung cancersSelf-inflicted injuries5Road traffic accidentsConditions during perinatal6Alcohol useLower respiratory infections7Osteoarthritis• According to the Global Burden of Disease project, sponsored by the World Health Organization, World Bank, and Harvard School of Public Health, manifestations of atherothrombosis (ischemic heart disease and cerebrovascular disease) were the primary causes of death and disability in developed countries in This finding remains true even when underdeveloped countries are added to the analysis.• Despite advances in medical and surgical therapies, ischemic heart disease is projected to remain the primary cause of morbidity and mortality in developed countries in the yearReferences1. Murray CJL, Lopez AD. In: Murray CJL, Lopez AD, eds. Global Burden of Disease. Vol 1. Boston, MA: Harvard University Press; 1996.2. Murray CJL, Lopez AD. Lancet 1997; 349: 1498–1504.Congenital anomalies8Dementia and other CNS disordersColon and rectal cancers9COPDStomach cancer10Self-inflicted InjuriesNote:Disease burden is measured in disability-adjusted life years (DALYs), a measure that combines the impact on health of years lost due to premature death and years lived with a disability. One DALY is equivalent to one lost year of healthy life1. Murray and Lopez. Global Burden of Disease Study. 19962. Murray and Lopez. Global Burden of Disease Study. 1997
12Distribution of systolic pressure with age Framingham , Health Survey for England 1994
14Distribution of systolic pressure with age among Thai elderly. P Distribution of systolic pressure with age among Thai elderly P. Assantachai. Comprehensive study of the Thai elderly. Mahidol Fund 2000centralnorthsouthnortheast
15Hypertension in the Elderly What should be concerned before diagnosis ?Why do they need treatment ?When is the best time of intervention ?What is precaution before starting treatment ?How many forms of management ?What is the most appropriate drug of choice ?How far should blood pressure be lowered?Is it the same between the young old elderly and the very old elderly ?
16Special Characteristics in Geriatrics RAMPSReduced body reserveAtypical presentationMultiple pathologyPolypharmacySocial adversity
17What should be concerned before diagnosis of hypertension in the elderly ? Variability: white-coat (labile) hypertensionPseudohypertension: Osler manoeuvreISH :exclude aortic insufficiency, severe anemia, hyperthyroidism, arteriovenous fistula, fever.Secondary hypertension: renal artery stenosisAssociated disease : DM, dyslipidemiaPersonal factors : salt intake, obesity, exercise, smoking, drinking
18958 cases followed up 42 months: White-coat vs. Sustained Hypertension in the Elderly Kario K, et al. J Am Coll Cardiol 2001;38:958 cases followed up 42 months:147 (normal), 236 (white-coat), 575 (HT)Stroke occurrence:Normal: 3 (2.0%)White-coat : 5 (2.1%)HT : 54 (9.4%)Incidence of stroke :in white-coat hypertension = in normotensives = ¼ risk in sustained hypertension.
20Secondary hypertension in the elderly Early diagnosis of HT before 30 yrs.old without family historyRecent worsening of blood pressure + premature target organ damageResistant to treatmentRecent poor control without obvious reasonARF after ACEI or ARB
21Hypertension in the Elderly What should be concerned before diagnosis ?Why do they need treatment ?When is the best time of intervention ?What is precaution before starting treatment ?How many forms of management ?What is the most appropriate drug of choice ?How far should blood pressure be lowered?Is it the same between the young old elderly and the very old elderly ?
22Mulrow et al. Hypertension in the elderly. JAMA 1994, p.1932-8. Why do they need treatment?__ 3 stages of clinical trials of hypertension in the elderly5-yr NNTAustEWPHE16143752STOPSHEPMRCOA-betaSummary
23Second stage of antihypertensive trial in the elderly การศึกษาโดยใช้ยาในกลุ่ม calcium channel blocker ในช่วงปี ค.ศ ได้แก่ การศึกษา STONE (ใช้ยา nifedipine), SYST-CHINA (ใช้ยา nitrendipine), HOT (ใช้ยา felodipine ) และ PREVENT (ใช้ยา amlodipine)พบว่าสามารถลดอุบัติการณ์ของโรคระบบหัวใจและหลอดเลือดได้ถึงร้อยละ
25Hypertension in the Elderly What should be concerned before diagnosis ?Why do they need treatment ?When is the best time of intervention ?What is precaution before starting treatment ?How many forms of management ?What is the most appropriate drug of choice ?How far should blood pressure be lowered?Is it the same between the young old elderly and the very old elderly ?
