DorlandHealth

A Controversy That Care Managers Should Know About

PART I

This is the first of a two-part series about cardiovascular risk, identifying people with those risks, and helping them lower it — and importantly, what role care managers can play in that effort. In part one, we present the statistics on cardiovascular risk and define an actor — metabolic syndrome — that started an ongoing controversy in the medical community. In part two, we will describe how different areas of the medical community have disagreed with the definition and focus of the condition, and how this lack of consensus may be affecting a concerted effort to decrease cardiovascular risk. We also focus on how care managers can respond to the needs of the patient in the face of the controversy — helping them identify and decrease their cardiovascular risks and improve quality of life while, at the same time, the medical community clarifies the evidence.

Look around. In malls, on bleachers at ball games, in offices, at family dinners. Every place you go, you will find us. We are young and old, male and female, from every ethnic group, and we look like a cross-section of America. We are busy living our lives, going to work, taking care of our families. We feel well, and many of us consider ourselves healthy. But the truth is there are those among us who are “walking cardiovascular time-bombs.” And in many cases, we don’t even know it — until it’s too late.

The statistics on cardiovascular disease in America aren’t pretty. Coronary heart disease (CHD) is the largest major killer of both American males and females, causing one in five deaths in the U.S. Every 25 seconds an American suffers a coronary event, and every minute one of us dies from it, according to statistics from the American Heart Association (AHA). This year, approximately 785,000 Americans will experience a new coronary attack, 470,000 will have a recurrent one, and an additional 195,000 will have a silent event. 

Age, gender and ethnicity will play a strong predictive role in who lives, who dies, and who goes on to acquire co-morbid chronic illness associated with CHD. The AHA reports that approximately 37 percent of people who experience a coronary attack in a given year will die from it. For those who survive a first cardiac event, the morbidity expected to occur within five years is significant, and depending on age and ethnicity, some of us can expect to face co-morbid states that could include heart failure, stroke or sudden death. Men die at higher rates than women, and blacks at higher rates than whites (with some age differences). And let’s not forget the projected price tag of CHD for 2009 — $165.4 billion for direct and indirect costs, says that AHA.

And those are just coronary events. What about stroke? In 2005, stroke accounted for roughly one out of every 17 deaths in the U.S. Mortality one year after stroke is significant. Depending on age it stands at 21 percent for men and 24 percent for women age 40 and above. Stroke leaves us with terrible morbidities. For survivors of stroke age 65 and above, patients experience the following just six months after the event:

• 50 percent have some hemiparesis, or weakness on one side of the body.
• 30 percent are unable to walk without some assistance.
• 26 percent are dependent in activities of daily living.
• 35 percent have symptoms of depression.
• 19 percent have aphasia, a form of language impairment.
• 26 percent are institutionalized in a nursing home.

As we see from the data, stroke leaves a significant number of us with life challenges — difficulty with daily tasks and communication that we take for granted, loss of independence, and high rates of depression — all adding to a lower quality of life. These stroke statistics, added to the CHD statistics, point out the need to identify and target those of us at risk and to intervene on those risks early — before the time-bomb explodes.

THIS YEAR, APPROXIMATELY 785,000 AMERICANS WILL EXPERIENCE A NEW CORONARY ATTACK, 470,000 WILL HAVE A RECURRENT ONE AND AN ADDITIONAL 195,000 WILL HAVE A SILENT EVENT.

Given this frightening information on cardiovascular risk, one would hope the entire medical community would be firmly amassed behind a well-defined effort to identify and decrease risks in this population. That is not so. Instead, there is a significant disconnect between various sectors of the medical community that do not agree on how to find the right people, nor what to do about them. Before delving into the controversy, we have to understand what metabolic syndrome is, and what is known about it. There is no time to waste, and care managers can play a role in helping all of us stay well.

IDENTIFYING THOSE AT RISK

In response to identifying individuals with cardiovascular risk, in 2005 the American Heart Association (AHA) and the National Heart, Lung, and Blood Institute (NHLBI) released a joint statement (known as Adult Treatment Panel III, or ATP III), which provided guidance for health care professionals on the diagnosis and management of what has been termed metabolic syndrome (MetS) in adults. Yet this definition is center stage of the unfolding drama over how we identify and treat these individuals. MetS (also referred to by other names such as Syndrome X and Insulin Resistance Syndrome) refers to a clustering of risk factors within a single individual that increases the risk for heart disease and diabetes. The factors include elevated blood pressure, dyslipidemia, central obesity with an increase in waist diameter, and high blood glucose levels or pre-diabetes. In addition, the statement noted that individuals with MetS typically manifest pro-inflammatory and hypercoagulable states (specifically, elevations of fibrinogen, plasminogen activator inhibitor-1, and other coagulation factors, also known as a prothombotic state). Insulin resistance is also considered to be an important factor in the syndrome’s etiology, according to Diagnosis and Management of the Metabolic Syndrome, a statement put forth by the AHA and the NHLBI.

