Chapter 26

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The term metabolic syndrome refers to a constellation of interrelated conditions that directly promote the development of atherosclerotic cardiovascular disease (CVD) and type 2 diabetes mellitus. The term metabolic syndrome has become widely accepted in the medical literature. The primary care provider is faced with the implications of the diagnosis of the metabolic syndrome for patients. Identification of one risk component of the metabolic syndrome should prompt evaluation of other components.1 Early identification of the cluster of risks of CVD and diabetes may be important in educating patients on lifestyle interventions to avert or delay the development of CVD and type 2 diabetes. Pharmacologic treatment for metabolic syndrome does not differ from the treatment for the traditional risks for CVD including diabetes, hypertension, and hyperlipidemia, although more research on prevention and treatment of metabolic syndrome is clearly needed.

In 1988, Reaven first described a cluster of risk factors associated with CVD, which included hyperglycemia, low high-density lipoprotein, hypertriglyceridemia, and hypertension. He coined the phrase “syndrome X” and proposed that the pathophysiology leading to CVD is related to insulin resistance resulting in hyperinsulinemia. Reaven recognized an association with obesity and syndrome X but did not consider obesity a central component of syndrome X.2

Since Reaven’s landmark presentation, other names have been applied to the syndrome including metabolic syndrome X, dysmetabolic syndrome, plurimetabolic syndrome, and the insulin resistance syndrome. Failure to reach consensus on a universally acceptable title stems from the fact that the exact causes of metabolic syndrome remain elusive. Strictly speaking, this is an association of conditions, not a syndrome3, however, the term gained popularity during the last few years. Extensive research in the areas of epidemiology, pathophysiology, and clinical care related to metabolic syndrome has been done.

Multiple methods have been used during the last 10 years to define the metabolic syndrome criteria. The World Health Organization proposed diagnostic criteria of metabolic syndrome in 1998.4 These guidelines were not widely accepted, as there is a requirement for evaluation of insulin resistance either by oral glucose tolerance test or euglycemic clamp. Both methods are difficult to conduct in the clinical setting. The National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) proposed a set of criteria in 2001 based on common clinical measures including waist circumference, triglycerides (TG), HDL cholesterol, blood pressure (BP), and fasting glucose level. Abnormal findings in 3 of the 5 areas constitute a positive diagnosis.1 Modifications to these criteria have been suggested by several organizations since 2001, including the American Heart Association (AHA), the National Heart, Lung, and Blood Institute,5 and the International Diabetes Foundation (IDF).6Table 26-1 lists the diagnostic criteria for the modified ATP III guidelines as suggested by the AHA and National Heart, ...

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