Metabolic syndrome, dyslipidemia, hypertension and type 2 diabetes in youth: from diagnosis to treatment

Overweight and obesity in youth is a worldwide public health problem. Overweight and obesity in childhood and adolescents have a substantial effect upon many systems, resulting in clinical conditions such as metabolic syndrome, early atherosclerosis, dyslipidemia, hypertension and type 2 diabetes (T2D). Obesity and the type of body fat distribution are still the core aspects of insulin resistance and seem to be the physiopathologic links common to metabolic syndrome, cardiovascular disease and T2D. The earlier the appearance of the clustering of risk factors and the higher the time of exposure, the greater will be the chance of developing coronary disease with a more severe endpoint. The age when the event may occur seems to be related to the presence and aggregation of risk factors throughout life

Updated cardiovascular prevention guideline of the Brazilian Society of Cardiology: 2019

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Subclinical atherosclerosis and inflammation, insulin resistance and genetic markers in hyperglycemic patients

A doença aterosclerótica macrovascular se inicia em fases precoces das alterações do metabolismo glicídico. Este estudo teve por objetivos: 1) avaliar a prevalência de aterosclerose subclínica diagnosticada por métodos não-invasivos em indivíduos com indicação de teste oral de tolerância a glicose; 2) avaliar a distribuição de biomarcadores e de marcadores genéticos nessa população; e 3) determinar os fatores de risco para aterosclerose subclínica em pacientes disglicêmicos. Indivíduos em prevenção primária foram inicialmente submetidos a teste oral de tolerância a glicose e classificados em grupos controle, glicemia de jejum alterada, intolerância à glicose e diabete melito; posteriormente, foram submetidos a pesquisa de aterosclerose subclínica e de biomarcadores, e a avaliação de polimorfismos genéticos e expressão gênica. Foram incluídos 103 pacientes no grupo controle, 80 no grupo glicemia de jejum alterada, 98 no grupo tolerância diminuída à glicose e 59 no grupo diabete melito, com média de idade de 59 + 7,4 anos, sendo 62,4% mulheres. Não foram encontradas diferenças quanto às características clínicas e laboratoriais entre os grupos. Foi observada alta prevalência de aterosclerose subclínica na população (77,1%) e, apesar de não haver diferença entre os grupos, houve tendência a prevalência crescente de acordo com a piora do perfil glicídico. Dentre os biomarcadores, foi encontrada diferença entre os grupos na análise de microalbuminúria, resistina, fator de necrose tumoral alfa e fosfolipase A2 associada a lipoproteína. Não houve diferença com relação aos polimorfismos, mas o grupo glicemia de jejum alterada apresentou maior expressão de mRNA do gene da fosfolipase A2 associada a lipoproteína. Concluímos que indivíduos com indicação de teste oral de tolerância a glicose têm alta prevalência de aterosclerose subclínica, independentemente do perfil glicídico. Após análise multivariada, os fatores que determinaram aterosclerose subclínica foram idade, pressão arterial sistólica, colesterol ligado à lipoproteína de alta densidade, fator de necrose tumoral alfa e uso de estatinas.Atherosclerotic macrovascular disease begins in early phases of glucose metabolism alterations. The objectives were: 1) To evaluate the prevalence of subclinical atherosclerosis diagnosed by non-invasive methods in patients with an indication for oral glucose tolerance test. 2) To evaluate the distribution of biomarkers and genetic markers in this population. 3) Determine the risk factors for subclinical atherosclerosis in dysglycemic patients. Individuals in primary prevention underwent oral glucose tolerance test and were classified as controls, impaired fasting glucose, decreased glucose tolerance and diabetics and submitted to subclinical atherosclerosis search, evaluation of biomarkers, genetic polymorphisms and gene expression. A group of 103 patients were included as controls, 80 as impaired fasting glucose, 98 as decreased glucose tolerance and 59 as diabetes with a mean age of 59 ± 7.4 years, 62.4% women. No differences were found between clinical and laboratory characteristics of the groups. High prevalence of subclinical atherosclerosis (77.1%) was observed, although there was no significant difference between groups, a tendency of higher prevalence according to worsening of glucose increasing profile was verified. Among the biomarkers difference between groups were found in the analysis of microalbuminuria, resistin, tumor necrosis factor alfa and phospholipase A2 associated with lipoprotein. There was no difference regardind the polymorphisms, but the impaired fasting glucose group had higher expression of PLA2G7. After multivariate analysis, the factors that determined subclinical atherosclerosis were age, systolic blood pressure, HDL-cholesterol, tumor necrosis factor alfa and statins. We concluded that individuals with indication of oral glucose tolerance test have a high prevalence of subclinical atherosclerosis regardless of glucose profile. The factors that determine the presence of subclinical atherosclerosis were age, systolic blood pressure, HDL-cholesterol, tumor necrosis factor alfa and statins

