2014

. .

, 55 , , ,

: 170 cm, : 89 kg, : 30.8 kg/m2, W: 110cm

. .:
..: 145/95 mmHg

:
Glu: 115mg/dl , U:35 , Cr:0,90, eGFR:96,51 , TChol:257mg/dl
HDL: 34mg/dl
LDL: 149 mg/dl , TG: 220 mg/dl , UA: 8.4 mg%,
: (-),ALT:128,AST:135,-GT:35

: , (48 )
2

 ,
,
()
()

, Reaven 1988,

 ()

VITA 2004

 ..

:
IGT
2
*

*Insulin resistance defined under

hyperinsulinemic, euglycemic
conditions as glucose uptake below
the lowest quartile for the background
population under investigation

:
IGT 2
*

140/90 mmHg

1.7 mmol/l or 150 mg/dl and/or
HDL
< 0.9 mmol/l or 35 mg/dl ();
< 1.0 mmol/l or 39 mg/dl ()

waist:hip ratio > 0.90 (), > 0.85
(); / BMI > 30 kg/m2

20 g/min
30 mg/g

World Health Organization. Definition, diagnosis and classification of diabetes mellitus and its complications.
Part I: Diagnosis and classification of diabetes mellitus. WHO Department of Noncommunicable Disease Surveillance; 1999.

NCEP:

> 102 cm (> 40 in)

> 88 cm (> 35 in)

150 mg/dl ( 1.70 mmol/l)

HDL

< 40 mg/dl (< 0.52 mmol/l)

< 50 mg/dl (< 1.29 mmol/l)

130/85 mmHg

110 mg/dl ( 6.12 mmol/l)

Some

males can develop multiple metabolic risk factors when the waist circumference is only marginally
increased, e.g. 94102 cm, and may have a strong genetic contribution to insulin resistance. They should
benefit from changes in life habits, similarly to men with categorical increases in waist circumference.
National Institutes of Health. Third report of the National Cholesterol Education Program (NCEP) Expert Panel on detection,
evaluation and treatment of high blood cholesterol in adults (Adult Treatment Panel III). Publication No. 02-5215: 2002.

 IDF

(mg/dl)

BMI (kg/m2)
W/H (/)
W (/, cm)
(mmHg)

WHO (1998)
IGT IR
& 2

NCEP ATP

/IFG/IGT

110

(2001)
3

IDF (2005)
W(cm): 94/80
& 2
100 2

30
> 0.9/0.85
> 102/88

140/90

130/85

130/85

HDL (/, mg/dl)

TG (mg/dl)

< 35/39
150

< 40/50
150

40/50
150

(g/min)

20-200

---

---

(mg/dl)

/IFG/IGT

110

100 2

Lipoprotein lipase

Agiotensinogen

IL-6

Inflammation

Hypertension
Insulin

TNF

Adipose

tissue

Adipsin
(Complement D)
Adiponectin

Atherosclerosis

FFA
Resistin
Leptin
Lactate

Plasminogen
activator inhibitor-1
(PAI-1)

Thrombosis
Lyon Endocrinology 2003; 144: 2195 -2200.
Trayhurn et al. Br. J Nutr. 2004; 92: 347- 55
Eckel et al. Lancet 2005; 365: 1415 -1428.

Atherogenic
dyslipidaemia

Type
2 diabetes

 -
NCEP-AHA/NHLBI vs IDF-EASD-EAS

NCEP

AHA/NHLBI

IDF

N=9,669

70

*=p<0.0001

60

*=p<0.0001

50

*
40

30

20

10
0
18-70+

18-29

30-39

40-49

50-59

60-69

70+

Athyros et al. Curr Med Res Opin 2005;21:1157-9.

