Endocrine Society recently published new guidelines on metabolic risk. Metabolic risk is characterized similarly to metabolic syndrome (syndrome X) but with the name change to emphasize action rather than description. Presence of three or more of the following entities defines high metabolic risk: high blood pressure, high glucose, high triglycerides, low HDLc, and increased waist circumference.

Although guidelines are similar to those of other national association such as ACC/AHA, ADA, AACE, and NLA; they introduce or emphasize the following elements:

In individuals with blood pressure >130/80 mmHg and a 10YR ≤10%, we suggest lifestyle management to lower blood pressure to <130/80 mmHg and to reduce the risk for ASCVD.
In individuals without a history of ASCVD with metabolic risk who have a 10-year cardiovascular risk of >10% and blood pressure of >130/80 mmHg, we suggest the use of blood pressure–lowering medication in addition to lifestyle modifications for primary prevention of ASCVD only when lifestyle modification alone has failed.

Preventing Type 2 diabetes

In individuals with prediabetes, we recommend prescribing lifestyle modification before drug therapy to reduce plasma glucose levels.
In individuals with prediabetes who have limitations to physical activity or are not responding to lifestyle modifications, we recommend metformin as a first pharmacologic approach to reduce plasma glucose levels.

In individuals 40 to 75 years of age without diabetes and a 10-year risk ≥7.5%, we recommend high-intensity statin therapy either to achieve a LDLc goal <100 mg/dL or a LDLc reduction of ≥50%.
In individuals 40 to 75 years of age without diabetes and a 10-year risk of 5-7.5%, we recommend moderate statin therapy as an option after consideration of risk reduction, adverse events, drug interactions, and individual preferences, to achieve either a LDLc goal <130 mg/dL or a LDLc reduction of 30% to 50%.
In individuals with metabolic risk, without diabetes, on statin therapy, we suggest monitoring glycemia at least annually to detect new-onset diabetes mellitus.
In individuals aged >75 years without diabetes and a 10-year risk ≥7.5%, we recommend discussing the benefits of statin therapy with the patient based on expected benefits vs possible risks/side effects.
In individuals at metabolic risk who are taking statins with adequate LDLc reduction, elevated triglyceride levels [≥200 mg/dL], and reduced HDLc [≤50 mg/dL in females, or ≤40 mg/dL in males], we suggest considering fenofibrate adjunct therapy.
In individuals ≥40 years of age at metabolic risk with LDLc at target, an estimated 10-year ASCVD risk >7.5%, and without clinical ASCVD or other ASCVD risk factors, we suggest treatment with a moderate-intensity statin.

Blood pressure reduction

In individuals with blood pressure >130/80 mmHg and a 10YR ≤10%, we suggest lifestyle management to lower blood pressure to <130/80 mmHg and to reduce the risk for ASCVD.
In individuals without a history of ASCVD with metabolic risk who have a 10-year cardiovascular risk of >10% and blood pressure of >130/80 mmHg, we suggest the use of blood pressure–lowering medication in addition to lifestyle modifications for primary prevention of ASCVD only when lifestyle modification alone has failed.

Preventing Type 2 diabetes

In individuals with prediabetes, we recommend prescribing lifestyle modification before drug therapy to reduce plasma glucose levels.
In individuals with prediabetes who have limitations to physical activity or are not responding to lifestyle modifications, we recommend metformin as a first pharmacologic approach to reduce plasma glucose levels.

In individuals identified as having metabolic risk, we recommend global assessment of 10-year risk for either CHD or ASCVD to guide the use of medical or pharmacological therapy.
In individuals with LDLc ≥190 mg/dL or TGs ≥500 mg/dL, we recommend ruling out secondary causes of hyperlipidemia. If a secondary cause can be excluded, primary hyperlipidemia should be suspected.

Cholesterol Reduction

In individuals 40 to 75 years of age with LDLc ≥190 mg/dL, we recommend high-intensity statin therapy to achieve a LDLc reduction of ≥50%.
In individuals 40 to 75 years of age with LDLc 70-189 mg/dL, we recommend a 10-year risk for ASCVD should be calculated.
- In individuals 40 to 75 years of age without diabetes and a 10-year risk ≥7.5%, we recommend high-intensity statin therapy either to achieve a LDLc goal <100 mg/dL or a LDLc reduction of ≥50%.
- In individuals 40 to 75 years of age without diabetes and a 10-year risk of 5-7.5%, we recommend moderate statin therapy as an option after consideration of risk reduction, adverse events, drug interactions, and individual preferences, to achieve either a LDLc goal <130 mg/dL or a LDLc reduction of 30% to 50%.
- In individuals with metabolic risk, without diabetes, on statin therapy, we suggest monitoring glycemia at least annually to detect new-onset diabetes mellitus.
- In individuals aged >75 years without diabetes and a 10-year risk ≥7.5%, we recommend discussing the benefits of statin therapy with the patient based on expected benefits vs possible risks/side effects.
- In individuals at metabolic risk who are taking statins with adequate LDLc reduction, elevated triglyceride levels [≥200 mg/dL], and reduced HDLc [≤50 mg/dL in females, or ≤40 mg/dL in males], we suggest considering fenofibrate adjunct therapy.
- In individuals ≥40 years of age at metabolic risk with LDLc at target, an estimated 10-year ASCVD risk >7.5%, and without clinical ASCVD or other ASCVD risk factors, we suggest treatment with a moderate-intensity statin.

