Identification and Management of Metabolic Syndrome: The Role of the APN

Douglas H. Sutton, EdD, MSN; Deborah A. Raines, PhD

Disclosures

Topics in Advanced Practice Nursing eJournal. 2007;7(2) 

In This Article

Case Study

Robert, a 46-year-old man, presents for a routine physical examination for his new job. He denies any complaints at present, and states that he generally feels "pretty good." He denies any recent history of illness or injury.

Robert is a married, newly employed salesman with 2 grown children. He states that he has experienced good health except for a "few aches and pains every now and then." He does not have a primary healthcare provider, as he has just recently been able to obtain health insurance. His last physical examination was over 10 years ago for a job-related injury to his knee. Robert has no allergies, takes no prescription medications, and is able to perform all activities of daily living. He takes acetaminophen occasionally for his "aches and pains."

Family history is significant for his mother and brother having heart disease, hypertension, and obesity.

His mother has had 2 myocardial infarctions (MIs), and his older brother takes oral medication for type 2 DM.

Social history is significant for:

  • High-fat, high-cholesterol diet that he attributes to his frequent travels associated with his job;

  • Sedentary lifestyle that he also attributes to his traveling; and

  • Moderate alcohol use.

Robert denies the use of tobacco products or illegal drug use.

Robert, who appears his stated age of 46, is a moderately obese, white man. Vital signs include:

  • Temperature, 98.8°F (37.1°C);

  • Heart rate, 88 beats per minute;

  • Respirations, 16 breaths per minute;

  • Average BP reading of 144/90 mm Hg in both arms (repeated measurements confirmed after 5 minutes of rest between readings);

  • Weight, 237 lb (107.7 kg);

  • Height, 68 in (173 cm); and

  • Calculated BMI, 36 kg/m2.

Robert seems to carry a significant portion of his excess weight in his abdominal area (central obesity). Waist circumference measurement is noted to be 44 in (112 cm). The rest of his physical examination is essentially unremarkable. The working diagnoses of obesity and hypertension are attributed to Robert's history and physical examination, and warrant the following diagnostic and teaching plans. Robert was rescheduled for a second office visit in 2 weeks to discuss the results of his diagnostic work-up.

The following diagnostic tests are recommended on the basis of the "Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)" guidelines[34]:

  1. Electrocardiogram;

  2. Urinalysis;

  3. Fasting blood glucose;

  4. Hematocrit;

  5. Serum potassium;

  6. Creatinine (or the corresponding estimated glomerular filtration rate);

  7. Calcium; and

  8. Lipid profile (after a 9- to 12-hour fast) that includes HDL-C, LDL-C, and triglycerides.

Because of Robert's significant family history and current working diagnoses, the hsCRP test would also be recommended for Robert at this time.

A follow-up visit is scheduled and teaching is initiated in regard to TLC, specifically diet and physical activity. According to the JNC 7 guidelines, the adoption of healthy lifestyles by all individuals is an indispensable part of the management of those with hypertension, as well as those with obesity.[34] The major lifestyle modifications for Robert include[35,36]:

  • Weight reduction;

  • Adoption of the Dietary Approaches to Stop Hypertension (DASH) eating plan, including fruits, vegetables, low-fat dairy, whole grains, poultry, fish, and nuts; and minimal amounts of fats, red meat, sweets, and sugar-containing beverages

  • Reduction in dietary sodium intake;

  • Increased physical activity; and

  • Moderation of alcohol consumption.

Because metabolic syndrome can represent numerous abnormalities, the differential diagnoses can be broad. For Robert, after a comprehensive history and physical examination, his working diagnoses include obesity, stage I hypertension, and metabolic syndrome.

On the basis of his age and family history, the clinician might also consider type 2 DM and atherosclerotic CVD. Because of the insidious nature of each of these disorders, Robert provides no chief complaint and believes himself to be healthy. He is unaware of the potential risk that he has for experiencing an MI and coronary death.

Upon arriving at the clinic for his 2-week follow-up visit, Robert reported making some lifestyle changes. His weight was 233 lb (105.9 kg), down 4 lb (approximately 2 kg) from his initial visit, and his adjusted BMI was 35.4 kg/m2. BP readings in both arms average 145/86 mm Hg. He attributes the change in his weight to his adherence to the prescribed dietary plan, as well as to his daily effort to walk a minimum of 20-30 minutes. Since his initial visit 2 weeks ago, Robert reports only 1 occasion of alcohol use, and reaffirms that he does not smoke. In addition, he is making efforts to include his family and colleagues in his new lifestyle changes.

A review of the various diagnostic assessment results is presented in Table 3 .

On the basis of the history and physical examination, as well as diagnostic testing, Robert meets the AHA/NHLBI criteria for the diagnosis of metabolic syndrome. Of the 5 diagnostic criteria used to screen for metabolic syndrome, Robert has abnormal results in all 5 areas. In addition to the AHA/NHLBI criteria, Robert has a 16% coronary heart disease risk projection according to the Framingham criteria.[37]

For the clinician, the primary purpose of recognizing this clustering of diagnostic criteria into a formal diagnosis of metabolic syndrome is to establish treatment goals for a multitude of associated risk factors, namely, hypertension, hyperlipidemia, and hyperinsulinemia -- all of which result in increased cerebrovascular and cardiac morbidity and mortality in these patients.

