VANCOUVER, B.C. — Nearly a third of primary care patients met criteria for metabolic syndrome, yet just 1% had the powerful risk indicator noted in their charts, according to a cross-sectional audit of records from 30 primary care practices in Rhode Island.
“Metabolic syndrome is highly prevalent but seldom diagnosed,” concluded the authors of a poster presented at the annual meeting of the North American Primary Care Research Group.
The investigators found the cluster of factors defining metabolic syndrome in the charts of 32% (1,348) of 4,240 patients aged 20–80 years, but only 50 patients' charts reflected that diagnosis.
Subclinical metabolic syndrome—the term used to designate patients who lack diagnosed hypertension, diabetes, or hyperlipidemia, but who otherwise met criteria for the syndrome—was found in 113 patient charts (3%), reported Dr. David Anthony and his associates from the department of family medicine at Brown University, Providence, R.I., and the Brown University Center for Primary Care and Prevention.
Failure to recognize metabolic syndrome in the chart may have serious consequences, because it is intended to alert physicians to patients who may be at high risk of diabetes and cardiovascular disease based on a “perfect storm” of risk factors.
However, Dr. Anthony said in an interview that the low rate of metabolic syndrome diagnosis in charts may reflect the fact that the concept is “confusing and ultimately not helpful to primary care docs in communicating with their patients.”
“Primary care physicians have effective means of communicating cardiovascular risk using the Framingham risk score, but lack the same for diabetes risk,” he said.
“Metabolic syndrome attempts to combine the two in a way that is confusing to patients and doctors alike. What primary care docs really need is an effective and accurate predictor of a patient's risk of developing diabetes, along with useful tools for communicating that risk to their patients, so they can make good decisions about their health behaviors such as diet and exercise.”
Dr. Anthony and his associates used data from the Cholesterol Education and Research Trial to examine findings in patients' charts that would merit a diagnosis of metabolic syndrome according to the National Cholesterol Education Program, including three of the following five factors:
▸ Systolic blood pressure of less than 130 mm Hg, or diagnosed hypertension in the chart.
▸ Serum triglyceride level of 150 mg/dL or higher, adjusted for lipid medications in the study.
▸ HDL cholesterol level less than 40 mg/dL in men or less than 50 mg/dL in women, adjusted for lipid medications in the study.
▸ Fasting glucose of 110 mg/dL or higher, or diagnosed diabetes in the chart.
▸ Waist circumference greater than 102 cm in men or 88 cm in women, approximated from the body mass index for study purposes, according to the third National Health and Nutrition Examination Survey (NHANES III) adjustments.
Analysis showed that patients with metabolic syndrome in the study were older than those without the diagnosis (mean age 57 vs. 51 years); had a higher BMI (33 vs. 26 kg/m
Among patients with metabolic syndrome, 80% had hyperlipidemia, 73% had hypertension, and 26% had diabetes—rates significantly higher than those in the nonmetabolic syndrome population (P less than .001).
Their lipids were worse than those of nonmetabolic syndrome patients by every measure. They also were more likely to have gastroesophageal reflux disease and depression, and were significantly less likely to be physically active. In addition, they were slightly more likely to be smokers than were the nonmetabolic syndrome patients (15% vs. 12%), although this difference was not significant.
They were more likely to have received a referral to a nutritionist, been advised to increase their physical activity, and been counseled about smoking cessation, yet they were less likely to be at cholesterol or blood pressure goals than were patients without metabolic syndrome.
There was a stepwise increase by age in the percentage of patients who met criteria for metabolic syndrome: 19% of patients aged 40–49 years, 34% of those aged 50–59 years, 41% of those aged 60–69 years, and 48% of patients aged 70 years or older.
It is noteworthy that the metabolic syndrome patients were no more likely than were other patients to have a family history of early coronary artery disease.
The authors noted that most patients with metabolic syndrome had other major cardiovascular risk factors, which may have served to alert their physicians to their overall cardiometabolic risk, even when the metabolic syndrome diagnosis was missed.
Patients with subclinical metabolic syndrome may be less well recognized as being at elevated risk of diabetes and cardiovascular disease, because they may lack the telltale diagnoses of hypertension, diabetes, and hyperlipidemia, although they have other important risk factors.