Blood pressure reduction

In individuals with blood pressure >130/80 mmHg and a 10YR ≤10%, we suggest lifestyle management to lower blood pressure to <130/80 mmHg and to reduce the risk for ASCVD.
In individuals without a history of ASCVD with metabolic risk who have a 10-year cardiovascular risk of >10% and blood pressure of >130/80 mmHg, we suggest the use of blood pressure–lowering medication in addition to lifestyle modifications for primary prevention of ASCVD only when lifestyle modification alone has failed.

Preventing Type 2 diabetes

In individuals with prediabetes, we recommend prescribing lifestyle modification before drug therapy to reduce plasma glucose levels.
In individuals with prediabetes who have limitations to physical activity or are not responding to lifestyle modifications, we recommend metformin as a first pharmacologic approach to reduce plasma glucose levels.

In individuals at metabolic risk, we recommend that lifestyle modification be first-line therapy.
For individuals at metabolic risk with excess weight (defined by BMI and/or WC), we recommend that comprehensive programs to support the adoption of a healthy lifestyle should aim to achieve a weight loss of ≥5% of initial body weight during the first year.
In individuals at metabolic risk, we recommend prescribing a cardiovascular-healthy diet.
In individuals at metabolic risk, we recommend prescribing daily physical activity, such as brisk walking, and reduction in sedentary time.

Pharmacological therapy

In individuals identified as having metabolic risk, we recommend global assessment of 10-year risk for either CHD or ASCVD to guide the use of medical or pharmacological therapy.
In individuals with LDLc ≥190 mg/dL or TGs ≥500 mg/dL, we recommend ruling out secondary causes of hyperlipidemia. If a secondary cause can be excluded, primary hyperlipidemia should be suspected.

Cholesterol Reduction

In individuals 40 to 75 years of age with LDLc ≥190 mg/dL, we recommend high-intensity statin therapy to achieve a LDLc reduction of ≥50%.
In individuals 40 to 75 years of age with LDLc 70-189 mg/dL, we recommend a 10-year risk for ASCVD should be calculated.
- In individuals 40 to 75 years of age without diabetes and a 10-year risk ≥7.5%, we recommend high-intensity statin therapy either to achieve a LDLc goal <100 mg/dL or a LDLc reduction of ≥50%.
- In individuals 40 to 75 years of age without diabetes and a 10-year risk of 5-7.5%, we recommend moderate statin therapy as an option after consideration of risk reduction, adverse events, drug interactions, and individual preferences, to achieve either a LDLc goal <130 mg/dL or a LDLc reduction of 30% to 50%.
- In individuals with metabolic risk, without diabetes, on statin therapy, we suggest monitoring glycemia at least annually to detect new-onset diabetes mellitus.
- In individuals aged >75 years without diabetes and a 10-year risk ≥7.5%, we recommend discussing the benefits of statin therapy with the patient based on expected benefits vs possible risks/side effects.
- In individuals at metabolic risk who are taking statins with adequate LDLc reduction, elevated triglyceride levels [≥200 mg/dL], and reduced HDLc [≤50 mg/dL in females, or ≤40 mg/dL in males], we suggest considering fenofibrate adjunct therapy.
- In individuals ≥40 years of age at metabolic risk with LDLc at target, an estimated 10-year ASCVD risk >7.5%, and without clinical ASCVD or other ASCVD risk factors, we suggest treatment with a moderate-intensity statin.

Blood pressure reduction

In individuals with blood pressure >130/80 mmHg and a 10YR ≤10%, we suggest lifestyle management to lower blood pressure to <130/80 mmHg and to reduce the risk for ASCVD.
In individuals without a history of ASCVD with metabolic risk who have a 10-year cardiovascular risk of >10% and blood pressure of >130/80 mmHg, we suggest the use of blood pressure–lowering medication in addition to lifestyle modifications for primary prevention of ASCVD only when lifestyle modification alone has failed.

Preventing Type 2 diabetes

In individuals with prediabetes, we recommend prescribing lifestyle modification before drug therapy to reduce plasma glucose levels.
In individuals with prediabetes who have limitations to physical activity or are not responding to lifestyle modifications, we recommend metformin as a first pharmacologic approach to reduce plasma glucose levels.