26salt intake In general: every Na 100 mmol SP 4-5 mmHg When is the best time of intervention? How many forms of management? _Nonpharmacologicalsalt intakeIn general: every Na 100 mmol SP 4-5 mmHg DP 2 mmHgIn elderly: every Na 100 mmol SP 10 mmHgIn elderly with 95 percentile of BP: every Na 100 mmol SP 15 mmHgLaw MR, et al. Br Med J 1991; 312:
27How many forms of management? _Nonpharmacological ObesityAmong the Thai elderly:Hypertensive cases BMI, subcutaneous fat, percent body fatประเสริฐ อัสสันตชัย โครงการศึกษาวิจัยครบวงจรเรื่องผู้สูงอายุไทย ม.มหิดล 2542.INTERSALT study BW 10 kg. SP 3 mmHgDyer et al. J Hum Hypertension 1989; 3: 299.
28How many forms of management? _Nonpharmacological ExerciseRegular exercise decrease blood pressurein general : 3 / 3 mmHgin mild hypertensives : 6 / 7 mmHgin overt hypertensives : 10 / 8 mmHgFagard RH J Hypertension 1993; 11(Suppl.5) : S47-52.
29Hypertension in the Elderly What should be concerned before diagnosis ?Why do they need treatment ?When is the best time of intervention ?What is precaution before starting treatment ?How many forms of management ?What is the most appropriate drug of choice ?How far should blood pressure be lowered?Is it the same between the young old elderly and the very old elderly ?
30What are precautions before starting antihypertensive treatment? High prevalence of postural hypotensionHigh prevalence of multiple pathologyPolypharmacyPoor drug compliance due to inadequate knowledgeHeterogeneity among the elderly
31Hypertension in the Elderly What should be concerned before diagnosis ?Why do they need treatment ?When is the best time of intervention ?What is precaution before starting treatment ?How many forms of management ?What is the most appropriate drug of choice ?How far should blood pressure be lowered?Is it the same between the young old elderly and the very old elderly ?
32DM CRF CVD MI CHF BPH PAD COPD diuretic BB CCB ACEI ARB Aldo. AntagoAFBDMCRFCVDMICHFBPHosteoporosisPADCOPD
33General Guidelines in Prescription for the Elderly Complete and correct diagnosisNon-pharmacological treatment firstWell known pharmacokinetics and pharmacodynamics in the elderlyStart low go slowAvoid polypharmacyFriendly to useNew symptom may be the warning signCheck compliance regularly
34Hypertension in the Elderly What should be concerned before diagnosis ?Why do they need treatment ?When is the best time of intervention ?What is precaution before starting treatment ?How many forms of management ?What is the most appropriate drug of choice ?How far should blood pressure be lowered?Is it the same between the young old elderly and the very old elderly ?
36How far should blood pressure be lowered How far should blood pressure be lowered? Is it the same between the young old elderly and the very old elderly ?RationaleA 5-year retrospective study in Finland in 561 older people aged > 85 yrs,mortality was greatest among lowest BP, and lowest among SP > 160, DP > 90 mmHg.Mattila et al. Br Med J 1988; 296:887-9.A study in California, a paradoxical increase in survival was found in men aged > 75 yrs with increasing DP.Langer et al. Br Med J 1989; 298:
3780 years old milestone !!Antihypertensive treatment in < 80 years old : stroke 25 – 40% cardiac events 13 – 27% all cardiovascular events 17 – 40%Antihypertensive treatment in > 80 years old ??
38The Hypertension in the Very Elderly Trial (HYVET). Bulpitt CJ et al The Hypertension in the Very Elderly Trial (HYVET) Bulpitt CJ et al. J Hypertension 2003;21:submitted for entry = 1372excluded 89 cases:SBP< 160, DBP<90 & >109antihypertensives treatmentage<80mental test score < 7creatinine > 150 μmol/l1283 cases assigned to groups
39The Hypertension in the Very Elderly Trial (HYVET) Diureticn = 426ACE inhibitor n = 431No treatmentn = 426pilot trail : March 1994 – June 1998died n = 30lost n = 9complete 386died n = 27lost n = 7complete = 397died n = 22lost n = 8complete = 394
40Treatment betterControl better0.20.40.60.81.01.21.41.61.82.02.2Total mortalityDouble-blind trials (meta-analysis)(RR=1.14, p =0.05)All trails (meta-analysis)(RR=1.06, p =0.30)(RR=1.307, p=0.34)HYVET-Pilot (diuretic)(RR=1.143, p=0.65)HYVET-Pilot (ACE)(RR=1.227, p=0.42)HYVET-Pilot (all active)
42HYVET-Pilot study_CONCLUSION Treatment of 1000 patients for 1 year may reduce stroke events by 19 (9 non-fatal), but may be associated with 20 extra non-stroke deaths.Each stroke saved by antiHT treatment, there was one non-stroke death.
