International Journal of Diabetes Mellitus
Volume 2, Issue 2 , Pages 83-87, August 2010

Parameters of metabolic syndrome are markers of coronary heart disease – An observational study

  • Faria Afsana

      Affiliations

    • Department of Endocrinology, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM), Dhaka, Bangladesh
    • Corresponding Author InformationCorresponding author. Address: Diabetologist and Endocrinologist, Department of Endocrinology, Room No. 110, 122 Kazi Nazrul Islam Avenue, BIRDEM, Dhaka-1000, Bangladesh. Tel.: +880 2 8116648, mobile: 01817564963; fax: +880 2 9677772.
    • ,
  • Zafar Ahmed Latif

      Affiliations

    • Department of Endocrinology, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM), Dhaka, Bangladesh
    • ,
  • M. Maksumul Haq

      Affiliations

    • Department of Interventional Cardiology, Ibrahim Cardiac Hospital and Research Institute (ICHRI), Dhaka, Bangladesh

Received 18 April 2010; received in revised form 5 May 2010; accepted 16 May 2010. published online 14 June 2010.

Article Outline

Abstract 

Aims

This study was undertaken to identify the parameters of metabolic syndrome which can predict cardiovascular and peripheral vascular disease.

Subject

A total of 260 subjects were selected from Ibrahim Cardiac Hospital and Research Institute (ICHRI), who reported for coronary angiogram as per advice of a cardiologist.

Method

Each subject undergoing angiogram was interviewed with a preset structured questionnaire. The study subjects were screened for PVD (peripheral vascular disease) by examining peripheral pulses and ankle brachial index measured. Subjects with absent pulse or non-recordable ankle brachial index was considered as ankle brachial index <0.9. Positive angiographic finding was defined by presence of mild to severe degree of coronary vascular narrowing of one or multiple of three coronary arteries.

Result

Among the study subjects 64.6% had metabolic syndrome, 79.2% had positive and 20.8% had normal angiographic finding. Among the CAG positive subjects 38.8% had single vessel disease, 30.0% had double vessel disease and 31.08% had triple vessel disease. CAG positive subjects are mostly 40–60years of age, 78.6% male, 54.8% smoker, 62.1% had waist circumference above normal, and about 90% have dyslipidemia and dysglycemia (DM/IGT/IFG). In this study subjects 83.9% of diabetic and 69.7% of non-diabetic had positive angiographic finding. Among the CAG positive subjects 16.6% had low ABI (<0.9).

Conclusions

This study reveals that hypertriglyceridemia, waist circumference and hypertension are significantly related with angiographic positivity. Peripheral vascular disease was not significantly higher among CAG positive subjects and no association was observed between metabolic syndrome and PVD.

Keywords: Metabolic syndrome, Coronary angiogram, Coronary artery disease

 

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1. Introduction 

Metabolic syndrome is a clustering of metabolic abnormalities that has been associated with a risk of coronary heart disease, stroke and cardiovascular mortality greater than that of its individual component. The prevalence of metabolic syndrome has varied markedly between different studies, most likely because of the lack of accepted criteria for the definition of the syndrome [1]. The International Diabetes Federation (IDF) published new criteria for identifying subjects with metabolic syndrome in 2005 [2]. Using the IDF definition, the age-adjusted prevalence of MetS was 43.4% and included the majority of subjects older than 50years. In IDF MetS, the prevalence of abdominal obesity and high fasting plasma glucose levels was much higher compared with the NCEP ATP III definition [3].