In individuals aged 40 to 75 years in the office setting, we suggest providers screen for all five components of metabolic risk at the clinical visit. The finding of at least three components should specifically alert the clinician to a patient at metabolic risk = at higher risk for ASCVD and DM2).
In individuals aged 40 to 75 years in the office setting who do not yet have ASCVD or DM2 and already have at least one risk factor, we advise screening every 3 years for all five components of metabolic risk as part of the routine clinical examination.
To establish metabolic risk in the general population, we recommend that clinicians measure waist circumference as a routine part of the clinical examination.
In individuals previously diagnosed with prediabetes, we suggest testing at least annually for the presence of overt type 2 diabetes mellitus (DM2).
We recommend that all individuals at metabolic risk in the office setting have their blood pressure measured annually and, if elevated, at each subsequent visit.
For individuals with elevated blood pressure >130/80 mmHg who are not documented as having a history of hypertension, we recommend confirmation of elevated blood pressure on a separate day within a few weeks or with a home blood pressure monitor.

Lifestyle

In individuals at metabolic risk, we recommend that lifestyle modification be first-line therapy.
For individuals at metabolic risk with excess weight (defined by BMI and/or WC), we recommend that comprehensive programs to support the adoption of a healthy lifestyle should aim to achieve a weight loss of ≥5% of initial body weight during the first year.
In individuals at metabolic risk, we recommend prescribing a cardiovascular-healthy diet.
In individuals at metabolic risk, we recommend prescribing daily physical activity, such as brisk walking, and reduction in sedentary time.

Pharmacological therapy

In individuals identified as having metabolic risk, we recommend global assessment of 10-year risk for either CHD or ASCVD to guide the use of medical or pharmacological therapy.
In individuals with LDLc ≥190 mg/dL or TGs ≥500 mg/dL, we recommend ruling out secondary causes of hyperlipidemia. If a secondary cause can be excluded, primary hyperlipidemia should be suspected.

Cholesterol Reduction

In individuals 40 to 75 years of age with LDLc ≥190 mg/dL, we recommend high-intensity statin therapy to achieve a LDLc reduction of ≥50%.
In individuals 40 to 75 years of age with LDLc 70-189 mg/dL, we recommend a 10-year risk for ASCVD should be calculated.
- In individuals 40 to 75 years of age without diabetes and a 10-year risk ≥7.5%, we recommend high-intensity statin therapy either to achieve a LDLc goal <100 mg/dL or a LDLc reduction of ≥50%.
- In individuals 40 to 75 years of age without diabetes and a 10-year risk of 5-7.5%, we recommend moderate statin therapy as an option after consideration of risk reduction, adverse events, drug interactions, and individual preferences, to achieve either a LDLc goal <130 mg/dL or a LDLc reduction of 30% to 50%.
- In individuals with metabolic risk, without diabetes, on statin therapy, we suggest monitoring glycemia at least annually to detect new-onset diabetes mellitus.
- In individuals aged >75 years without diabetes and a 10-year risk ≥7.5%, we recommend discussing the benefits of statin therapy with the patient based on expected benefits vs possible risks/side effects.
- In individuals at metabolic risk who are taking statins with adequate LDLc reduction, elevated triglyceride levels [≥200 mg/dL], and reduced HDLc [≤50 mg/dL in females, or ≤40 mg/dL in males], we suggest considering fenofibrate adjunct therapy.
- In individuals ≥40 years of age at metabolic risk with LDLc at target, an estimated 10-year ASCVD risk >7.5%, and without clinical ASCVD or other ASCVD risk factors, we suggest treatment with a moderate-intensity statin.

Blood pressure reduction

In individuals with blood pressure >130/80 mmHg and a 10YR ≤10%, we suggest lifestyle management to lower blood pressure to <130/80 mmHg and to reduce the risk for ASCVD.
In individuals without a history of ASCVD with metabolic risk who have a 10-year cardiovascular risk of >10% and blood pressure of >130/80 mmHg, we suggest the use of blood pressure–lowering medication in addition to lifestyle modifications for primary prevention of ASCVD only when lifestyle modification alone has failed.

Preventing Type 2 diabetes

In individuals with prediabetes, we recommend prescribing lifestyle modification before drug therapy to reduce plasma glucose levels.
In individuals with prediabetes who have limitations to physical activity or are not responding to lifestyle modifications, we recommend metformin as a first pharmacologic approach to reduce plasma glucose levels.

Should measure waist circumference routinely.
Include A1c in the definition of metabolic risk (vs. fasting glucose only).
Be more aggressive in using statin therapy for primary prevention.
Can add fenofibrate rather than ezetimibe if triglycerides are above 200 mg/dL and HDLc is low.

