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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Truncal obesity

  • Insulin resistance with fasting hyperglycemia

  • Elevated triglycerides and reduced high-density lipoprotein (HDL) cholesterol

  • Hypertension

  • Hyperuricemia

  • Premature coronary and peripheral artery disease

GENERAL CONSIDERATIONS

  • The metabolic syndrome consists of the constellation of:

    • – Hypertension

    • – Dyslipidemia

    • – Insulin resistance

    • – Obesity

  • Other associated abnormalities include:

    • – Microalbuminuria

    • – High uric acid blood levels

    • – Augmented blood clotting

    • – Premature atherosclerosis

  • Generally, 40% of people with hypertension also have hypercholesterolemia

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Angina or acute coronary syndrome

  • Symptoms of congestive heart failure

  • Intermittent claudication

PHYSICAL EXAM FINDINGS

  • S4

  • Signs of heart failure

  • Body mass index > 30 kg/m2

  • Reduced peripheral pulses

DIFFERENTIAL DIAGNOSIS

  • Other causes of premature coronary artery disease

  • Other causes of hypertension

  • Other causes of obesity

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Fasting glucose, hemoglobin A1C, lipids, uric acid

  • Urine albumin and protein

ELECTROCARDIOGRAPHY

  • May show evidence of left ventricular hypertrophy or myocardial infarction

IMAGING STUDIES

  • Echocardiography frequently shows:

    • – Impaired diastolic function of the left ventricle

    • – Left heart chamber enlargement

    • – Left ventricular systolic dysfunction

DIAGNOSTIC PROCEDURES

  • CT calcium score and coronary angiography

  • Invasive coronary angiography in selected patients

  • Ankle–brachial index

  • Peripheral angiography in selected patients

TREATMENT

CARDIOLOGY REFERRAL

  • Suspected cardiac disease

  • Difficult to control hypertension

  • Suspected peripheral arterial disease

HOSPITALIZATION CRITERIA

  • Acute coronary syndromes

  • Heart failure

  • Critical limb ischemia

MEDICATIONS

  • Oral hypoglycemic agents, insulin sensitizers, and insulin to bring the hemoglobin A1C to < 7%

  • Pharmacologic treatment of hypertension with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers to < 130/80 mm Hg. If further blood pressure control is required, diuretics and calcium blockers are preferred to beta blockers.

  • Pharmacologic lipid-lowering therapy to lower low-density lipoprotein (LDL) cholesterol < 100 mg/dL with statins

  • Pharmacologic therapy to reduce triglycerides and increase HDL with fibrates, nicotinic acid, or omega-3 fatty acids

THERAPEUTIC PROCEDURES

  • Coronary revascularization may be necessary

  • Peripheral revascularization may be necessary

SURGERY

  • Coronary bypass surgery may be indicated

  • Peripheral artery bypass may be indicated

MONITORING

  • ECG monitoring in hospital as appropriate

  • Monitor metabolic parameters during specific therapy

DIET AND ACTIVITY

  • Low-fat, low-sodium, low-calorie diet or DASH diet

  • Activity restriction if heart disease is active

ONGOING MANAGEMENT

HOSPITAL DISCHARGE CRITERIA

  • Resolution of problem

FOLLOW-UP

  • Depends on problem and treatment

COMPLICATIONS

  • Myocardial ...

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