1.1. Metabolic syndrome and cardiovascular risk 

Each of the metabolic syndrome criteria is related to an increased risk of developing cardiovascular disease. NHANES III showed that approximately 24% of adult American had three or more of five metabolic syndrome criteria [4]. Metabolically, several risk factors tend to cluster in middle aged adults including HDL, BMI, systolic blood pressure, triglyceride, cholesterol and blood glucose. Some risk factors are related to the greater risk of CHD. The presence of three or more metabolic risk factors leads to a doubling of risk for CHD in men and a fivefold increase in risk factor for women [5]. The Framingham Study [6] shows that the components of the syndrome that contributed most to cardiovascular disease outcome were high blood pressure (33%) and low HDL cholesterol (25%). The higher the number of abnormalities in an individual and the more severe the magnitude of each abnormality, the more likely the individual is to be insulin resistant/hyperinsulinemic. The prevalence of metabolic syndrome depends on age, ethnic background and gender [7]. It increases linearly from 20 to 50years of age, and plateaus thereafter, with middle aged Mexican–American women showing the highest (∼50%) and black men the lowest. The role of the parental history of DM and HTN in the occurrence of metabolic syndrome was studied in the risk of atherosclerosis in communities’ study [7]. Metabolic syndrome (MetS) is associated with an increased risk of cardiovascular disease events in the general populations [8]. The Hisayama Study, a prospective cohort study of a general Japanese population with a long duration of follow up, reported the association of metabolic syndrome with the incidence of cardiovascular disease, using a modified NCEP definition [9]. It also revealed that the risk of cardiovascular disease increased in an incremental fashion, with the number of components of metabolic syndrome, and becomes predictive of cardiovascular disease when the number of components reached to three.

The objective of the study was to observe different parameters of metabolic syndrome among people undergoing coronary angiogram, and to measure the impact of different component combinations of the metabolic syndrome on cardiovascular disease, as well as peripheral vascular disease.

1.2. Metabolic syndrome and peripheral vascular disease 

Peripheral vascular disease (PVD) is a manifestation of systemic atherosclerosis, in which the arterial lumen of the lower extremities becomes progressively occluded by atherosclerotic plaque [10]. The prevalence of a peripheral vascular disease is elevated in subjects with metabolic syndrome [11]. The assessment of peripheral pulses and measurement of ankle brachial index are tools for assessing peripheral vascular disease. The ankle brachial index (ABI), i.e. the ratio of the ankle to brachial systolic blood pressure, is the gold standard for the diagnosis of peripheral arterial disease, and is a highly specific method for the assessment of vascular risk in otherwise asymptomatic patients. An ABI⩽0.90 is diagnostic of PAD. The measurement of ABI by palpation in the setting of primary care, in patients at intermediate cardiovascular risk, is a sufficiently sensitive method to consider its use as a screening test for the exclusion of PAD [12].

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2. Patients and methods 

The study was conducted in Ibrahim Cardiac Hospital and Research Institute (ICHRI) during the period July 2008–March 2009. It was an observational study. Subjects of 30–80years age undergoing coronary angiogram in ICHRI who reported coronary angiogram (CAG) for the first time, having either a cardiac event in the past or enough clinical or investigational evidence (ECG, Echo, ETT) of coronary artery disease were included in this study. Subjects aging >80years, or with associated co morbid disease (as CKD, CLD or any acute illness), were excluded from the study. Study subjects were chosen by purposive convenient sampling. Two hundred and sixty subjects undergoing coronary angiogram, as per the advice of a cardiologist, were interviewed through a preset structured questionnaire, and examined on the morning of the angiogram. Each subject undergoing angiogram completed a questionnaire covering medical history, family history of cardiovascular disease, exercise, treatment for hypertension or diabetes, smoking habits and alcohol intake. Fasting blood sugar was determined by a glucometer (the most accurate and popular meter supplied by Abbott Company, named Optium Omega Glucometer) on the day of CAG as routine test; the angiogram report was collected on the subsequent day. Angiogram findings were scored by the same physician. The scoring system was defined as mild (40–50% block); moderate (50–70% block); or severe (>70% block).

Patients were briefed about the study and written consent obtained.

