Multiple comorbidities: additive and predictive of cardiovascular risk. Peter M. Nilsson Lund University University Hospital Malmö, Sweden

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1 Multiple comorbidities: additive and predictive of cardiovascular risk Peter M. Nilsson Lund University University Hospital Malmö, Sweden

2 Clinical outcomes: major complications of CVD Heart Attack/ACS Stroke/TIA ACS=acute coronary syndrome; CVD=cardiovascular disease; TIA=transient ischaemic attack

3 Myocardial ischaemia Atherosclerosis LV hypertrophy Chain of events leading to cardiovascular mortality Coronary thrombosis Coronary artery disease Stroke Myocardial infarction Renal failure Neurohormonal activation Arrhythmias Loss of muscle Remodeling Ventricular dilation Sudden death Risk factors Hyperlipidaemia Hypertension Diabetes Smoking Psychosocial stress Dzau, Braunwald. Am Heart J Heart failure Death

4 Genetic influences on CVD risk and Type 2 diabetes

5 Secular trends in CVD in the UK Coronary heart disease mortality per 100,000 population Men Women Year Secular trends in age-standardised mortality per 100,000 population from coronary heart disease for men and women, , England and Wales Lawlor et al. BMJ

6 The challenge: the clustering of related risk factors Hypertension Obesity Atherosclerosis Hyperinsulinaemia Type 2 diabetes Hypertriglyceridaemia Small, dense LDL Low HDL Type 2 diabetes HDL=high-density lipoprotein; LDL=low-density lipoprotein Deedwania. Am J Med. 1998

7 Kylin E. Studien über das Hypertonie- Hyperurikemiesyndrom. Zentralblatt für Innere Medizin 1923;7:105 Es kil Kylin ( )

8 Metabolic syndrome: does it exist? arguments PRO Historical observations of the syndrome; it has been around for a long time! Logical clustering of risk factors for the metabolic syndrome is based on evolutionary selection and brain reward systems Risk prediction of CVD is possible based on the metabolic syndrome Treatment of metabolic syndrome/insulin resistance and associated risk factors is beneficial

9 NCEP ATP III criteria for the metabolic syndrome Fasting plasma glucose 6.1 mmol/l Abdominal obesity: waist circumference >88 cm (women) or >102 cm (men) Triglycerides 1.7 mmol/l 3 of the following: HDL cholesterol <1.29 mmol/l (women) or <1.03 mmol/l (men) Blood pressure 130/ 85 mmhg NCEP ATP III=National Cholesterol Education Program Adult Treatment Panel III Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Available at:

10 Age-specific prevalence of the metabolic syndrome among 8814 US adults Third National Health and Nutrition Examination Survey (NHANES III) 50 Men Women 40 Prevalence (%) Ford et al. JAMA. 2002

11 Adverse prognostic implications of cardiovascular metabolic syndrome Population-based observational study in 1209 Finnish men Metabolic syndrome present Metabolic syndrome absent Coronary heart disease mortality CVD mortality All-cause mortality Cumulative hazard (%) 20 RR (95% CI): 3.77 ( ) RR (95% CI): 3.55 ( ) 6.43) RR (95% CI): 2.43 ( ) Follow-up (years) Follow-up (years) Follow-up (years) No. at risk of metabolic syndrome Yes No Lakka et al. JAMA. 2002

12 Incidence of cardiovascular events in non- diabetic subjects with the metabolic syndrome NCEP ATP III EGIR IDF No metabolic syndrome Number (N) Incident MI / stroke (n/n) 33 / / / / / / / / 1000 Age + sex (adjusted hazard ratio) 1.95 ( ) 1.62 ( ) 1.27 ( ) Risk factors (adjusted * hazard ratio) 1.66 ( ) 1.46 ( ) 1.06 ( ) +C-reactive protein (adjusted**hazard ratio) 1.47 ( ) 1.36 ( ) 1.02 ( ) EGIR=European Group for the Study of Insulin Resistance IDF=International Diabetes Federation MI=myocardial infarction Nilsson P. et al. Diabetic Med. 2006, in press

13 Key neurochemical systems comprising the brain reward circuitry Gardner. In: Lowinson et al, eds. Substance Abuse. 4th ed. Lippincott Williams and Wilkins; Kruger et al. Photographic Atlas of the Rat Brain. Cambridge Press; 1995

14 Brain reward system triggered

15 but also by these things!

16 Prevalence of obesity in the USA, Mokdad et al. JAMA. 2001

17 Life expectancy at age 40: impact of excess body weight Framingham Heart Study Normal kg/m 2 50 Overweight kg/m 2 Obese 30 kg/m 2 Life expectancy (years) y 7.1 y y 5.8 y Female non-smoker Male non-smoker Peeters et al. Ann Intern Med. 2003

18 Potential contribution of expanded visceral adipose tissue to the atherothrombotic pro-inflammatory profile of abdominally obese patients Apo B Glucose Insulin Triglycerides Liver HL Insulin resistance (IR) syndrome of atherogenic dyslipidaemia PAI-1 Adiponectin Thin fibrous cap Unstable plaque Impaired fibrinolysis Increased collagen Endothelial dysfunction Expanded Visceral AT NEFAs IL-6 Adiponectin TNF-α IR? Glucose X Subcutaneous AT NEFAs IR LPL Skeletal Muscle Després et al. Ann Endocrinol. 2001

19 Additive effect of cholesterol and systolic blood pressure on risk of coronary heart disease death Cholesterol quintile (mg/dl) Deaths per 10,000 patient-years < N=316, Systolic blood <118 pressure quintile (mmhg) Neaton et al. Arch Intern Med. 1992

20 INTERHEART: importance of APO B and AI levels Large VLDL 1 Small VLDL 2 Low apo B Large LDL Small LDL Large LDL High apo B High apo AI Large HDL 2 Small HDL 3 Large HDL 2 Small HDL 3 Low apo AI VLDL=very low-density lipoprotein Yusuf et al. Lancet Healthy profile Metabolic syndrome and Type 2 diabetes

21 Fetal growth, retardation, and risk: - Arterial hypertension? - Type 2 diabetes? - Cardiovascular disease? - Insulin resistance syndrome? The Barker Fetal Origin Hypothesis

22 Ten-year risk of fatal CVD in high-risk regions of Europe by gender, age, SBP, total cholesterol, and smoking status Conroy et al. Eur Heart J Future Forum DEFINING GLOBAL STANDARDS IN VASCULAR DISEASE

23 Sverige

24

25 Vascular ageing: atherosclerosis and arterial stiffening Foam cells Fatty streak Intermediate lesion Atheroma Fibrous plaque Complicated lesion/rupture Endothelial dysfunction From first decade From third decade From fourth decade Butler et al. Eur Heart J Growth of the lipid core Smooth muscle and collagen Thrombosis

26 Conclusions Evolutionary biology and evolutionary medicine can provide new perspectives on the metabolic syndrome and clusters of CVD risk factors Survival genes do not match with modern lifestyle, resulting in abdominal obesity, chronic inflammation, and insulin resistance A life course approach takes into account the early programming (fetal life, catch-up post-natal growth) for prediction of cardiovascular risk and Type 2 diabetes Lifestyle programmes have to be tailored to brain reward systems and may prevent vascular ageing

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