Metabolic Syndrome

Ischemic heart disease is the headline - Endothelial dysfunction, dyslipidemia, and hypertension converge on coronary artery disease, and low adiponectin drives the atherosclerosis directly. A baseline 12-lead ECG is what you look at for ischemia, prior infarct, arrhythmia, and the left ventricular hypertrophy of long-standing hypertension.

Structural heart disease - Hypertension raises vascular resistance and stiffness and produces left ventricular hypertrophy and cardiomyopathy. Echocardiography is the study that answers wall thickness and ventricular function when the ECG or exam raises the question.

Blood pressure - Their outpatient target under Joint National Committee guidance is under 140/90 in the general population, under 130/80 with diabetes, and under 150/90 at age 60 or older. A pressure well off target on arrival tells you the chronic control is poor, not that they are just nervous.

Glucose handling - Hemoglobin A1c is the screen for insulin resistance and type 2 diabetes, and a basic metabolic panel gives you the working glucose. A patient needing more than 1 unit/kg/day of exogenous insulin is insulin-resistant and more than 200 units a day is severely resistant, so a standard sliding scale will underperform.

Sleep apnea travels with it - Sleep apnea and sleep deprivation both feed metabolic syndrome, and three months of CPAP in moderate to severe OSA lowers blood pressure and reverses some of the metabolic derangement. Ask whether they use home CPAP and get the machine to the floor for the first night.

Renal function - Insulin resistance and hypertension both damage the kidney. Check the creatinine on the basic metabolic panel before you commit to renally cleared drugs.

Fatty liver - Metabolic syndrome causes steatosis that progresses through nonalcoholic steatohepatitis to fibrosis and cirrhosis. A liver panel is worth having before you lean on hepatically cleared agents.

The blood is prothrombotic - Raised plasminogen activator inhibitor type 1 and altered adipokines make the blood thrombogenic. Ischemic stroke risk is higher than was long assumed, and atrial fibrillation, aortic stenosis, and thromboembolic disease all appear more often. Do not let DVT prophylaxis slide.

What to look for on the preop exam - Physical manifestations of insulin resistance are peripheral neuropathy, retinopathy, and acanthosis nigricans; listen for arterial bruits from atherosclerotic disease and look for xanthomas in dyslipidemia. Documenting a preexisting neuropathy before induction protects you when a positioning injury is later alleged.

Bariatric surgery is the most effective single therapy - Offered at BMI 40 or above, or 35 or above with comorbidities, so you will see these patients for laparoscopic adjustable gastric banding, Roux-en-Y bypass, and sleeve gastrectomy, and again later for nutritional and surgical complications.

Metabolic syndrome is the diagnosis when any three of the cluster are present — central adiposity by waist circumference, hypertension, elevated triglycerides, low HDL, and impaired glucose handling. The engine is visceral adipose tissue: enlarged fat releases tumor necrosis factor, leptin, resistin, and plasminogen activator inhibitor while adiponectin falls, producing insulin resistance plus a proinflammatory, prothrombotic state. Upper-body fat releases nonesterified fatty acids that deposit in liver and muscle and deepen the resistance. Downstream, endothelial dysfunction and hypertension give vascular stiffness, left ventricular hypertrophy and cardiomyopathy, renal impairment, and accelerated atherosclerosis; the liver runs from steatosis to steatohepatitis, fibrosis, and cirrhosis. Prevalence sits near a quarter of US adults, so this is a comorbidity you meet constantly rather than a rare syndrome.