Anthropometric Measurement was taken as follows: standing height was measured using appropriate scales with minimal clothes. Height was recorded in centimeters, to the nearest 5mm. The balance was placed on a hard flat surface, and checked for zero balance before measurement. Weight was recorded to the nearest 0.5kg. Body mass index (BMI) of the subjects was calculated using a standard formula: BMI=Weight (kg)/(height in meter)2. Waist circumference was measured to the nearest 0.5cm, with a soft non-elastic measuring tape. Blood pressure was measured using a standard sphygmomanometer in the supine position, after a rest of at least 5min. Among the laboratory reports, dysglycemia was considered with fasting blood glucose ⩾5.6mmol/l, or previously diagnosed or treated as IGT/IFG/DM, and dyslipidemia was considered if S. Cholesterol>200mg/dl/TG>150mg/dl/HDL<40mg/dl/LDL>100mg/dl and/or the patient was using lipid lowering agents. ECG, ETT, Echocardiography and Lipid profile data were collected from the patient’s previous record (recent reports done before angiogram). A Hewlett Packard conventional machine was used for ECG. Conventional coronary angiography was done to all subjects. In this study, metabolic syndrome is defined by using the criteria recommended by IDF.

Statistical analysis was performed using SPSS (Statistical Package for Social Sciences) version 16. All data were expressed as a mean and standard deviation (SD). The standard error of mean (SE), range, percentage and 95% Confidence Interval (CI) for a continuous variable. Chi square test (χ2) was used for the comparison of qualitative data, and the comparison between groups was done by t-test. Results were considered statistically. Data was considered significant at P-value <0.05. The Odds Ratio was calculated by the following formula:

Multiple regression analysis was done to see the effect of different risk factors on clinical outcome.

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3. Results 

3.1. Clinical and biochemical characteristics of study subjects 

Seventy five (28.84%) subjects were female, and 185 (71.15%) were male. The age (years) as mean±SD was 53.58 (±9.70). Smoking habit and alcohol ingestion were present in 59 (22.69%) and 7 (2.69%) subjects. One hundred and fifteen (44.23%) subjects had a family history of cardiovascular disease. BMI (kg/m2) was 24.84 (±3.22). FPG (mmol/l) (mean±SD) was 7.92 (±2.72). The mean (±SD) of waist circumference was 91.71 (±7.97). TG (mean±SD), cholesterol (mean±SD), LDL (mean±SD), HDL (mean±SD) were 123.94 (±11.67), 190.89 (±46.09), 117.69 (±73.35) and 37.02 (±9.08). The mean±SD of systolic blood pressure (mmHg) and diastolic blood pressure (mmHg) was 123.94 (±11.67) and 78.71 (±5.06).

3.2. Angiographic characteristics of study subjects 

Among the study subjects 20.8% (n=54) had normal and 79.2% (206) had positive angiographic finding (Table 1). Among the positive cases, 30.8% (n=80) had single vessel disease, 23.8% (n=62) had double vessel disease, and 24.6% (n=64) had triple vessel disease.

Table 1. Distribution of angiographic findings among study subjects.
FrequencyPercent
Normal5420.8

Abnormal
Single vessel8030.7
Double vessel6223.8
Triple vessel6424.6

Total260100.0

3.3. Characteristics of different parameters of metabolic syndrome 

Among the subjects having normal angiographic finding (Table 2) 75.92% had a waist circumference above normal (>80cm for female and >90cm for female), 88.88% had hypertriglyceridemia, 87.03% had raised fasting glucose (or any form of dysglycemia), 85.18% had raised systolic pressure, 74.07% had raised diastolic pressure and 12% had low HDL. Subjects having positive angiographic findings had the following distribution of different parameters of metabolic syndrome: 62.13% had a waist circumference above normal, 96.11% had hypertriglyceridemia, 90.29% had raised fasting glucose (or any form of dysglycemia), 85.1% had raised systolic pressure, 75.72% had raised diastolic pressure and 21.97% had low HDL. Normal and positive angiographic groups had a statistically significant difference in waist circumference, S. triglyceride level and systolic blood pressure (P=0.040, 0.047, 0.007, respectively). Considering the different angiographic finding (single vessel/double vessel/triple vessel) there is a significant difference in waist circumference, and S. triglyceride level (P=0.041, 0.022, respectively) in these three variants (Table 2).

