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Despite therapeutic advances, cardiovascular disease remains the leading cause of death (USA)

Survey data from the Centers for Disease Control National Center for Health Statistics in the USA illustrate the continuing burden of mortality arising from cardiovascular disease.

The left hand axis shows the numbers of deaths attributed to specific conditions in men and women in 2002. The right hand axis expresses the number of deaths in men and women combined as a percentage of the total numbers of deaths during that year.

Cardiovascular disease remains the leading killer, with more impact on mortality rates than other major sources of mortality, such as cancer, respiratory disease, accidents, or diabetes.

National Center for Health Statistics. Health, United States, 2004 With Chartbook on Trends in the Health of Americans. Hyattsville, Maryland: 2004.

Hypertension Is a Risk Factor for Cardiovascular Disease

Our understanding of hypertension as a disease process is highlighted by epidemiologic studies that demonstrate that individuals with elevated BP have an increased risk of developing cardiovascular disease. This slide presents prospective, longitudinal analysis of 36-year data from the Framingham Heart Study, showing that hypertensive men or women have two- to four-times the risk of developing coronary artery disease, stroke, peripheral vascular disease, or congestive heart failure than normotensive men or women.6

The goal in treating hypertension is thus a reduction in the incidence of cardiovascular disease. In order to assess our success in treating hypertensive patients, we have to determine the impact of our treatment on the incidence of cardiovascular disease in hypertensive patients.

6 Kannel WB. Blood pressure as a cardiovascular risk factor. JAMA 1996;275:1571-1576.

Abdominal obesity increases the risk of developing type 2 diabetes

These data are from the Nurses’ Health Study,1 an observational study that followed a cohort of 43,581 women between 1986 and 1994 in the USA. The analysis presented here was designed to define the association between waist circumference and the risk of developing type 2 diabetes.

The risk of developing type 2 diabetes increased linearly with an increasing waist circumference. The relative risk for women at the 90th percentile of waist circumference (equivalent to a waist measurement of 92 cm [36 in]) was 5.1 (95% CI 2.9-8.9) compared with women at the 10th percentile (waist measurement of 67 cm [26.2 in]). High waist circumference is a powerful predictor of an increased risk of developing type 2 diabetes.

Previous slides have defined the central role of abdominal obesity in the diagnostic criteria for the metabolic syndrome. People with the metabolic syndrome have a 5-fold greater risk of developing type 2 diabetes, if not already present.2

1. Carey VJ, Walters EE, Colditz GA et al. Body fat distribution and risk of non-insulin-dependent diabetes mellitus in women. The Nurses' Health Study. Am J Epidemiol 1997;145:614-9.

2. Stern MP, Williams K, Gonzalez-Villalpando C, Hunt KJ, Haffner SM. Does the metabolic syndrome improve identification of individuals at risk of type 2 diabetes and/or cardiovascular disease? Diabetes Care 2004;27:2676-81.

Multiple cardiovascular risk factors drive adverse clinical outcomes

Cardiovascular disease remains the number one cause of death despite recent advances in cardiovascular care, such as the introduction of new effective drugs for the management of individual cardiovascular risk factors.

The overall risk of an adverse cardiovascular event is often driven by multiple individual risk factors, including abdominal obesity, dyslipidaemia, insulin resistance/glucose intolerance and raised blood pressure.

Accordingly, new approaches that address these multiple sources of overall cardiometabolic risk, rather than individual risk factors, may be required for the next advance in cardiovascular and diabetes care.

Prevalence of the NCEP metabolic syndrome: NHANES III by sex and race/ethnicity

This slide shows the prevalence of the metabolic syndrome as defined by NCEP in NHANES III participants by sex and ethnicity. The prevalence of the metabolic syndrome is highest in Mexican American women and lowest in African American men. The prevalence of the metabolic syndrome (using the NCEP definition) is low in African Americans because African Americans have low triglycerides and high HDL-C levels and also because NCEP has separate criteria for triglycerides and HDL-C. Thus, the reports of the low prevalence of the metabolic syndrome in African Americans should be taken with caution since this ethnic group is known to have high rates of glucose intolerance and hypertension.

Reference:

Ford ES, Giles WH, Dietz WH. Prevalence of the metabolic syndrome among US adults: findings from the third National Health and Nutrition Examination Survey. JAMA 2002;287:356-359.

This figure shows the following: In men in NHANES III, the prevalence of individual components with MetS increases with age. In addition, there are ethnicity-specific differences: For example, high BP is much more frequent in blacks, and both dyslipidemia and elevated FPG more frequent in Mexican Americans.

As in the previous slide, this figures shows age and ethnicity-specific prevalence figures for individual components of MetS. Women tend to have more frequently low HDL-C, a fact that may be driven by the cut-off point for HDL-C in women.

These data organized in a similar way to the ones from NHANES III in the previous slides and shows that the components of MetS are more common in men than in women, and that the prevalence of some components such as high BP and obesity increases with age in both sexes.

Although the criteria to diagnose metabolic syndrome in this overview of European studies uses the WHO criteria that are known to identify not exactly the same types of patients, the overall incidence is roughly comparable to the one seen in the US, albeit the difference between men and women is larger than in the US.

This graph presents some selected articles from different regions around the world. Some of the studies used the ATP III criteria for diagnosis, others did not, or did adapt them to local circumstances. Globally, emerging economies are catching up, especially women seem to be more prone to have MetS than men, inversely to what is found in Western populations. As a word of caution, it should be taken into consideration that the used criteria may eventually not wholly appropriate to the populations studied.

Very recently, CRP has attracted considerable attention. In this paper from the NHANES III survey, it is shown that in the general population, the level of CRP is related to the presence of individual components of the metabolic syndrome, and that there is an obvious graded relationship between the number of components and the probability of a subject having low-grade inflammation.

Metabolic syndrome has a negative impact on CV health and mortality

Although it has been widely assumed that the metabolic syndrome is associated with an increased risk of cardiovascular disease, relatively little research has been done on the prevalence of cardiovascular morbidity and mortality in patients with the syndrome.

Isomaa and colleagues assessed cardiovascular morbidity and mortality in a cohort of subjects (N=3606; age, 35 to 70 years) participating in a longitudinal study in Finland and Sweden (the Botnia study). Median follow-up was 6.9 years.

Subjects meeting the definition of metabolic syndrome were significantly more likely to have a history of CHD, myocardial infarction, and stroke than those without the syndrome. The presence of metabolic syndrome was associated with significantly increased risk of CHD (RR, 2.96, p<0.001), myocardial infarction (RR 2.63, P<0.001), and stroke (RR 2.27, p<0.001).

Overall, individuals with the metabolic syndrome were therefore 2–3-fold more likely to die from an adverse cardiovascular event than individuals without the metabolic syndrome.

People with the metabolic syndrome are at increased risk of being twice as likely to die from and tree times as likely to have a heart attack or stroke compared to people without metabolic syndrome.

Isomaa B, Almaren P, Tuomi T, et al. Cardiovascular morbidity and mortality associated with the metabolic syndrome. Diabetes Care 2001;24:683-689.