Hypercholesterolemia secondary targets

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Phone:617-632-7753; Associate Editor(s)-In-Chief: Kashish Goel, M.D.

The Metabolic Syndrome

The metabolic syndrome is identified as a secondary target of therapy in the NCEP ATP III guidelines, beyond LDL cholesterol. The metabolic syndrome is a constellation of multiple risk factors which are lipid and non-lipid in origin. The basic metabolic abnormality associated with the metabolic syndrome is insulin resistance. Two main factors are responsible for the development of insulin resistance which include abdominal obesity and physical inactivity. The definition of the metabolic syndrome includes:

Clinical Identification of the Metabolic Syndrome

Risk Factor	Defining level
Abdominal Obesity: Men Women	Waist Circumference: >102 cm (>40 in) >88 cm (>35 in)
Triglycerides	≥ 150 mg/dL
HDL cholesterol Men Women	<40 mg/dL <50 mg/dL
Blood pressure	≥ 130/≥ 85 mmHg
Fasting glucose	≥ 110 mg/dL

Management

The management of the metabolic syndrome is multifold. It is considered as a secondary target for therapy after the LDL goal has been achieved. It mainly includes 3 main components:

Weight reduction

Obesity and overweight are major underlying risk factors for CHD. After the LDL goal has been achieved, targeted interventions towards weight reduction should be designed for each individual. This will help in reducing the LDL and reduce other risk factors associated with the metabolic syndrome.

Physical activity

Sedentary lifestyle and physical inactivity are major risk factors for CHD. Regular physical activity raises HDL, reduces VLDL and may also lower LDL levels. It also helps in improving cardiovascular fitness and insulin resistance and should be a part of the regimen of each patients on LDL lowering therapy.

Individual components

In addition to the 2 main underlying risk factors (obesity and physical inactivity), it is important to modify the individual components of the metabolic syndrome. This would include better control of hypertension, use of aspirin for primary prevention to reduce the prothrombotic state), better control of diabetes and impaired glucose intolerance and treatment of elevated triglycerides and low HDL.