Table 2. Characteristics of different parameters of metabolic syndrome according to angiographic positivity.
CAG status%WC above normal (%)Hyper TG (%)Dysglycemia (%)Raised SBP or on anti HTN (%)Raised DBP or on anti HTN (%)Low HDL (%)
Normal (n=54)20.875.988.887.085.174.012
Abnormal (n=206)79.262.196.190.285.175.721.9
P-value0.0400.0470.3160.0070.4640.082
Single vessel (n=80)30.868.795.085.095.078.723.5
Double vessel (n=62)23.851.696.793.598.367.719.2
Triple vessel (n=64)24.764.096.893.795.379.622.8
P-value0.0410.0220.3720.2190.1950.417

WC, waist circumference; Hyper TG, hypertriglyceridemia; dysglycemia, raised FPG or previously diagnosed DM/IGT/IFG; SBP, systolic blood pressure; DBP, diastolic blood pressure; AntiHTN, antihypertensive drug.

3.4. Clinical and biochemical characteristics of subjects with different angiographic findings 

The total number of study subjects undergoing coronary angiogram was 260. Of these, 79.23% (n=206) were angiogram positive (Table 2). Among the subjects undergoing coronary angiogram 87.5% (n=162) male and 58.6% (n=44) female had positive angiographic findings. Positive angiographic findings were found in 56% of subjects <40years of age, 80.7% of 40–60years and 87% of subjects >60years of age. About 81% (81.6%) of exercising subjects and 77.03% of no exercising subjects showed angiogram positivity. Smokers were 88.13% angiogram positive and non-smokers 70.99%. Subjects with a positive family history of cardiac disease were angiogram positive at 80.86%, in contrast to 77.93% with no previous family history. Angiogram was positive in 83.3% of subjects with normal BMI (<25kg/m2) and 89.2%with higher BMI (>25kg/m2). Subjects with normal waist circumference were 85.71% angiogram positive, 75.73% of subjects with abnormal waist circumference were angiogram positive. Among subjects with high cholesterol, 80.93% were angiogram positive and 62.5% of subjects with normal cholesterol were angiogram positive. High LDL and normal LDL showed 78.9% and 82.6% of angiographic positivity, respectively. Subjects with normal triglyceride were 57.14% angiogram positive, and hypertriglyceridemic subjects were 80.48% angiogram positive. Among subjects, 76.34% with normal HDL and 86.95% with low HDL were angiogram positive. Subjects with low ankle brachial index were 55.67% angiography positive and subjects with normal ankle brachial index were 93.2% angiography positive. About 62.13% of subjects with metabolic syndrome showed angiographic positivity. Angiographic positivity was found in 81.14% of hypertensive (systolic) subjects, and 50% of normotensive subjects. Subjects with diastolic hypertension were 79.59% angiogram positive, in contrast to 78.12% with normal diastolic blood pressure. Male sex, increased age, smoking, waist circumference, raised S. Cholesterol and S. triglyceride and systolic hypertension were significantly related to angiogram positivity (P=0.000, 0.003, 0.004, 0.040, 0.037, 0.047, 0.007, respectively).

3.5. Characteristics of angiogram positive subjects 

Among angiogram positive subjects, 78.64% were male and 21.36% were female, 8.29% were <40years, 68.7% were 40–60years and 22.92% were >60years of age. Among them, 48.51% took exercise, 54.85% were smokers, 45.15% had a positive family history of CAD, 44.18% had a high BMI, 62.13% had a waist circumference above normal, 16.6% had low ankle brachial index, 92.7% had hypercholesterolemia, 96.11% had hypertriglyceridemia, 19.41% had low HDL, 90.71% had high LDL, 90.29% had raised fasting blood glucose, and 62.13% had metabolic syndrome.

3.6. Distribution of metabolic syndrome and diabetes in study subjects 

Of the total subjects in this study that underwent coronary angiogram, 66.9% (n=174) were diabetic and 33.1% were non-diabetic (Table 3). On the other hand, all the control subjects were diabetic. Among the total study subjects (n=260), 64.6% (n=168) had metabolic syndrome and 35.4% had not (according to IDF criteria).

