Rationale for multiple risk intervention: The need to move from theory to practice

Figures & data

Table 1 The new International Diabetes Federation definition for the metabolic syndrome (IDF 2006)

Central obesity (defined as waist circumference ≥94 cm for Europid men and ≥80 cm for Europid women, with ethnicity specific values for other groups)
And any two of the following four factors:	Level
Reduced HDL cholesterol	<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 abnormality.
Raised BP	systolic BP ≥130 or diastolic BP ≥85 mmHg, or treatment of previously diagnosed hypertension.
Raised triglyceride level	≥150 mg/dL (1.7 mmol/L), or specific treatment for this lipid abnormality.
Raised fasting plasma glucose	≥100 mg/dL (5.6 mmol/L), or previously diagnosed type 2 diabetes. If above 5.6 mmol/L or 100 mg/dL, oral glucose tolerance test is strongly recommended but is not necessary to define presence of the syndrome.

Figure 1 Cumulative effects of modifiable risk factors in the INTERHEART study – risk of acute MI associated with exposure to multiple risk factors. Copyright © 2004. Reprinted with permission from Elsevier from Yusuf S, Hawken S, Ounpuu S, et al 2004. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet, 362:937–52.

Figure 2 Relative risk for cardiovascular disease mortality in men (aged 42 and 60 years at baseline) with and without metabolic syndrome. Copyright © 2002 American Medical Association. All rights reserved. Reprinted from Lakka HM, Laaksonen DE, Lakka TA, et al 2002. The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men. JAMA, 288:2709–16.

Figure 3 Change in risk for cardiovascular disease deaths with increasing age (based on the European Society of Cardiology (ESC) SCORE chart) for a woman in a high-risk population who smokes and has high cholesterol and high blood pressure, compared with a nonsmoker with lower cholesterol and blood pressure values. Data drawn from Conroy RM, Pyorala K, Fitzgerald AP, et al 2003. Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J, 24:987–1003.

Table 2 Major intervention strategies and recommendations for the management of the individual risk factors associated with cardiovascular and metabolic disease

Intervention	Recommendations
Lifestyle changes (Chobanian et al 2003, NCEP Expert Panel 2002; ESH-ESC Guidelines Committee 2003):
Weight reduction	Maintain BMI of 18.5–24.9 kg/m^2.
Adoption of DASH eating plan	Consume a diet rich in fruits, vegetables and low-fat dairy products with a reduced content of saturated and total fat.
Reduction of dietary sodium	≤100 mmol/day.
Regular aerobic activity	≥30 minutes per day, most days of the week.
Moderation of alcohol consumption	≤2 drinks* per day for men ≤1 drink per day for women and lighter-weight individuals.
Smoking cessation	If necessary, nicotine replacement or bupropion therapy should be considered.
Obesity management	Primarily through lifestyle changes but anti-obesity drugs (eg, sibutramine, orlistat and topiramite) may be used if required. (Klein 2004; Li et al 2005).
Insulin resistance management	Lifestyle modifications are recommended as firstine therapy (Daskalopoulou 2004; Zieve 2004; Wagh and Stone 2004; Grundy 2005; Vitale 2006), however, if this does not stop blood glucose levels rising towards diabetic levels and clustering of risk factor progresses, intervention with drugs is essential (Grundy 2006).
BP lowering	BP should be <140/90 mmHg in individuals with hypertension and no other risk factors or <130/80 mmHg in patients with diabetes or chronic kidney disease (De Backer et al 2003; Erhardt and Gotto 2006).
Dyslipidemia management	All patients aged ≤80 years with active coronary heart disease, peripheral arterial disease, history of ischemia, stroke or long-standing type 2 diabetes should receive a statin if their total cholesterol is >3.5 mmol/L. Patients without CV disease or recent on-set diabetes whose estimated 10 year CV risk ≥20% should also receive a stain if their total cholesterol is >3.5 mmol/L (ESH-ESC Guidelines Committee 2003).
New-onset diabetes prevention	Treatment with oral antidiabetic agents and potentially ACE-Is or ARBs (McCall et al 2006).

Abbreviations: BMI, body mass index; ACE-Is, angiotensin converting enzyme inhibitors; ARBs, angiotensin II receptor blockers; CV, cardiovascular.

* Notes: defined as 1 oz or 30 mL ethanol eg, 24 oz of beer, 10 oz wine or 3 oz of 80-proof whiskey.

Figure 4 Comparison of actual versus perceived 10-year risk among 80 Swedish general practitioners when asked to estimate the risk of specific patient profiles. Data drawn from Backlund L, Bring J, Strender L-E. 2004. How accurately do general practitioners and students estimate coronary risk in hypercholesterolaemic patients? Primary Health Care Research and Development, 5:145–52.

Figure 5 Emergency resource utilization in fully compliant and partial/non compliant patients with high risk for coronary heart disease. Data drawn from Goldman DP, Joyce GF, Karaca-Mandic P. 2006. Varying pharmacy benefits with clinical status: the case of cholesterol-lowering therapy. Am J Manag Care, 12:21–8.

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