According to the AHA/NHLBI scientific statement, the primary goal of clinical management should focus on the reduction of risk factors that are known to lead to the development of atherosclerotic CVD and type 2 DM in patients who have yet to develop clinical diabetes but are considered to be at higher risk.[2] In light of the current recommendations from the AHA/NHLBI, and in consultation with Robert, the 2 primary interventions that have been agreed upon will focus on TLCs and pharmacologic treatment. In addition to the treatment plan, Robert must recognize the need for continued assessment and management of risk factors associated with his diagnosis of metabolic syndrome.

The first and most preferred intervention, as it relates to improvement in outcomes and long-term reduction of risks associated with atherosclerotic CVD and type 2 DM, will be TLCs. As was discussed at his initial visit, Robert will focus on diet, exercise, and other social and environmental factors that he can change in order to reduce the inherent risks associated with his diagnosis. The initial plan developed for Robert, using the principles of the DASH eating plan, includes a weight reduction goal of 7% to 10%, or approximately 20-24 lb (11 kg) over the next 6-12 months.[35,36]

Robert also agreed to:

  • Initiation of a walking program of approximately 30 minutes duration each day;

  • Achieve a total of at least 180 minutes per week of exercise; and

  • Reduce or eliminate alcohol from his diet.

Exercise leads to a reduction in body fat, particularly abdominal fat. The HEalth, RIsk factors, exercise Training, And GEnetics (HERITAGE) study demonstrated the utility of physical activity in improving a cluster of cardiovascular and metabolic risk factors simultaneously.[38]

According to the NCEP guidelines, the primary goal of pharmacologic therapy for Robert is to reduce his LDL-C to below 100 mg/dL.[33] Statins are considered to be the most effective pharmacologic agents to reduce LDL-C; on average, statins lower LDL-C by 18% to 55%.[29] In addition, statins:

  • Reduce cellular inflammation;

  • Lower C-reactive protein levels; and

  • Improve the antioxidative properties of LDL-C.

Fibrates are primarily effective in lowering triglycerides (by about 40%) and -- to a lesser extent -- reduce LDL-C (10% to 15%) and increase HDL-C (15% to 20%). Combination therapy with a fibrate and a statin is potentially useful for patients with atherogenic lipid profiles, for which fenofibrate appears to be a more appropriate choice due to less myopathic potential.

Alternatively, the clinician may consider adding a cholesterol absorption inhibitor, such as ezetimibe (Zetia). This reduces LDL-C levels by an additional 25% within approximately 2 weeks of combination therapy.[39] Due to the complexity of Robert's dyslipidemia (elevated LDL, low HDL, and high triglycerides), combination therapy may be required if Robert is to achieve the NCEP target goals.[40] It should also be noted that hyperglycemia and hypertriglyceridemia are related; improving hyperglycemia, therefore, can significantly lower triglyceride levels.[41]

A clear association has been established between diabetes and microvascular and macrovascular disease; thus, it would seem important to monitor for the development of type 2 DM in Robert and effectively treat his underlying insulin resistance. None of the marketed antidiabetic agents are currently approved for the prevention of type 2 DM; however, metformin has been studied and found to reduce insulin resistance in the Diabetes Prevention Program Trial.[42] From this same trial, it was found that patients randomized to diet and exercise reduced their risk for progression to type 2 DM by 58% compared with placebo, whereas those who received metformin reduced their risk by 31% compared with placebo.[34]

Robert has also been diagnosed with stage I hypertension (defined as systolic blood pressure [SBP], 140-159 mm Hg or diastolic blood pressure [DBP], 90-99 mm Hg); therefore, an antihypertensive medication should be considered as well. Because of the elevated serum glucose levels, which may be a precursor to the development of type 2 DM, the recommended drug choice for Robert is an angiotensin-converting enzyme (ACE) inhibitor (or angiotensin receptor blocker [ARB] in patients who cannot tolerate ACE inhibitors). The treatment goal for Robert is to achieve a target BP of < 130/80 mm Hg in order to prevent progressive nephropathy, MI, and stroke.

It should be noted that in the presence of diagnosed type 2 DM, many patients require combinations of 3-5 agents to achieve BP target goals.[40]

Initially, conservative pharmacologic therapy was implemented for Robert. He was placed on a low-dose ACE inhibitor to control his stage I hypertension, as well as atorvastatin (Lipitor) to reduce his LDL-C and triglyceride levels. It was discussed that his adherence to the TLC plan was critical in achieving an improvement in his HDL-C level, as well as reducing his hyperglycemia. Robert was scheduled for a return visit in 4 weeks to evaluate the effectiveness of his treatment plan. The need for frequent reassessment and follow-up care was discussed with Robert, who agreed that this approach was necessary to achieve an optimal clinical outcome.

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