Table 3. Metabolic syndrome and diabetes among study subjects.
FrequencyPercentage
Metabolic syndrome
Present16864.6
Absent9235.4

Diabetes
Present17466.9
Absent8633.1

3.7. Association of diabetes and metabolic syndrome 

Of the study subjects, 68.39% (n=119) of diabetic (subjects) and 58.13% (n=86) of non-diabetic (subjects) had metabolic syndrome (Table 4).

Table 4. Diabetes and metabolic syndrome in study subjects.
MSTotalP-valueOdds ratio
AbsentPresent
Non-diabetic
Count368686
% of total41.858.1100

Diabetic
Count551191740.0730.90
% of total31.668.3100

Count91169260
% of total3565100

Table 4 shows that concerning the risk of developing diabetes, among the people those who have metabolic syndrome has .90 times higher than those who do not have exposure among the risk factor.

3.8. Relation of positive angiographic finding with different components of metabolic syndrome 

Multiple regression analysis of different parameters of metabolic syndrome, with angiographic findings as the dependent variable, reveals that waist circumference (P=0.033), blood pressure (0.007) and S. triglyceride (0.036) are positively correlated with positive angiographic findings. S. HDL and FBG did not show any positive influence on angiographic positivity.

Table 5 shows that the Odds Ratio is greater than one and the P-value is significant (less than 0.05). This means that these factors lead to a high risk of developing MS among patients undergoing angiography; otherwise there was less risk of developing it.

Table 5. Multiple regression analysis with angiographic finding as a dependent variable and individual components of metabolic syndrome as independent variables in study subjects.
CAG positiveBP-valueOdds ratioConfidence interval
Lower boundUpper bound
Intercept3.50.055
Waist0.80.0332.21.064.84
B.P−1.50.0070.20.060.64
S.TG−1.30.0360.20.070.91
S. HDL−0.70.1130.40.171.20
FPG0.10.8451.10.363.37

3.9. Presence of metabolic syndrome in different angiographic finding 

Among the 260 subjects undergoing CAG, 168 had MetS. Among them, 56 (33.33%) had single vessel disease, 31 (18.45%) had double vessel disease, 41 (24.40%) had triple vessel disease, and 40 (23.80%) had normal angiographic finding (Fig. 1).

3.10. PVD among study subjects 

The study subjects were screened for PVD (peripheral vascular disease). It revealed that 74.62% (n=194) subjects had normal ankle brachial index and 25.3% (n=66) had ankle brachial index <0.9. Subjects with low ankle brachial index were 55.6% CAG positive and subjects with normal ankle brachial index were 93.2% CAG positive. It states that presence of PVD (Evidenced by ABI <0.9) does not affects angiographic positivity. On the other way among the CAG positive subjects 16.6% had low ankle brachial index.

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4. Discussion 

Metabolic syndrome has been most widely promoted as a means to identify patients for lifestyle intervention, so as to reduce risk factor levels and, in theory, incident disease, particularly CVD. The Framingham Risk Score is a widely available, extensively validated prediction rule for defining the probability of a coronary heart disease event in diverse population [1].

In this study, the prevalence of MetS is 64.6%. The age-adjusted prevalence of metabolic syndrome (MetS) is some what different between men and women. The prevalence of MetS was lower in women than men in NHANES 1988–1994; whereas the prevalence was higher in women in the later 1999–2002 cohort [13]. The reason for the increase is likely to be due to changes in the racial and ethnic composition of the female cohort. In this study, MetS is also more prevalent among female subjects.

The IDF consensus group states that this new definition emphasizes the importance of central obesity, with modifications according to ethnic group encouraging the clinical diagnosis of almost all cases of metabolic syndrome. The definition thus identifies the actual group of patients who are at increased risk of developing coronary artery disease and/or type 2 diabetes. In consequence, IDF definition, which has central obesity as its prerequisite, may be relatively less restrictive than NCEP: ATP III. In this study, in considering the IDF present statement, the new IDF definition is used to define metabolic syndrome.