43HYVET_main clinical trial International trial3,845 cases aged > 80 with SP mmHg.Indapamide SR or placeboAdd-on : ACEI (perindopril mg/d.)Target BP 150 / 80 mmHg.Results: all stroke (RR 0.59, p 0.009), relative risk reduction - 41% all death from any cause (RR 0.76, p 0.007), relative risk reduction – 24%
44Quality of life in Syst-Eur Trial. Fletcher AE, et al Quality of life in Syst-Eur Trial Fletcher AE, et al. J Hypertension 2002; 20:Isolated systolic hypertension in older people4695 cases aged > 60 yrs, SP & DP >95 mmHg.Double-blind RCT, nitrendipine+enalapril+HCTZTarget sitting SP<150 (at least 20 mmHg reduction from baseline) followed for 2 yrs.Result: 42% ↓strokes (p<.003), 26%↓cardiac events (p<.03)Quality of life:Sickness Impact Profile(SIP), Brief Assessment Index (BAI)Conclusion: active treatment was associated with some small adverse impacts on quality of life.
45การศึกษาที่ติดตามผู้ที่มีอายุ 80 ปีขึ้นไปที่เป็นโรคความดันเลือดสูงและได้รับยาลดความดันเลือดเป็นเวลา 5 ปี พบว่าในบรรดาผู้ที่มีระดับความดันเลือดอยู่ในเกณฑ์ที่ควบคุมได้ ผู้ที่มีระดับความดันเลือดต่ำกว่าจะมีอัตราการรอดชีวิตที่ 5 ปี (5-year survival rate) น้อยกว่า ผู้ที่มีระดับความดันเลือดสูงกว่าOates DJ, et al. Blood pressure and survival in the oldest old. J Am Geriatr Soc 2007 ; 55 : 383-8
46จากการศึกษา SHEP พบว่าในกลุ่มผู้ที่มีระดับความดันเลือดปกติหลังได้รับการรักษา ถ้า DP ลดลงไปอีก 5 มม.ปรอทจากค่าเฉลี่ย 77 มม.ปรอท จะมีความเสี่ยงต่อการเกิดโรคในระบบหัวใจและหลอดเลือดเพิ่มขึ้นถึงร้อยละ ปรากฏการณ์นี้เรียกว่า J – curve ซึ่งพบใน DP มากกว่าจาก SPSomes GW, et al. The role of diastolic blood pressure when treating isolated systolic hypertension. Arch Intern Med 1999 ; 159 :Cruickshank JM, et al. Benefits and potential harm of lowering high blood pressure. Lancet 1987; 1 :
47Endocrine Changes in Aging _ Diabetes mellitus Physiologic changes Clinical correlationimpaired glucose tolerance ↑ DM↑ BS 5.3 mg%/10yrs after 30 years old↑ serum insulin metabolic syndrome↓ DHEA ↓ libido↓free testosterone↓ T sick euthyroid syndrome↑ PTH interpretation & ↓Ca↓ vitamin D by skin ↓ Ca absorption↑ serum homocysteine ↑ atherosclerosis
48Natural History of Type 2 Diabetes GlucosePost-prandial glucose100200150300250350mg/dLFasting glucoseRelative to normal250Insulin resistance200(%)150100At risk fordiabetes50Beta-cell dysfunctionInsulin level-10-551015202530YearsR.M. Bergenstal, International Diabetes Center
49Changes in blood glucose levels with age PostprandialFastingElahi D, et al. Eur J Clin Nutr 2000; 54: S112-S120.
