Metabolic syndrome

Background

• Three or more of the following or if taking any medication to control disease.
  • Large waist circumference — At least 35 inches (89 centimeters) for women and 40 inches for men
  • High triglyceride level — 150 mg/dL or 1.7 mmol/L
  • Reduced high-density lipoprotein (HDL) cholesterol — less than 40 mg/dL (1.04 mmol/L) in men or less than 50 mg/dL (1.3 mmol/L) in women of this "good" cholesterol
  • Increased blood pressure — 130/85 or higher
  • Elevated fasting blood sugar — 100 mg/dL or higher

Clinical Features

Patients fit the diagnostic criteria below, these features put them at increased risk for BOTH Diabetes Mellitus and Cardiovascular disease.
Although several diagnostic features exist, below is the most widely accepted: The National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III).
Diagnostic Criteria
>3 of the following:
Waist circumference >/=102 cm in men or >/=88 cm in women
Plus 3 of the following:
Fasting blood glucose >/= to 100 mg/dL or requiring treamtment for elevated blood glucose
HDL </=40 in men or </=50 in women
TGs >/=150 mg/dL
BP >/= 130/85 or requiring drug treatment for HTN
Additional Markers
MSX is considered to be a prothrombotic, proimflammatory state. As such, it may be associated with elevated CRP, IL-6 and tissue plasminogen activator. The elevated inflammatory markers may be associated with increased risk for CVD and Type 2 Diabetes Mellitus. However, these markers have not been shown of any benefit in the ED. Rather, they should be used for evaluation of risk of CVD in the outpatient setting.

Differential Diagnosis

Differential should include other disease processes that could cause the features of Metabolic Syndrome X (i.e hypertension, hyperlipidemia and hyperglycemia.)
Hypothyroidism
Obstructive Sleep Apnea
Type 2 DM
Rarer Diagnoses
Pheochromacytoma
Glucagonoma

Evaluation

Workup should include:
Metabolic Panel-assess for renal function
HbA1c
Lipid panel
TSH
+/- Polysomnography-This is becoming more widely used in recent years as OSA has a confounding effect on obesity. If patient presents with excessive daytime somnolence or partner reported nighttime pauses in respiration, this test maybe helpful to obtain.
Determine the patients ASCVD 10 year risk

Management

Lifestyle modification
Metformin
BP control using ACEi or ARBs
Treatment of any underlying OSA
Depending on the level of obesity, and severity of the condition bariatric surgery may be advantageous to the patient

Disposition

Assuming the patient has not presented to the ED with any emergent concerns (Chest pain, new onset neurological deficit, limb pain with symptoms associated with possible limb ischemia, etc.), the patient can be managed by their primary care physician for appropriate medications and lifestyle modification to manage their disease.

See Also

https://www.uptodate.com/contents/the-metabolic-syndrome-insulin-resistance-syndrome-or-syndrome-x?source=search_result&search=metabolic%20syndrom%20x&selectedTitle=1~150

http://emedicine.medscape.com/article/165124-overview

References

Grundy, S. M. (2005). Diagnosis and Management of the Metabolic Syndrome: An American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement: Executive Summary. Circulation, 112(17). doi:10.1161/circulationaha.105.169405

Genuth, S. (2003). Follow-up report on the diagnosis of diabetes mellitus. Expert Committee on the Diagnosis and Classification of Diabetes Mellitus , 26(11). Retrieved from http://care.diabetesjournals.org/content/26/11/3160.long.

Tasali E, Ip MS. Obstructive sleep apnea and metabolic syndrome: alterations in glucose metabolism and inflammation. Proc Am Thorac Soc. 2008 Feb 15. 5(2):207-17.

Grundy SM. Metabolic syndrome: a multiplex cardiovascular risk factor. J Clin Endocrinol Metab. 2007 Feb. 92(2):399-404.

Heima NE, Eekhoff EM, Oosterwerff MM, Lips PT, van Schoor NM, Simsek S. Thyroid function and the metabolic syndrome in older persons: a population-based study. Eur J Endocrinol. 2013 Jan. 168(1):59-65.

James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014 Feb 5. 311(5):507-20.

Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Jul 1. 63(25 Pt B):2960-84.