SGD 3

Sweet and High Disposition

Metabolic Syndrome
D2

What are the salient features of

this case?
Subjective
Data
59/M
CC: right sided weakness
Nape pain and headache
Slurring of speech
Hypertensive for 5 yrs, DM for 5 yrs
(no maintenance medications)
FH: Father (+) HPN, Mother (+) DM
30 pack yrs
(+) polyuria, (+) polydipsia, (+) polyphagia
(+) bubbly urine, (+) intermittency

What are the salient features of

this case?
Objective
Data

Conscious, coherent, (+) dysarthria

BP: 210/120, CR: 88/min, RR: 18/min
Height 55, Weight 200 lbs
Apex beat at 6th LICS AAL, sustained, diffused
Grade 3/6 early systolic murmur at the apex
Abdomen central obesity, waist circumference of 110cm
2/5 MMT right upper and lower extremities
Right facial asymmetry

Compute for the patients BMI

Patients BMI = 90.91 kg/ 1.65m^2

= 33.4 kg/m^2

Discuss BMI Classification based

on WHO
Body Mass Index (BMI)
Asia-Pacific obesity
classification

4. Is this case a
hypertensive emergency
or urgency?
Salvosa, Katrina Marie M.

Hypertensive urgency
BP is severely elevated
Systolic: 180 or higher
Diastolic: 110 or higher

No associated organ damage

Symptoms:
Severe headache
Shortness of breath
Nosebleeds
Severe anxiety

Hypertensive emergency
Malignant Hypertension
BP is severely elevated
Systolic: 180 or higher
Diastolic: 120 or higher
Can be lower in patients whose bp had
not been previously high
Abrupt/ sudden onset

With associated organ damage

patient

5. What are the possible

target organ damage that
could be present in
hypertensive emergency and
if which among these were
present in this patient if
theres
any?
Salvosa,
Katrina
Marie M.

Target organ damage

Cardiovascular, Renal, Pulmonary

Stroke
Loss of consciousness
Memory loss
Heart atttack
Damage to the eyes and kidneys
Loss of kidney function
Aortic dissection
Angina
Pulmonary edema
eclampsia

Patient
BP on physical examination: 210/120
Cc: right sided weakness
MMT: 2/5, right upper and lower
extremities
With slurring of speech
With right facial assymetry
stroke

6. What are the cardiovascular risk

factors and identify which among the
risk factors are present in this
patient?
Modifiable risk factors
Hypertension
Abnormal blood lipid levels,

high total cholesterol

high levels of triglycerides
high levels of low-density lipoprotein
low levels of high- density lipoprotein

Tobacco use
smoking
chewing tobacco
Passive smoking

Physical inactivity
Obesity

Type 2diabetes
Diethigh in saturated fat

(HDL) cholesterol

6. What are the cardiovascular risk

factors and identify which among the
risk factors are present in this
patient?
Modifiable risk factors
Being poor

A chronically stressful life

social isolation
Anxiety
Depression

Alcohol consumption

one to two alcohol drinks a day may lead to a 30% reduction in heart disease,

but above this level alcohol consumption will damage the heart muscle

Certain medicines

contraceptive pill and hormone replacement therapy (HRT).

Left ventricular hypertrophy (LVH)

6. What are the cardiovascular risk

factors and identify which among the
risk factors are present in this
patient?
Non-Modifiable risk factors
Age
risk of stroke doubles every decade after age 55.

Family History
If a first-degree blood relative has had coronary heart disease or stroke
before the age of 55 years (for a male relative) or 65 years (for a female
relative) your risk increases.

Gender
man has greater risk of heart disease than a pre-menopausal woman. But
once past the menopause, a womans risk is similar to a mans. Risk of stroke
is similar for men and women.

Ethnic Origin
People with African or Asian ancestry are at higher risks of developing
cardiovascular disease than other racial groups.

7. What laboratory tests or ancillary

procedures will you request for the
patient?
American Heart Association
(Grundy, S.M. et al. 1999. Diabetes and Cardiovascular Disease: A
Statement for Healthcare Professionals from the American Heart
Association. Circulation.)

Evaluation of Major Risk Factors in Diabetic

Patients
Evaluation of Predisposing Risk Factors in
Diabetic Patients
Detection of Clinical and Subclinical
Cardiovascular Disease in the Diabetic
Patient

01/28/15

8. How do you manage

hypertensive emergency vs
hypertensive urgency?
(JNC 7)
HYPERTENSIVE EMERGENCY
HYPERTENSIVE URGENCY
Admit to an intensive care unit
-continuous monitoring of
BP
-parenteral administration
of an
appropriate agent
Initial goal of therapy:
-reduce mean arterial BP by no
more than 25 percent (within
minutes to 1 hour), then if
stable, to 160/100110 mmHg
within the next 26 hours.
-if the BP level is well tolerated
and the
patient is clinically stable,
further gradual reductions
toward a normal BP can be

Treatment with an oral, shortacting

agent such as captopril,
labetalol, or clonidine followed by
several hours of observation.
Adjustment in their
antihypertensive
therapy, particularly the use of
combination drugs, or
reinstitution of medications if
noncompliance is a problem.
Patients should not leave the ER
without a confirmed followup
visit within several days

9. What is the recommended

drug of choice in this
patient? (JNC 7)

10. Discuss the algorithm for the

treatment of hypertension

Discuss the recommendation for

management of hypertension based on
JNC 8

Discuss the recommendation for

management of hypertension based on
JNC 8

MANAGEMENT OF METABOLIC
SYNDROME

Obesity is the driving force

behind metabolic
syndrome, therefore weight
reduction is the primary
approach to this disorder

MANAGEMENT OF METABOLIC
SYNDROME
PHARMACOLOGIC/SURGI
LIFESTYLE

DIET
500kcal DAILY

WEIGHT
= 1lb
MANAGEME
WEEKLY

Adherence to the diet

is more
NT
important
than which diet is
DYSLIPIDEMI
A

DM/ INSULIN
RESISTA
NCE
HYPERTENSI
ON

chosen.

