Should we screen Should we screen for metabolic syndrome ?for metabolic syndrome ?

Bruno PornelBruno PornelBrussels Menopause CenterBrussels Menopause Center

Belgian Menopause Society SymposiumBelgian Menopause Society SymposiumJune 2009June 2009

Causes of Causes of deathdeath in men and womenin men and women

European cardiovascular disease statistics, 2008 European cardiovascular disease statistics, 2008

Diseases Men (%) Women (%)CAD 21 22

Stroke 11 17

Other CVD 11 15

Cancer 21 17 ( breast 3 % )

Respiratory 7 6

Injuries-Poisonning 12 5

Other 17 18

DiabetesDiabetes

nearly 200 million people ( 5 % of the adult population)nearly 200 million people ( 5 % of the adult population)

the 4th or 5th leading cause of deaththe 4th or 5th leading cause of death

by 2025, it is expected affecting 333 million peopleby 2025, it is expected affecting 333 million people

risk of CHD increased fourfold in women ( 2.5 in men)risk of CHD increased fourfold in women ( 2.5 in men)

induced CHD risk similar to myocardial infarctinduced CHD risk similar to myocardial infarct

Metabolic syndromeMetabolic syndrome

a cluster of the most dangerous heart attack risk factors: a cluster of the most dangerous heart attack risk factors: diabetes and prediabetes, abdominal obesity, high cholesterol andiabetes and prediabetes, abdominal obesity, high cholesterol and d high blood pressure. high blood pressure.

around 25 % of the worldaround 25 % of the world’’s adult : s adult :

•• they are twice as likely to die fromthey are twice as likely to die from

•• three times as likely to have a heart attack or stroke three times as likely to have a heart attack or stroke

•• fivefold greater risk of developing type 2 diabetes.fivefold greater risk of developing type 2 diabetes.

Female Metabolic SyndromeFemale Metabolic Syndrome((Worldwide definition for use in clinical practice, Worldwide definition for use in clinical practice, IDF 2006)IDF 2006)

Central obesity Central obesity

( waist circumference ( waist circumference ≥≥ 80 cm, 80 cm, for European women) for European women)

Female Metabolic SyndromeFemale Metabolic Syndrome

+ + any 2 any 2 of the following 4 factors: of the following 4 factors:

TG level: TG level: ≥≥ 150 mg/dL (1.7 mmol/L), or specific Ttt150 mg/dL (1.7 mmol/L), or specific Ttt

HDL cholesterol: < 50 mg/dL (1.29 mmol/L), or HDL cholesterol: < 50 mg/dL (1.29 mmol/L), or specific Tttspecific Ttt

Systolic BP Systolic BP ≥≥ 130 or diastolic BP 130 or diastolic BP ≥≥ 85 mm Hg, or 85 mm Hg, or specific Tttspecific Ttt

Fasting plasma glucose Fasting plasma glucose ≥≥ 100 mg/dL (5.6 mmol/L), 100 mg/dL (5.6 mmol/L), or previously diagnosed type 2 diabetesor previously diagnosed type 2 diabetes

Postmenopausal transitionPostmenopausal transition

Are menopausal lipid changes independent of age Are menopausal lipid changes independent of age effects ?effects ?

Total Cholesterol and LDL : Total Cholesterol and LDL : acceptedaccepted

HDL and Triglycerides : HDL and Triglycerides : inconsistentinconsistent

Lipoprotein (a) : Lipoprotein (a) : unclearunclear

Postmenopausal transitionPostmenopausal transition

Mesures of health statusMesures of health status

Obesity : impact on lipid profilesObesity : impact on lipid profiles

BMI : impact on E2 and FSH levelsBMI : impact on E2 and FSH levels

Smoking : early menopause, CHD riskSmoking : early menopause, CHD risk

Physical activity : impact on lipids and weight gainPhysical activity : impact on lipids and weight gain

Derby, C. A. et al. Am. J. Epidemiol. 2009 169:1352-1361

Study of Women's Health Across the NationAdjusted mean of T-C, LDL-C, and TG, by menopausal status stratified on baseline weight tertile,