Statin dose reduction with complementary diet therapy: A pilot study of personalized medicine

Objective: Statin intolerance, whether real or perceived, is a growing issue in clinical practice. Our aim was to evaluate the effects of reduced-dose statin therapy complemented with nutraceuticals. Methods: First phase: Initially, 53 type 2 diabetic statin-treated patients received a supplementation with fish oil (1.7 g EPA + DHA/day), chocolate containing plant sterols (2.2 g/day), and green tea (two sachets/day) for 6 weeks. Second phase: “Good responders” to supplementation were identified after multivariate analysis (n = 10), and recruited for a pilot protocol of statin dose reduction. “Good responders” were then provided with supplementation for 12 weeks: standard statin therapy was kept during the first 6 weeks and reduced by 50% from weeks 6–12. Results: First phase: After 6 weeks of supplementation, plasma LDL-C (−13.7% ± 3.7, P = .002) and C-reactive protein (−35.5% ± 5.9, P = .03) were reduced. Analysis of lathosterol and campesterol in plasma suggested that intensity of LDL-C reduction was influenced by cholesterol absorption rate rather than its synthesis. Second phase: no difference was observed for plasma lipids, inflammation, cholesterol efflux capacity, or HDL particles after statin dose reduction when compared to standard therapy. Conclusions: Although limited by the small sample size, our study demonstrates the potential for a new therapeutic approach combining lower statin dose and specific dietary compounds. Further studies should elucidate “good responders” profile as a tool for personalized medicine. This may be particularly helpful in the many patients with or at risk for CVD who cannot tolerate high dose statin therapy. Trial registration: ClinicalTrials.gov, NCT02732223. Keywords: Atherosclerosis, Omega-3 fatty acids, Plant sterols, Polyphenols, Responder

Brazilian guidelines on prevention of cardiovascular disease in patients with diabetes : a position statement from the Brazilian Diabetes Society (SBD), the Brazilian Cardiology Society (SBC) and the Brazilian Endocrinology and Metabolism Society (SBEM)

Background: Since the first position statement on diabetes and cardiovascular prevention published in 2014 by the Brazilian Diabetes Society, the current view on primary and secondary prevention in diabetes has evolved as a result of new approaches on cardiovascular risk stratification, new cholesterol lowering drugs, and new anti-hyperglycemic drugs. Importantly, a pattern of risk heterogeneity has emerged, showing that not all diabetic patients are at high or very high risk. In fact, most younger patients who have no overt cardiovascular risk factors may be more adequately classified as being at intermediate or even low cardiovascular risk. Thus, there is a need for cardiovascular risk stratification in patients with diabetes. The present panel reviews the best current evidence and proposes a practical riskbased approach on treatment for patients with diabetes. Main body: The Brazilian Diabetes Society, the Brazilian Society of Cardiology, and the Brazilian Endocrinology and Metabolism Society gathered to form an expert panel including 28 cardiologists and endocrinologists to review the best available evidence and to draft up-to-date an evidence-based guideline with practical recommendations for risk stratification and prevention of cardiovascular disease in diabetes. The guideline includes 59 recommendations covering: (1) the impact of new anti-hyperglycemic drugs and new lipid lowering drugs on cardiovascular risk; (2) a guide to statin use, including new definitions of LDL-cholesterol and in non-HDL-cholesterol targets; (3) evaluation of silent myocardial ischemia and subclinical atherosclerosis in patients with diabetes; (4) hypertension treatment; and (5) the use of antiplatelet therapy Conclusions: Diabetes is a heterogeneous disease. Although cardiovascular risk is increased in most patients, those without risk factors or evidence of sub-clinical atherosclerosis are at a lower risk. Optimal management must rely on an approach that will cover both cardiovascular disease prevention in individuals in the highest risk as well as protection from overtreatment in those at lower risk. Thus, cardiovascular prevention strategies should be individualized according to cardiovascular risk while intensification of treatment should focus on those at higher risk