50Diabetes mellitusSymptoms of DM + random blood glucose > 200 mg/dl.(8 hours) Fasting plasma glucose > 126 mg/dlTwo-hour plasma glucose > 200 mg/dlNB: repeat testing on a different day
51Diabetes mellitus Ideal goals for glycemic control normal goal action Preprandial < <80, >140glucoseHbA1c(%) < 6 < 7 > 8
52Diabetes Mellitus One of the most common non-communicable diseases Fourth leading cause of death in most developed countriesMore than 194 million people with diabetes worldwideIncidence of diabetes is increasing – estimated to rise to 333 million by 2025To more than double in Africa, the Eastern Mediterranean and Middle East, and South-East AsiaTo rise by 50% in North America, 20% in Europe, 85% in South and Central Americas and 75% in the Western PacificDiabetes is now one of the most common non-communicable disease globally. It is the fourth leading cause of death in most developed countries.1There are currently more than 194 million people with diabetes worldwide and there is evidence to suggest that it is epidemic in many developing countries. World Health Organisation figures estimate that the number of people developing diabetes will rise to 333 million byIn 2003, the five countries with the largest numbers of persons with diabetes were India (35.5 million), China (23.8 million), the United States (16 million), Russia (9.7 million) and Japan (6.7 million). By 2025, the prevalence of diabetes is expected to more than double in Africa, the Eastern Mediterranean and Middle East, and South-East Asia, to rise by 50% in North America, 20% in Europe, 85% in South and Central Americas and 75% in the Western Pacific. For developing countries, there will be a projected increase of a 170% of cases; for developed countries, there will be a projected rise of 42%.1Reference1. International Diabetes Federation website. (http://www.idf.org/home/index.cfm?node=6)International Diabetes Federation website
53The Chronic Complications of Diabetes Mellitus Macrovascular complications:Cardiovascular diseaseLeading cause of diabetes related deaths (increases mortality and stroke by 2 to 4 times)Microvascular complications:RetinopathyLeading cause of adult blindnessNephropathyAccounts for 44% of new cases of ESRDNeuropathy60-70% of patients with diabetes have nervous system damageThe complications of diabetes include an increased risk of heart disease and stroke, hypertension, retinopathy, renal disease and neuropathy.1Heart disease is the leading cause of diabetes-related deaths. Adults with diabetes have heart disease death rates about 2 to 4 times higher than adults without diabetes. The risk for stroke is 2 to 4 times higher among people with diabetes.Diabetes is the leading cause of new cases of blindness among adults 20 to 74 years old, and diabetic retinopathy causes from 12,000 to 24,000 new cases of blindness each year. Diabetes is the leading cause of treated end-stage renal disease (ESRD), accounting for 44 percent of new cases, and about 60 to 70 percent of people with diabetes have mild to severe forms of nervous system damage. The results of such damage include impaired sensation or pain in the feet or hands, slowed digestion of food in the stomach, carpal tunnel syndrome, and other nerve problems. Severe forms of diabetic nerve disease are a major contributing cause of lower-extremity amputations. More than 60 percent of nontraumatic lower-limb amputations in the United States occur among people with diabetes.Reference1. National Diabetes Statistics. General information and national estimates on diabetes in the United StatesNational Diabetes Statistics US 2000
54Patients with Diabetes at Similar Risk to No Diabetes with CVD: OASIS 3182124691215Months of follow-up0.250.200.150.100.05Event rate (Total mortality)diabetes plus CVD (n=1448)RR 2.88no diabetes/no CVD (n=2796)RR 1.0no diabetes plus CVD (n=3503)RR 1.71diabetes plus no CVD (n=569)RR 1.99The Organization to Assess Strategies for Ischaemic Syndromes (OASIS) study assessed the 2-year prognosis of patients with diabetes and patients with no diabetes, with and without prior cardiovascular disease (hospitalisation for unstable angina or non-Q-wave myocardial infarction).1 The study showed that patients with diabetes and previous cardiovascular disease were at greatest risk of death, and that of patients with diabetes without prior cardiovascular disease had a similar event rate to patients with no diabetes with previous cardiovascular disease, showing that diabetes is a CHD risk equivalent.ReferenceMalmberg K, Yusuf S, Gerstein HC et al. Circulation 2000;102:1014–1019.Adapted from Circulation 2000;102:1014–1019, with permission from Lippincott Williams & Wilkins.RR relative reductionMalmberg K et al. Circulation 2000;102:
