Atlas of Cardiometabolic Risk - W. Cefalu, et. al., (Informa, 2007) WW

172 Pages·2007·9.13 MB·English

Atlas of
CARDIOMETABOLIC RISK

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Atlas of

CARDIOMETABOLIC RISK

William T Cefalu MD

Professor and Chief, Division of Nutrition and Chronic Diseases
Pennington Biomedical Research Center
Louisiana State University System
Baton Rouge, Louisiana, USA

and

Christopher P Cannon MD

Senior Investigator, Thrombolysis in Myocardial Infarction (TIMI) Study Group
Cardiovascular Division, Brigham and Women’s Hospital
Associate Professor of Medicine, Harvard Medical School
Boston, Massachusetts, USA

Foreword by

Eugene Braunwald MD

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5

At the beginning of the twentieth century
cardiovascular
disease
was
responsible
for
approximately 10% of all deaths in the United States.
During the first half of the century, with urbanization
and the transition from a largely agricultural to an
industrial economy, the percentage of deaths due to
cardiovascular disease rose rapidly to about 35%,
becoming the most common cause of mortality in the
United States and, indeed, in the entire industrialized
world. By mid-century, the recognition that an acute
coronary event is not “a bolt out of the blue” but often
occurs in susceptible patients in whom the classic
coronary risk factors of hypercholesterolemia,
hypertension, and/or smoking had been present
sparked an interest in preventive measures. The
development of coronary care units,
coronary
revascularization, as well as antihypertensive and
cholesterol-reducing agents first stopped the steady
rise in cardiovascular deaths and then delayed such
deaths substantially. By the beginning of the last
decade of the century it appeared that the tide had
turned and that, at last, atherosclerotic vascular disease
was beginning to come under control.

However, despite this encouraging progress, all was not
well. With the transition from the industrial economy
to an information-service economy,
the wide
availability and popularity of very high caloric, fast
foods (the “McDonald’s culture”) and the reduction in

physical activity, the twin epidemics of type 2 diabetes
and obesity began to grow at an alarming rate. The
percentage of the population that is overweight or
obese has risen by 5% per decade since 1960, and the
percentage with diabetes has almost doubled in just
the last ten years. A cluster of risk factors, including
but not limited to insulin resistance, central obesity,
dyslipidemia, impaired glucose tolerance, essential
hypertension and inflammation is associated with a
state of increased cardiometabolic risk that is now
present in at least one quarter of the adult population.
As we approach the end of the first decade of the
twenty-first century, the seeming relentless rise in
cardiometabolic risk threatens to reverse the earlier
progress in the battle against atherosclerotic coronary
and non-coronary vascular disease.

In order to control cardiometabolic risk we must first
understand this cluster of risk factors and examine the
several modes of prevention and treatment that are
now or will soon be at our disposal. Dr Cefalu, an
expert on metabolic diseases, and Dr Cannon, a
cardiologist, have teamed up with a group of talented
authors
to
prepare
this
splendid
Atlas
of
Cardiometabolic Risk. The excellent explanatory
diagrams and the lucid accompanying text provide the
reader with the knowledge required to engage in this
next
critical
battle
against
atherosclerotic
cardiovascular disease.

Eugene Braunwald, MD
Brigham and Women’s Hospital
Harvard Medical School
Boston, MA

Foreword

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7

Cardiovascular disease is the leading cause of death
and disability worldwide. Although our understanding
of this disease has progressed enormously, we have
much to improve in identification of the disease and
applying optimal treatments to prevent progression of
disease and its consequences.
Beginning nearly 50 years ago, the Framingham
Heart Study forever changed our approach to coro-
nary artery disease by identifying major risk factors for
myocardial infarction (MI) – namely hypertension,
smoking, hypercholesterolemia, diabetes and a family
history of MI. Since then, countless other risk factors
and markers of disease have been identified. Our cur-
rent approach to prevention (either primary preven-
tion of a first event, or secondary prevention of
recurrent events) is largely focused on controlling
these individual risk factors. This single risk factor
approach has led to multiple classes of drugs to treat
each condition, and guidelines are developed centered
on improvements of each one (e.g., hypertension –
JNC VII, or the ADA) In addition, decades ago, the
United States government established national pro-
grams, such as the National Cholesterol Education
Program (NCEP) that develops guidelines for manage-
ment of cholesterol.

A new approach is emerging however – that looks
not at individual risk factors, but at the overall risk of
disease in a patient. This involves looking at a long list
of contributing risk factors – to assess a patient's over-
all cardiometabolic risk. It is this new approach to
diagnosis and management that this book embraces.
We aim to provide the best possible care to our
patients, and taking this comprehensive approach is
the best strategy to do so.
We cover many aspects of cardiometabolic risk in
this Atlas. The initial chapters delve into the new
understanding of the pathophysiology of the cardio-
metabolic risk, with colorful illustrations of the various
pathways involved. Then, we cover many of the mark-
ers of cardiometabolic risk that can be used to identi-
fy patients in clinical practice. The final chapters
review the newest trial data on the natural history of
the disease with clinical outcomes of patients, as well
as a brief overview of all the current treatments for
cardiometabolic risk. We hope that this book will pro-
vide clinicians with a readily accessible guide to this
important disease, that will help in caring for this large
group of patients.
Christopher P Cannon, MD
William T Cefalu, MD

Preface

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9

Contents

Foreword – Eugene Braunwald
5

Preface
7

Contributors
11

1
Classification and evolution of increased cardiometabolic risk states
13

William T Cefalu

2
Insulin resistance and cardiometabolic risk
27

William T Cefalu

3
Role of obesity and body fat distribution in cardiometabolic risk
39

William T Cefalu

4
Physiologic systems regulating energy balance, including the EC system
55

William T Cefalu

5
Traditional metabolic risk factors
69

Kausik K Ray, Christopher P Cannon

6
Non-traditional risk factors of cardiometabolic risk
87

Kausik K Ray, Christopher P Cannon

7
Clinical outcomes of patients with cardiometabolic risk factors
105

Gregory Piazza, Christopher P Cannon

8
Managing cardiometabolic risk – a brief review
137

Benjamin A Steinberg, Christopher P Cannon

Index
167

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