Brazilian guidelines on prevention of cardiovascular disease in patients with diabetes: a position statement from the Brazilian Diabetes Society (SBD), the Brazilian Cardiology Society (SBC) and the Brazilian Endocrinology and Metabolism Society (SBEM)

Abstract Background Since the first position statement on diabetes and cardiovascular prevention published in 2014 by the Brazilian Diabetes Society, the current view on primary and secondary prevention in diabetes has evolved as a result of new approaches on cardiovascular risk stratification, new cholesterol lowering drugs, and new anti-hyperglycemic drugs. Importantly, a pattern of risk heterogeneity has emerged, showing that not all diabetic patients are at high or very high risk. In fact, most younger patients who have no overt cardiovascular risk factors may be more adequately classified as being at intermediate or even low cardiovascular risk. Thus, there is a need for cardiovascular risk stratification in patients with diabetes. The present panel reviews the best current evidence and proposes a practical risk-based approach on treatment for patients with diabetes. Main body The Brazilian Diabetes Society, the Brazilian Society of Cardiology, and the Brazilian Endocrinology and Metabolism Society gathered to form an expert panel including 28 cardiologists and endocrinologists to review the best available evidence and to draft up-to-date an evidence-based guideline with practical recommendations for risk stratification and prevention of cardiovascular disease in diabetes. The guideline includes 59 recommendations covering: (1) the impact of new anti-hyperglycemic drugs and new lipid lowering drugs on cardiovascular risk; (2) a guide to statin use, including new definitions of LDL-cholesterol and in non-HDL-cholesterol targets; (3) evaluation of silent myocardial ischemia and subclinical atherosclerosis in patients with diabetes; (4) hypertension treatment; and (5) the use of antiplatelet therapy. Conclusions Diabetes is a heterogeneous disease. Although cardiovascular risk is increased in most patients, those without risk factors or evidence of sub-clinical atherosclerosis are at a lower risk. Optimal management must rely on an approach that will cover both cardiovascular disease prevention in individuals in the highest risk as well as protection from overtreatment in those at lower risk. Thus, cardiovascular prevention strategies should be individualized according to cardiovascular risk while intensification of treatment should focus on those at higher risk

Brazilian guidelines on prevention of cardiovascular disease in patients with diabetes : a position statement from the Brazilian Diabetes Society (SBD), the Brazilian Cardiology Society (SBC) and the Brazilian Endocrinology and Metabolism Society (SBEM)

Background: Since the first position statement on diabetes and cardiovascular prevention published in 2014 by the Brazilian Diabetes Society, the current view on primary and secondary prevention in diabetes has evolved as a result of new approaches on cardiovascular risk stratification, new cholesterol lowering drugs, and new anti-hyperglycemic drugs. Importantly, a pattern of risk heterogeneity has emerged, showing that not all diabetic patients are at high or very high risk. In fact, most younger patients who have no overt cardiovascular risk factors may be more adequately classified as being at intermediate or even low cardiovascular risk. Thus, there is a need for cardiovascular risk stratification in patients with diabetes. The present panel reviews the best current evidence and proposes a practical riskbased approach on treatment for patients with diabetes. Main body: The Brazilian Diabetes Society, the Brazilian Society of Cardiology, and the Brazilian Endocrinology and Metabolism Society gathered to form an expert panel including 28 cardiologists and endocrinologists to review the best available evidence and to draft up-to-date an evidence-based guideline with practical recommendations for risk stratification and prevention of cardiovascular disease in diabetes. The guideline includes 59 recommendations covering: (1) the impact of new anti-hyperglycemic drugs and new lipid lowering drugs on cardiovascular risk; (2) a guide to statin use, including new definitions of LDL-cholesterol and in non-HDL-cholesterol targets; (3) evaluation of silent myocardial ischemia and subclinical atherosclerosis in patients with diabetes; (4) hypertension treatment; and (5) the use of antiplatelet therapy Conclusions: Diabetes is a heterogeneous disease. Although cardiovascular risk is increased in most patients, those without risk factors or evidence of sub-clinical atherosclerosis are at a lower risk. Optimal management must rely on an approach that will cover both cardiovascular disease prevention in individuals in the highest risk as well as protection from overtreatment in those at lower risk. Thus, cardiovascular prevention strategies should be individualized according to cardiovascular risk while intensification of treatment should focus on those at higher risk