The Metabolic Syndrome Under Diagnosed in Primary Care

The Metabolic Syndrome Under Diagnosed in Primary Care Katherine Hurst MSc, MD and Krishna Khanal MD Cedar Rapids Medical Education Foundation and Linn Community Care Cedar Rapids, Iowa Abstract Objectives The metabolic syndrome (Met. S) has surpassed smoking as the number one cause of cardiovascular deaths in the US. However, it remains under diagnosed and misunderstood in primary care. To test this hypothesis a chart review was done to calculate the prevalence of patients assigned to residents diagnosed with the metabolic syndrome. This number was then compared to the estimated national average which according to the International Diabetes Federation the prevalence of the metabolic syndrome is 24%. Background The World Health Organization (WHO) first developed the definition of metabolic syndrome in 1998. The central features of the metabolic syndrome are insulin resistance, visceral adiposity, atherogenic dyslipidemia and endothelial dysfunction 1. Metabolic syndrome ties together insulin resistance, visceral adiposity, dyslipidemia and hypertension, which are known to be interrelated. According to the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) 2 definition, metabolic syndrome is present if three or more of the following five criteria are met: see table 1. Proper identification of the metabolic syndrome helps clinicians incorporate key recommendations proven the help decrease mortality and morbidity from metabolic syndrome. Patients that are diagnosed with metabolic syndrome, or have some of the clinical criteria, carry a significant risk for a variety of chronic diseases. Patients with metabolic syndrome are twice as likely to develop cardiovascular disease and five times as likely to develop type 2 diabetes 3, 4. Currently metabolic syndrome affects 24% of adult patients in the US and the incidence increases with age 5. The proposed pathologic origin of the metabolic syndrome is the visceral adiposity. The adipose cells gathered at the waist line act as a rogue endocrine gland producing inflammatory chemicals and ignoring feedback loops. This results in a constant mild state of inflammation that damages blood vessels, increases insulin resistance, and leads to more cytokine release. The inflammatory state leads to a cascade of unfortunate events that include myocardial infarction, high blood pressure, diabetes, stroke, and even prostate, pancreatic and colon cancer. Table 1. NCEP-ATP III 3/5 Criteria for Metabolic Syndrome waist circumference >40 inches (men) , 35 inches (women) blood pressure >130/85 mm. Hg fasting triglyceride level >150 mg/dl fasting HDL cholesterol level <40 mg/dl (men) or 50 mg/dl (women) fasting blood sugar >100 mg/dl 1. Calculate the prevalence of Met. S in a practice that patients are under resident care in urban Iowa. 2. Compare this to the Met. S prevalence national average of 24%5 3. Increase awareness of the prevalence of Met. S in primary care 4. Increase understanding of the Met. S in primary care. 5. Incorporate Met. S teaching into curriculum at postgraduate medical education Results Total Number of patients 4613 Number of Patients with Met. S as diagnosis ICD code 277. 7 43 Prevalence of Met. S in resident patient panel 0. 93% US National Prevalence according to International Diabetes Federation 24% Conclusion Methods • This a retrospective study done using an electronic chart review. Patient charts assigned to residents were reviewed. The residency uses Logician electronic medical record software. Met. S was found to be prevalent at only 0. 93% of over 4600 patient charts. When compared to an estimated national prevalence of 24% this study shows Met. S remains under diagnosed in primary care. • There are 3 teams and each resident’s patient panel was reviewed by using report tab on software. • Boolean logic criteria were current ICD diagnosis code 277. 7. for Met. S and patients over age eighteen. Analysis In this study the prevalence was calculated using this equation: • Number of patients with a disease/total number of patients over age 18 assigned to residents The prevalence is expressed as a percentage. Recommendations Residencies should start to teach about the clinical criteria for Met. S. Applying the NCEP-ATP III criteria to a patient panel can aid in identifying patients with Mets. This can result in early identification of patients that are highly likely to have an adverse cardiovascular event and develop type 2 diabetes. In the future guidelines for Mets can be applied to these patients and prevent stroke and heart attack. References 1. Alberti KG, Zimmet PZ. Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus provisional report of a WHO consultation. Diabet Med 1998; 15: 539 -53. 2. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002; 106: 3143 -421. 3. Grundy SM. Metabolic syndrome pandemic. Arterioscler Thromb Vasc Biol 2008; 28: 629 -36. 4. Nesto RW. The relation of insulin resistance syndromes to risk of cardiovascular disease. Rev Cardiovasc Med 2003; 4 Suppl 6: S 11 -8. 5. Ford ES. Prevalence of the metabolic syndrome defined by the International Diabetes Federation among adults in the U. S. Diabetes Care 2005; 28: 2745 -9