Lipid Profile
LDL
<130mg/dL*
TC
<200mg
daily
TG <150mg/dL
HDL >40mg/dL
FPG
HbA1c
DM 126mg/dL
6.5%

60-90mins daily
PHYSICAL
= modest
ACTIVITY
reduction

goal: regular
moderateintensity
physical
activity for at
least 30
minutes
continuously
at least 5
days per
week
(ideally,
2-h PG
7 days per
week)
200mg/dL

JNC-7: <140/90, DM: <130/80

low sodium, high potassium;
high-quality

CAL
appetite suppressants,
absorption inhibitors,
bariatric surgery*
LDL: statins
>Bile acids
sequestrants
(cholestyramine
and
colestipol) > cholesterol
absorption
inhibitor
(ezetimibe)
Fibrates: used to lower LDL
when TG are elevated
HDL: nicotinic acid/niacin,
fibrates, omega-3 FA
biguanides, thiazolidinediones
(TZDs): increase insulin
sensitivity

MS (+) DM (-): ACE

inhibitors or ARBs

WEIGHT MANAGEMENT
Diet
Avoid diets enriched in saturated fats

Physical activity
High risk patients should undergo formal CV evaluation
before initiating an exercise program 30 mins can be beneficial
to obese patients of moderate intensity

Beyond lifestyle modification

1. Weight loss drugs
appetite suppressants (phentermine, sibutramine), absorption
inhibitors (Orlist)

2. Bariatric surgery

metabolic syndrome + BMI >40 kg/m 2 or >35 kg/m2 with

comorbidities.

29

DYSLIPIDEMIA
statins (HMG-CoA reductase inhibitors)
First choice medication to lower LDL

cholesterol absorption inhibitor (ezetimibe)

bile acid sequestrants cholestyramine and colestipol
are more effective than ezetimibe
can increase triglycerides
should not be administered when fasting triglycerides are >200
mg/dL
Adverse effect: GI disturbance (bloating, belching, constipation)

Fibrates
DOC for lowering fastring TG
Lower LDL cholesterol when TG are elevated

Nicotinic acid: HDL cholesterol raising properties

For patients with the metabolic syndrome and diabetes:
LDL cholesterol should be reduced to <100 mg/dL and perhaps
further in patients with a history of CVD events.

IMPAIRED FASTING GLUCOSE

Glycemic control improve fasting
TG and/ or HDL cholesterol levels
Lifestyle modification
IFG without DM type
Weigh reduction, dietary fat restriction,
increase physical activity

METFORMIN
reduce incidence of Type II DM
31

Insulin Resistance
Biguanide and
Thiazolidinediones
Increase insulin sensitivity
Enhance insulin action in liver
Suppress endogenous glucose production
Reduce markers of inflammation and small
dense LDL
Thiazolidinediones improve insuline medicated
glucose uptake in muscle and adipose tissue

What are the possible complications of

hypertension in this patient if left
untreated?

Stroke
Loss of consciousness
Memory loss
Heart attack
Damage to the eyes and kidneys
Loss of kidney function
Aortic dissection
Angina
Pulmonary edema
Eclampsia

01/28/15

Is metabolic syndrome present in this

patient? What criteria did the patient
fulfill?

Yes. According to the NCEP (ATPIII) criteria

3 out of 5 were met: central obesity (WC=
110cm), BP: 210/120 and previously
diagnosed DM2.
01/28/15

How do you manage metabolic

syndrome?
Goals of Therapy:
Reduce cardiovascular disease and
renal morbidity and mortality.

How do you manage metabolic

syndrome?
HPN: Treat BP < 140/90 or BP <130/80 in
patients with diabetes or chronic kidney
disease. Achieve SBP goal especially in
persons older than 50 years of age.
Weight Management:
Lifestyle Modification
Weight reduction: 5-20 mmHg/ 10 kg weight
loss.
Physical activity: 30 minutes of aerobic
exercise for 4x a week
Moderation of alcohol consumption: 3 oz of
alcohol.

How do you manage metabolic

syndrome?
Dyslipidemia: LDL reduced to
<100mg/dL, diet restricted in saturated
fat, trans fat and cholesterol. If LDL
remains above goal, use statins,
ezetimibe or cholestyramine. Triglyceride
value of <150 mg/dL, weight reduction of
>10%, fibrate, omega-3 fatty acids and
statins can be used.
DM/ Insulin resistance: glycemic
control, weight reduction, fat restriction,
increased physical activity. Biguanides,
TZDs can increase insulin sensitivity.