While comparing the subgroups of subjects (normal vs. positive angiographic group) undergoing coronary angiogram male sex, aging and smoking significantly influence the angiographic findings. Accordingly waist circumference, dyslipidemia (hypercholesterolemia and hypertriglyceridemia) and hypertension are more prevalent in angiogram positive subjects, i.e. higher percentage of angiogram positive subjects are having these three parameters of metabolic syndrome than their normal counterpart. One of the primary observations regarding the clustering of metabolic disorders was the association of these features with increased cardiovascular risk. It is well accepted and established that multiple risk factors confer greater risk than a single risk factor. The more components of MetS that are present, the greater the cardiovascular risk [13]. The Framingham experience has certainly suggested that multiple risk factors increase the risk of CVD more than the sum of the individual risk factors [13]. In different studies, individual components of MetS are analyzed, to detect which component is more powerfully related to Mets. As in the Framingham Study, the factor which contributed most to cardiovascular disease outcome was high blood pressure and low HDL [14]. In this study, multiple regression analysis was done, taking angiographic finding as dependent variable and waist circumference, FPG, S. TG, S. HDL, blood pressure as independent variable. It reveals that three MetS components (waist circumference above normal, hypertriglyceridemia, and hypertension) significantly predict the cardiovascular events in the study population. Hypertriglyceridemia is also significantly related to the severity of angiographic finds. But other parameters of MetS were not related to the severity of different angiogram findings (single vessel/double vessel/triple vessel).

Here, the study of different clinical and biochemical characteristics of angiogram positive subjects’ shows that they are mostly of 40–60years of age, mostly present or previous smokers and 62% had metabolic syndrome. In considering the individual parameter of MetS, hypertriglyceridemia and fasting dysglycemia were present in ninety percent of angiogram positive subjects. Serum cholesterol and LDL had the same type of distribution. In correlating the waist circumference with metabolic syndrome 62% had a waist circumference above normal. Single vessel disease was the most prevalent among the entire angiogram positive group. Among the subjects undergoing coronary angiogram, 66.9% were diabetic, and the presence of diabetes was significantly related to presence of CAD (positive angiographic finding). Among all study subjects, diabetic subjects were experienced a greater prevalence of metabolic syndrome than non-diabetic ones.

The metabolic abnormalities of MetS and diabetes are associated with atherosclerosis including coronary artery calcification [15] and there is also involvement of other peripheral vessels. In a large cohort study, it was found that low ankle brachial index is associated with an increased risk of cardiovascular events and mortality [16]. In this study, 25.3% of subjects undergoing CAG had peripheral vascular disease. As the measurement of ankle brachial index was undertaken manually by sphygmomanometer, it may be that peripheral vascular disease may be more accurately measured if a Doppler study is feasible, and in this situation, peripheral vascular disease may be more prevalent among study subjects. There may be other reasons for this controversy, as ABI may be falsely raised in diabetic patients who have severe disease in smaller arteries [17]. A good number of study subjects (66.9%) were diabetic. Another noteworthy point is that ABI may appear normal at rest in patients with significant arterial disease [17]. Hence, post exercise vascular assessment can diagnose peripheral vascular disease more accurately, which was not feasible for all the study subjects undergoing coronary angiogram. For the diagnosis of a small number of cases of PVD in this study, the association between peripheral vascular disease and coronary artery disease was not significant.

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5. Study limitation 

Sample size was not that much adequate because the specialized services provided by the cardiac center is only the part of the tertiary care hospital, BIRDEM. Color Doppler was not available in that center. Further study including more number of subjects may be helpful.

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6. Conclusion 

In this study different parameters of metabolic syndrome among people undergoing coronary angiogram were studied. Among them, waist circumference, hypertriglyceridemia and hypertension I influenced cardiovascular disease occurrence. Among the demographic parameters aging, male sex, smoking habit and family history of cardiovascular disease are related to angiographic positivity. In this study, the presence of PVD does not influence CAG positivity.

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Acknowledgements 

I acknowledge the continuous support of the Bangladesh Diabetic Association and Ibrahim Cardiac Hospital and Research Institute.

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PII: S1877-5934(10)00029-9

doi:10.1016/j.ijdm.2010.05.007

International Journal of Diabetes Mellitus
Volume 2, Issue 2 , Pages 83-87, August 2010

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