A New Approach to Cardiometabolic Management
We now offer a cardiometabolic program which allows us to identify and treat metabolic abnormalities, as cholesterol problems, which substantially increase the risk of heart disease. Cardiovascular Disease (CVD) is the major cause of morbidity and mortality in the U.S. A variety of metabolic issues have been identified that are associated with an increased risk of cardiovascular disease (CVD). While many people think that their total serum cholesterol adequately describes these risks, in fact, total serum cholesterol in the individual person is probably an outdated way to assess cardiac risk, which is probably not as useful.
Other clinical and laboratory markers for the risk of CVD are receiving much more support now. Many of these are metabolic in nature and include insulin resistance, abdominal obesity, diabetes mellitus, hypertension, and a variety of specific abnormalities in cholesterol metabolism. Some of these are very detailed problems involving cholesterol metabolism, and a complete understanding of them in each person requires a much more detailed approach than merely a total cholesterol level, or even, in many cases, a standard cholesterol profile (lipid profile).
One major clinical condition, which confers enhanced risk, is metabolic syndrome. This is a multidimensional metabolic problem, which involves multiple risk factors for CVD. These include a pre-diabetic, state, high blood pressure and various abnormalities in cholesterol and fat (triglyceride) metabolism. To a large degree, these problems occur because of the secretion of a number of newly discovered hormones by abdominal fat, which change the regulation of blood sugar, blood pressure, and cholesterol and fat metabolism. Some of the key clinical markers for metabolic syndrome include:
- Abdominal waist circumference >88cm (35 inches) in women and >102 cm (40 inches) in men
- Blood pressure ≥ 130/85 mm Hg or drug treatment for elevated blood pressure
- Serum triglycerides ≥ 150 mg/dl or drug treatment for elevated triglycerides
- Serum HDL-C < 40 mg/dl in men and <50 mg/dl in women or drug treatment for low HDL
- Fasting glucose ≥ 100 mg/dl or drug treatment for elevated blood glucose
Of these, the most easily recognizable characteristic to suggest that a person may have metabolic syndrome is carrying more weight in the abdomen than in the legs and buttocks (the “beer belly”). Metabolic syndrome is associated with many obesity-related disorders including polycystic ovary syndrome, fatty liver disease, obstructive sleep apnea, and sleep disturbances. A recent study in Columbus suggests that over 1/3rd of the adult population may have this condition.
Testing for the different aspects of metabolic syndrome involves, in part, the testing we are now offering for all patients where there is a significant worry about their heart risk: very detailed profiling of cholesterol metabolism (described below); assessment of blood pressure regulation; and assessment of blood sugar and insulin metabolism. In addition, women may have an excessive production of male sex hormones from this condition: therefore, we study those hormone levels in women.
A key part of testing for CVD risk is to profile cholesterol and fat (triglyceride) metabolism. Important problems in this metabolic system may be complex. Specialized lipid testing beyond a total cholesterol level, or even a typical cholesterol profile (lipid profile), allows us to further identity those at risk for CVD and to determine the specific issues. This testing measures fractions of cholesterol metabolism, which are more advanced and complex. In many patients, there is a growing concept not only that total cholesterol is not helpful in most patients, but also that the measure of the “bad” cholesterol fraction – LDL-cholesterol – may not be the best test in many patients. New research has shown that fractions, such as non-HDL-cholesterol or a newer measure of LDL levels, LDL particle count is superior to LDL-C in predicting CVD risk in many patients.
These and other newer concepts led to our development of the most advanced cardiac risk factor testing program in the area. In addition to the typical cholesterol profile, we measure many other metabolic factors, which influence cardiac risk, including lipoprotein a, apolipoprotein B, LDL particle size, big VLDL levels, lipoprotein-associated phospholipase A2, and plasminogen activator inhibitor. We also measure markers for cardiac inflammation, such as CRP (hs-CRP), interleukin 6 and tumor necrosis factor (TNF-alpha). These proteins influence cardiac risk as well as cholesterol fractions.
As part of our cardiometabolic program, we offer a team approach that encompasses an array of trained professionals such as nurse educators, a psychologist and a registered dietitian. This allows us to tailor dietary and lifestyle approaches for each individual patient in support of our treatment to reduce cardiac risk. These educators are able to spend time with each patient individualizing the changes needed to help reach the patient’s goals.
Our new program should emphasize that the approach to cardiometabolic risk is more complex and comprehensive than many people realize. This is especially true for individuals at high risk. This includes people with a known history of prior cardiovascular disease, diabetes, hypertension, elevated cholesterol levels, and metabolic syndrome, marked by increased abdominal girth. In addition, persons with a strong family history of these problems should consider such evaluation as well.