MetS has become increasingly common in the United States. Based on the definition, in 2007 an estimated 76 million American adults were diagnosed with MetS. The prevalence increases with age: 42–44 percent of individuals age 60–69 years of age met criteria for metabolic syndrome, according to a study published in Diabetes Care. Children and adolescents are also not immune to its grasp. The prevalence of metabolic syndrome in adolescents age 12–19 was 9.4 percent, or 2.9 million persons in 2002. Among overweight or obese adolescents, 44 percent meet criteria for metabolic syndrome, according to statistics from the Third National Health and Nutrition Examination Survey.

Obesity in Americans has become epidemic. The increase in obesity has been paralleled by an increase in the prevalence of metabolic syndrome. It appears that your weight destiny is correlated with where you live — the range of obesity by state is lowest in Colorado at 19.3 percent and highest in Mississippi at 32.6 percent. (The median for all states is 26.3 percent.) Over 30 years, one in two persons is at risk for becoming overweight, one in four obese (defined as BMI > 30 kg/m2), and one in 10 at stage II obesity (defined as BMI > 35 kg/m2). Worldwide, central obesity (i.e., expanding waist line) is a risk factor for CVD. Additionally, it is associated with numerous other co-morbidities including type 2 diabetes, hypertension, certain cancers and sleep apnea. As a whole, the continuum of overweight and obesity either predisposes or is associated with numerous cardiac complications such as coronary syndromes, heart failure, and sudden death through its impact on the cardiovascular system.

High blood pressure or hypertension (HTN) is one of the criteria for MetS, and 29 percent of all U.S. adults age 18 years or older have it. In a set of data from 2005-2006, for persons 20 years of age or older, 78.7 percent knew they had high blood pressure (which means that 21.3 percent did not), 69.1 percent were under treatment, 45.4 percent had controlled high blood pressure, and 54.6 percent were not under control. Analysis of the REGARDS study suggests that efforts made to raise awareness, and to communicate the importance of receiving high blood pressure treatment among blacks has been relatively successful. Despite this bright spot, there remains substantial racial disparity in blood pressure control that still must be overcome. Depending on your race, blood pressure control varies — lowest in control in Mexican Americans, followed by non-Hispanic white, then in non-Hispanic black Americans, according to data culled from the National Center for Disease Statistics.

The statistics on diabetes and pre-diabetes are also startling — 8 percent or 23.6 million people in the U.S. have diabetes, and another 57 million have pre-diabetes. Yet another 5.7 million are currently undiagnosed. In 2007, 1.6 million new cases of diabetes were diagnosed in people aged 20 years and above.

In 2007, an estimated 76 million American adults were diagnosed with MetS.

Another criteria for MetS is the presence of an elevated fasting blood glucose, either in a prediabetic state (fasting glucose > 100 mg/dl) or on medications for elevated blood glucose (i.e., diabetes). Elevated blood glucose that does not meet diabetes criteria is called either impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) (depending on how the abnormality is identified through Fasting Plasma Glucose (FPG) or the Oral Glucose Tolerance Test (OGTT)). Impaired fasting glucose is defined as having a FPG of 100 mg/dl to 125 mg/dl, and impaired glucose tolerance is defined as having a 2-hr plasma glucose of 140 to 199 mg/dl. Diabetes and pre-diabetes both have a strong genetic component, but, the good news is how we live and what we do in our daily lives influences whether we get it, and how well we control it.

Finally, we must look at lipid levels and lipid control. Dyslipidemia in MetS is described as reduced HDL-c (<40 mg/dL for men, <50 mg/dl for women, or on drug treatment for reduced HDL-c), and elevated triglycerides (>150 mg/dL or on drug treatment for elevated triglycerides). A focus on these “lesser” lipids (i.e., not the LDL cholesterol) may be surprising. In ATP III, however, there is a primary focus on treating LDL cholesterol, and MetS lipid abnormalities are termed “secondary targets.” A focus on weight control/management and physical activity are key interventions for the syndrome.

So now we have an understanding of the CV statistics and risk factors associated with the ATP III definition of MetS. Here is where the controversy begins. In the second part of this series, we’ll discuss this controversy, how understanding the controversy affects the way providers approach CV risk identification and treatment, and how case managers can be strong proponents for helping individuals avoid becoming one of the “walking cardiovascular time-bomb” statistics.