Nurs 777 - Metabolic Sydrome

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Metabolic syndrome features

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-insulin resistance with hyperinsulinemia, HTN, central obesity, dyslipidemia, high TG, high LDL, low HDL
-recently added: C-reactive protein level, PAI-1 level and microalbuminuria

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criteria for clinical d/x of MS

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-elevated waist circumference >35in woman, >40in male
TG>150
HDL<40 (M) <50 (F)
HTN or BP>135/85
FBG>100 or DM
*greater the amount of RF the greater the risk for CVD

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Pathophys of MS

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-abdominal obesityinsulin resistance= impaired insulin-stimulated glucose uptake by skeletal muscle, adipose tissue or liver
-insulin resistance may be from: abnormal insulin molecules, decreased insulin receptors, decreased glucose transporters, and defective postreceptor activity
-when cells become insulin resistant the body compensates by making more insulin to overcome the resistance and maintain normal blood glucose levels

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Hyperinsulinemia leads to:

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-HTN, dyslipidemia, atherosclerosis, proinflammatory stae, prothrombitic state and microalbuminuria

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How does hyperinsulinemia cause HTN?

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-insulin resistance and abd obesity are main factors
-insulin resistance leads to hyperinsulinemia which activate the SNS and RAAS and lead to increased sodium reabsorption which causes increased extracellular volume and ends up with HTN

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How does hyperinsulinemia cause dyslipidemia??

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-increased TG, low HDL, high LDL
-obesity causes the adipocytes in the abd adipose tissue to become insulin resistant which impairs ability to take up glucose and store free fatty acids then the adipocytes then release FFA into systemic circulation which causes the muscle cells take up FFA and become insulin resistant too this leads to diminished glucose disposal and hyperglycemia, beta cells try to make more insulinhyperinsulinemia, and the FFA not taken up by the muscles goes to the liver where they impair insulin mediated suppression of the hepatic glucose output, stimulate synthesis of lipoproteins
-increased risk atherosclerosis

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How does hyperinsulinemia cause prothrombotic state?

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-levels of PAI-1 correlate with insulin resistance
-reflect impaired fibrinolysis, impaired endothelial function, increased tendency towards arterial thrombosis

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How does hyperinsulinemia cause proinflammatory state?

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-CRP= independent CVD risk factor, marker of inflammation, increased in patients with metabolic syndrome, *marker of insulin resistance

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How does hyperinsulinemia cause microalbuminuria?

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-associated with metabolic syndrome secondary to the effects of insulin on renal hemodynamics
-acute hyperinsulinemia cause renal vasodilation which increased BF this leads to increased GFR and microalbuminuria
-predictor of CV M/M

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clinical presentation of MS

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-insulin resistance suspected in: abd obesity, increased TG, low HDL and HTN
-hyperkeratotic condition of acanthosis nigricans—hyperpigment velvety thickening of neck and axillae--indicates moderate to severe insulin resistance

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physical exam components for MS

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-BP, height and weight, BMI, waist to hip ratio
-screen for hyperglycemia, OGTT, t2dm, CV complications
-genetic or family history

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diagnostics for MS

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-definitive test for insulin resistance= euglycemic insulin clamp technique
-more practical: fasting plasma insulin concentration, 10=resistance
-HOMA: homeostasis model assessment=calculation that uses FPG and insulin concentrations to estimate basal state insulin resistance, FPGxFasting insulin / 22.5, high plasma insulin values with normal glucose are suggestive of resistance
-BMI calculation and waist to hip ratio
-check OGTT and FBG

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what is the definitive test for insulin resistance?

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euglycemic insulin clamp technique

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what is the most practical test to determine if insulin resistance is present?

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fasting plasma insulin concentration

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Treatment of MS

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-must treat the different components to reduce CV M/M
-nonpharm treatments: health lifestyle change in diet and exercise, weight reduction lowers LDL and raises HDL, lowers BP and glucose
*weight reduction and increased physical activity, 10% decrease in bosy weight in 6 months, low calorie diet
-ATP III: lower LDL
-exercise 30 mins a d/ 5 d a week
-pharm therapy: anti-HTN with ACEI, statin, asa, diabetes prevention program
*JNC 8 and new lipid guidelines!

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Metabolic syndrome complications:

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CVD, atherosclerosis, ischemic heart disease, CAD, MI, stroke, T2DM

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T/F: metformin can be initiated in metabolic syndrome patient for treatment.

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TRUE: reduces hyperinsulinemia and insulin resistance to lower TGs and assist in weight reduction and lower PAI-1 levels

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what classes of anti-HTN medications are helpful in reducing BP, and increasing insulin sensitivity?

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-alpha adrenergic antagonists
-ACEI

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DOC to lower LDL

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statins

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doc for hyperlipidemia if TG are >500?

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fibric acid or nicotinic acid