56Metabolic syndromeAbdominal obesity (waist circumference > 90 cm. in men and > 80 cm.in women)2 of 4 of the followings:Triglyceride > 150HDL < 40 in men, < 50 in womenHypertension : BP > 130 / 85Fasting blood glucose > 100 or DM case
57NCEP ATP III: The Metabolic Syndrome Recommends a diagnosis when 3 of these risk factors are presentRisk FactorDefining LevelAbdominal obesity (Waist circumference)Men Women>102 cm (>40 in) >88 cm (>35 in)TG150 mg/dL (1.7 mmol/L)HDL-CThe diagnosis of the metabolic syndrome, as defined by the NCEP ATP III guidelines, is established when 3 or more of the above risk determinants are present.1 The metabolic syndrome is a secondary target of risk-reduction therapy, after the primary goal of LDL-C reduction.The metabolic syndrome is associated with a constellation of lipid and non-lipid risk factors of metabolic origin, and include abdominal obesity, atherogenic dyslipidaemia, hypertension, insulin resistance (with or without glucose intolerance), and prothrombic and proinflammatory states.NCEP ATP III provides a clinically useful definition of the metabolic syndrome because of the measurement of fasting glucose, rather than insulin resistance as seen in the WHO definition.ReferenceExpert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001:285;2486–2497.Adapted from JAMA 2001;285:2486–2497, with permission from the American Medical Association. All rights reserved.Men Women<40 mg/dL (1.0 mmol/L) <50 mg/dL (1.3 mmol/L)Blood pressure130/85 mm HgFasting glucose110 mg/dL (6.0 mmol/L)NCEP, Adult Treatment Panel III, JAMA 2001:285;
58IDF Consensus Definition of the Metabolic Syndrome The new IDF definition is:Central obesity: waist circumference 94 cm for Europid men 80 for Europid women, with ethnicity specific values for other groups (for South Asians: > 90 cm. for men, > 80 cm. for women)Plus any two of the following four factors:raised TG level: 150 mg/dL (1.7 mmol/L) or specific treatment for this lipid abnormalityreduced HDL-C: <40 mg/dL (1.03 mmol/L) in males and <50 mg/dL (1.29 mmol/L) in females or specific treatment for this lipid abnormalityraised blood pressure: 130/85 mmHg or treatment of previously diagnosed hypertensionraised fasting plasma glucose (FPG) 100 mg/dL (5.6 mmol/L) or previously diagnosed type 2 diabetesIn April 2005, the International Diabetes Federation (IDF) issued a global consensus statement presenting a new worldwide definition of the metabolic syndrome to facilitate early detection and more intensive management, in hopes of reducing the long-term risk of cardiovascular disease (CVD) and diabetes.1 The IDF panel included experts from six continents who specialize in diabetes, cardiology, lipidology, public health, epidemiology, genetics, metabolism, and nutrition.The metabolic syndrome, which includes diabetes or prediabetes, abdominal obesity, unfavorable lipid profile and hypertension, triples the risk of myocardial infarction or stroke and doubles mortality from these conditions. It also increases the risk of developing type 2 diabetes, if not already present, fivefold. Recent data from Australia and the U.S. suggest that up to one quarter of the adult population may have the metabolic syndrome.1The new diagnostic criteria are central obesity, defined as waist equal to or more than 94 cm for males and 80 cm for females in Europids, and ethnic-specific levels in Chinese, Japanese and South Asians; together with two of the following: raised triglycerides of at least 1.7 mmol/L or 150 mg/dL; low HDL-cholesterol, defined as less than 1.04 mmol/L (40 mg/dL) in males and less than 1.29 mmol/L (50 mg/dL) in females; raised blood pressure of at least 130/85 mm Hg; and fasting hyperglycemia, defined as glucose equal to or greater than 5.6 mmol/L (100mg/dL) or previous diagnosis of diabetes or impaired glucose tolerance.1Reference1. IDF Consensus Worldwide Definition of the Metabolic Syndrome.IDF Consensus Worldwide Definition of the Metabolic Syndrome.
59Proportion with a major CHD event Risk of Major CHD Event Associated with High Insulin Levels in Men without DiabetesYearsProportion with a major CHD event50.050.100.150.200.251.0010152025Log rank:Overall P = .001Q5 vs. Q1 P < .001Q1Q2Q3Q4Q5The Helsinki Policemen Study,1 a large prospective epidemiological study, investigated the predictive value of hyperinsulinaemia with regard to CHD risk in 970 men aged 34 to 64 years during a 22 year follow-up who were free of CHD, other CVD and diabetes at baseline.The study showed that hyperinsulinaemia is predictive of CHD risk and to a large extent is independent of other CHD risk factors.Reference1. Pyörälä M, Miettinen H, Laakso M et al. Circulation 1998;98:398–404.Adapted from Circulation 1998;98:398–404, with permission from Lippincott Williams & Wilkins.Q1 to Q5 = quintiles of area under the curve (AUC) insulin (Q1=lowest quintile; Q5=highest quintile).Pyörälä M et al. Circulation 1998;98:398–404.