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Editor's Message  |   May 2009
Cardiometabolic Risk
Author Notes
  • Dr Strobl is professor and chairman, Cardiology Section, Department of Internal Medicine, Michigan State University College of Osteopathic Medicine, and director, Heart Disease Prevention Clinic, Thoracic Cardiovascular Institute in Lansing, Mich. 
  • Correspondence to David J. Strobl, DO, Thoracic and Cardiovascular Institute, 405 W Greenlawn, Suite 220, Lansing, MI 48910-2889. 
Article Information
Preventive Medicine
Editor's Message   |   May 2009
Cardiometabolic Risk
The Journal of the American Osteopathic Association, May 2009, Vol. 109, ii-S1. doi:
The Journal of the American Osteopathic Association, May 2009, Vol. 109, ii-S1. doi:
Back in 1970, Norman M. Kaplan, MD, first described a cluster of cardiac risk factors beyond elevated low-density lipoprotein cholesterol (LDL-C), which he coined “The Deadly Quartet”: abdominal obesity, hypertension, hypertriglyceridemia, and glucose intolerance.1 Later, in 1988, Gerald M. Reavan, MD, an endocrinologist from Stanford University Medical Center in California, expanded this constellation of associated cardiovascular risks and termed it “Syndrome X.”2 
Similar to Kaplan, Reavan included abdominal adiposity (increased waist-to-hip ratio), increased peripheral resistance (hypertension), and hypertriglyceridemia (triglyceride concentration >150 mg/dL). However, Reaven also included depressed high-density lipoprotein cholesterol (HDL-C; <40 mg/dL) and the presence of pattern B LDL-C phenotype (small, dense LDL particles). Reaven thought that at the core of this complex of cardiovascular risks was insulin resistance. This constellation of risk factors is now more commonly known as “metabolic syndrome” after an expert panel highlighted it in the Adult Treatment Panel (ATP) III guidelines published in 2001.3 
Our understanding of residual metabolic risk beyond elevated LDL-C levels is reflected in the evolution of the ATP guidelines.3 When the original ATP treatment guidelines were published in 1988,4 diabetes was simply viewed as one of the coronary risk factors considered in determining one's LDL-C goal. However, in ATP II (published in 1993),5 our paradigm of treatment changed with the designation of diabetes as a coronary artery disease risk equivalent. However, it soon became clear that there was a large group of patients in whom the LDL-C level was near goal, but significant cardiac risk was still present. Thus ATP III (published in 2001)3 recommended screening our patients for metabolic syndrome, which some experts thought is a pre-diabetic state. 
The articles in this supplement to JAOA—The Journal of the American Osteopathic Association are based on presentations at a symposium titled “Managing the Whole Patient: An In-depth Look at Key Factors of Metabolic Risk.” This program was held on October 29, 2008, at the AOA's 113th Annual Convention and Scientific Seminar in Las Vegas, Nev. James Gavin III, MD, PhD, moderated the program and properly described our current trend toward obesity and the resulting metabolic syndrome as an “epidemic.” 
In the first article in this supplement, Kelly Anne Spratt, DO, focuses on both nonpharmacologic and drug therapy for diabetic dyslipidemia and provides a useful algorithm for treatment of these challenging patients. Next, Craig W. Spellman, DO, PhD, provides what, in my opinion, is one of the best summaries on glycemic control in metabolic syndrome and patients with diabetes that I have reviewed. 
In the final article in this supplement with its emphasis on osteopathic medicine's practice of treating the whole patient, Thomas A. Haffey, DO, provides a compelling argument for comprehensive management of risk factors. He methodically tackles each intervention with an evidence-based approach. And, concluding this supplement is an illustrative case presentation developed from the transcript of introductory and concluding remarks by Dr Gavin during the symposium. 
I hope you enjoy this supplement and appreciate the efforts of each of the authors to enhance your understanding of the metabolic syndrome and the whole patient approach to its management to prevent major cardiovascular events. 
 Dr Strobl serves on advisory committees (consulting fees) and/or is on the national speakers bureau (honorariums) for the following companies: Abbott Laboratories, AstraZeneca United States, Merck/Schering-Plough Pharmaceuticals, and Novartis Pharmaceuticals Corporation.
 
Kaplan NM. The deadly quartet. Upper-body obesity, glucose intolerance, hypertriglyceridemia, and hypertension. Arch Intern Med. 1989;149:1514-1520.
Reaven GM. Banting lecture 1988. Role of insulin resistance in human disease. Diabetes. 1988;37:1595-1607.
Third Report of the National Cholesterol Education Program Expert (NCEP) Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Final Report. Bethesda, Md: National Institutes of Health, National Heart, Lung, and Blood Institute; NIH Publication No. 02-5215; September 2002. Available at: http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdf. Accessed April 24, 2009.
National Cholesterol Education Program. High Blood Cholesterol in Adults: Report of the Expert Panel on Detection, Evaluation, and Treatment. Bethesda, Md: National Institutes of Health, National Heart, Lung, and Blood Institute; NIH Publication No. 88-2925;1988 .
National Cholesterol Education Program. Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Bethesda, Md: National Institutes of Health, National Heart, Lung, and Blood Institute; NIH Publication No. 93-3095; 1993.