These guidelines are essential as they further raise awareness of the real cardiovascular and diabetes risk associated with metabolic syndrome, and more importantly encouraging providers to act upon it.

I anticipate elaboration and incorporation of the above critical changes in other national guidelines. Prevention, always first.

Also see:

J C E M

ES Guidelines

September 2019

Diagnosis

In individuals aged 40 to 75 years in the office setting, we suggest providers screen for all five components of metabolic risk at the clinical visit. The finding of at least three components should specifically alert the clinician to a patient at metabolic risk = at higher risk for ASCVD and DM2).
In individuals aged 40 to 75 years in the office setting who do not yet have ASCVD or DM2 and already have at least one risk factor, we advise screening every 3 years for all five components of metabolic risk as part of the routine clinical examination.
To establish metabolic risk in the general population, we recommend that clinicians measure waist circumference as a routine part of the clinical examination.
In individuals previously diagnosed with prediabetes, we suggest testing at least annually for the presence of overt type 2 diabetes mellitus (DM2).
We recommend that all individuals at metabolic risk in the office setting have their blood pressure measured annually and, if elevated, at each subsequent visit.
For individuals with elevated blood pressure >130/80 mmHg who are not documented as having a history of hypertension, we recommend confirmation of elevated blood pressure on a separate day within a few weeks or with a home blood pressure monitor.

Lifestyle

In individuals at metabolic risk, we recommend that lifestyle modification be first-line therapy.
For individuals at metabolic risk with excess weight (defined by BMI and/or WC), we recommend that comprehensive programs to support the adoption of a healthy lifestyle should aim to achieve a weight loss of ≥5% of initial body weight during the first year.
In individuals at metabolic risk, we recommend prescribing a cardiovascular-healthy diet.
In individuals at metabolic risk, we recommend prescribing daily physical activity, such as brisk walking, and reduction in sedentary time.

Pharmacological therapy

In individuals identified as having metabolic risk, we recommend global assessment of 10-year risk for either CHD or ASCVD to guide the use of medical or pharmacological therapy.
In individuals with LDLc ≥190 mg/dL or TGs ≥500 mg/dL, we recommend ruling out secondary causes of hyperlipidemia. If a secondary cause can be excluded, primary hyperlipidemia should be suspected.

Cholesterol Reduction

In individuals 40 to 75 years of age with LDLc ≥190 mg/dL, we recommend high-intensity statin therapy to achieve a LDLc reduction of ≥50%.
In individuals 40 to 75 years of age with LDLc 70-189 mg/dL, we recommend a 10-year risk for ASCVD should be calculated.
- In individuals 40 to 75 years of age without diabetes and a 10-year risk ≥7.5%, we recommend high-intensity statin therapy either to achieve a LDLc goal <100 mg/dL or a LDLc reduction of ≥50%.
- In individuals 40 to 75 years of age without diabetes and a 10-year risk of 5-7.5%, we recommend moderate statin therapy as an option after consideration of risk reduction, adverse events, drug interactions, and individual preferences, to achieve either a LDLc goal <130 mg/dL or a LDLc reduction of 30% to 50%.
- In individuals with metabolic risk, without diabetes, on statin therapy, we suggest monitoring glycemia at least annually to detect new-onset diabetes mellitus.
- In individuals aged >75 years without diabetes and a 10-year risk ≥7.5%, we recommend discussing the benefits of statin therapy with the patient based on expected benefits vs possible risks/side effects.
- In individuals at metabolic risk who are taking statins with adequate LDLc reduction, elevated triglyceride levels [≥200 mg/dL], and reduced HDLc [≤50 mg/dL in females, or ≤40 mg/dL in males], we suggest considering fenofibrate adjunct therapy.
- In individuals ≥40 years of age at metabolic risk with LDLc at target, an estimated 10-year ASCVD risk >7.5%, and without clinical ASCVD or other ASCVD risk factors, we suggest treatment with a moderate-intensity statin.

Blood pressure reduction

In individuals with blood pressure >130/80 mmHg and a 10YR ≤10%, we suggest lifestyle management to lower blood pressure to <130/80 mmHg and to reduce the risk for ASCVD.
In individuals without a history of ASCVD with metabolic risk who have a 10-year cardiovascular risk of >10% and blood pressure of >130/80 mmHg, we suggest the use of blood pressure–lowering medication in addition to lifestyle modifications for primary prevention of ASCVD only when lifestyle modification alone has failed.

Preventing Type 2 diabetes

In individuals with prediabetes, we recommend prescribing lifestyle modification before drug therapy to reduce plasma glucose levels.
In individuals with prediabetes who have limitations to physical activity or are not responding to lifestyle modifications, we recommend metformin as a first pharmacologic approach to reduce plasma glucose levels.