Derby, C. A. et al. Am. J. Epidemiol. 2009 169:1352-1361

Study of Women's Health Across the NationEstimated relative odds of LDL (>=130 mg/dL) for peri- and postmenopausal compared

with premenopausal women, full sample and stratified by baseline weight tertile,

Cardiovascular risk assessment in Cardiovascular risk assessment in gynaecological practice: physician survey gynaecological practice: physician survey

on current practice in Europe and USAon current practice in Europe and USA

Santiago Palacios Santiago Palacios

June 1-2, 2007, Seville

Online-survey: to keep the tendency of social desired answering to a minimum and perceived respondent anonymity at a maximum

Sample: office based gynaecologists, in UK GPs as well, in Spain and Italy office-based/ private hospital/ private gynaecological centre

Final sample sizes:

Study design and sample composition

Country Sample sizeFrance 103

Germany 101

Italy* 77

Spain* 90

UK 101

USA 200

Total 672

Q1: In your practice, please name the most common assessments you do in menopausal women. Please note down the assessments in the order of their relevance. Open question

GlobalN=610

(including N=44 for It and N=61 for Sp)

Q4: In your current practice, do you assess cardiovascular risks in your menopausal patients?

N=472 N= 200 N= 101 N= 101 N= 77 N= 90 N= 103

high normal systolic BP

= 130-139 mmHg

Q12: Please select the category/categories of systolic BP levels that reflect prehypertension/ high normal blood pressure.

N=472 N= 200

% of responses

blood pressure : only 20% as a standard assessments unspecified examination of cardiac health/CV risks :

10%. hypertension and CV disease : ranked as 3rd and 4th

most important diseases and indications recognized in menopausal women.

when asked directly, almost all physicians state that they assess CV risk factors as a standard or at least in special cases (EU: 94%, USA 90%)

Summary (1) : knowledge and assessment of CV risk factors in a gynecological setting

In cases when physicians do not measure factors that are perceived as easy to asses (e.g., diabetes and family history) the main reason is an attitude of not being responsiblefor these factors.

Summary (2)

N=472 N= 200

Q19: What guidelines for managing cardiovascular risks are you aware of?

!

% of responses

More than ⅓ of physicians : not aware of any of the guidelines shown

Around 50% are referred to a specialist.

80% receive advice for life style changes. Physicians across all countries feel responsible to

cooperate with other physicians for the treatment of CV risk factors and also involve specialists for determining CV risk factors. Treatment is to a higher extent seen to be the responsibility of a specialist.

In case physicians treat CV risk factors, 26% prescribe antihypertensives and 32% HRT.

Summary (3) : Management of CV risk factors and CV risk factors

Knowledge and assessment of CV risk Knowledge and assessment of CV risk factors in a Belgian gynecological settingfactors in a Belgian gynecological setting

online electronic and anonymous survey online electronic and anonymous survey

(March (March -- April 2008) (Nl + Fr)April 2008) (Nl + Fr)

same criteria as the US/European 2007 surveysame criteria as the US/European 2007 survey

1184 Belgian gynecologists invited by mail1184 Belgian gynecologists invited by mail

answer rate : 4 % (n = 47) answer rate : 4 % (n = 47)

Q1: In your practice, please name the most common Q1: In your practice, please name the most common assessments you do in menopausal women. Please assessments you do in menopausal women. Please

note down the assessments in the order of their note down the assessments in the order of their relevance. Open questionrelevance. Open question

Q4: In your current practice, do you assess Q4: In your current practice, do you assess cardiovascular risks in your menopausal patients? cardiovascular risks in your menopausal patients?

% Belgium Europe USA

No 17 4 10

Yes, but only in

certain cases

36 10 10

Yes, almost always

47 86 80

Correct answers regarding the Correct answers regarding the Metabolic Syndrome definitionMetabolic Syndrome definition

-- waist circumference waist circumference ≥≥ 80cm : 80cm : 40 %40 %

-- category/categories of systolic BP category/categories of systolic BP levels that reflect prehypertension/levels that reflect prehypertension/high normal blood pressure : high normal blood pressure : 42 %42 %

Should we screen Should we screen for metabolic syndrome ?for metabolic syndrome ?

YESYES

and rationally, and rationally, ……

Should we screen Should we screen for metabolic syndrome ?for metabolic syndrome ?

…… before breast cancer and before breast cancer and osteoporosis screeningosteoporosis screening

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