Athyros et al. Int J Cardiol 2006

METABOLIC SYNDROME IN GREECE

Men

Women

Age

 & :
BOTNIA
(%)

P < 0.001
P < 0.001

P = 0.04

(N = 1808)

P = 0.06

(N = 685)

(N = 1430)

(N = 3928)

Isomaa B et al, Diabetes Care 2001; 24:683-689


(%)

, &
S

% =

-/ -

M+/-

M-/+

M+/+

54.2%

28.7%

2.3%

14.8%

Alexander CM et al, Diabetes 2003; 52:1210-1214

Whatever The
Definition, The
Metabolic Syndrome
Increases 1.5 to 2fold The Risk of CV
Events

Dekker JM, et al. (Hoorn study). Circulation 2005;112:666-673.

 &
Metabolic Syndrome Carries Increased
Risk for both CHD and Stroke

Schmidt MI, et al. (ARIC study) Diabetes Care 2005;28:385-390.

,

(, , )

1. ;
2. ;
3. ;
4. ;

2
OGTT

(mg/dl)

(mg/dl)

126

200

(IFG)

100 - 125

< 140

(IGT)

< 126

140 - 199

OGTT
:114mg/dl
2 75 gr
:135mg/dl
IFG( )

ADA: 2014
.


(7% . )
(150 /)

()

(14 gr. /.)
grains ()
()
metformin 2
IGT (), IFG () 1C 5.7-6.4 ()
<60 ,>35
()



A, ,



/

E ,
Ludwig 1980




20-25%

-
(M) 2-7% (10-25% )

90%
( )

1, 2:


2

HDL


~ 90% 3

Buglanesi E et al. Hepatology 2005;42:987-1000.

G et al. Hepatology 2003;37:917-923.
3 Hamaguchi M et al. Ann Intern Med 2005;143:722-728.
2 Marchesisni

NAFLD <> MS
MS 2637% >x3 ..
MS NAFLD > control

NAFLD
56-63% >3x ..
(18%)

IDF

NAFLD

Non- NAFLD

437

1957

161
(36.84%)

105 (5.37%)

114
NCEP/ATP
III NAFLD 89

MS(4.55%)
> control
(26.09%)

Journal of Digestive Diseases 2011; 12; 125130

TNFx

STRESS
/

,
BA Neushwander-Tetri.

77%

( )

McCullough AJ. J Clin Gastroenterol. 2002:34:255-262.

ALT, AST 50% <200 U/L

AST/ALT <1
AST/ALT >1
ALP, -GT =2-3 50%

50%,



<25%
/

U/S ()
screening
,
NAFLD

> ,
U/S


RadioGraphics 2006; 26:16371653

Normal

NAFLD

Digestive and Liver Disease 2010;42:272282

2012

AGA

NAFLD

.(1)
+ NAFLD Fibrosis Score
NAFLD

. (1)
NAFLD



.

6. ()

NASH

NASH
>5%10%

T Masson
Cs +

Proceedings of Singapore Healthcare 2010;19:1

31%

28%
13%
J Hepatol 2008; 48: S5-S5 Gastroenterology 2005; 129: 113-121

15 , 7
Hepatology 2011; 54: 145-152

Hui et al, Hepatology 2003, Ratziu et al, Hepatology 2003


A
NAFLD


ALT
ALT







(,
-, )

LF (AGA 2012)

(+/- )
.

(1)

3-5%
. ( 10%)

/.
(1)

500

gr/ 1600 gr

(>150
/.)


St George et al, 2009


ESH/ESC2014

1
2
3

(mmHg)

<120
120-129
130-139
140-159
160-179
180
140

/
/
/
/
/
/

<80
80-84
85-89
90-99
100-109
110
<90

 &
Moderate weight loss with a very low calories diet in
obese patients with the metabolic syndrome markedly improves
all aspects of the metabolic syndrome

Esposito K, et al. JAMA 2004;292:1440-1446.


5001000/ - 5-10% 6-12

<25-35% ,
, , ,

(< 2,4 g/)
( < 2
/, < 1 /)
Grundy SM et al. Circulation
2005;112:2735-52


,
, , , -3

.

.

Rumawas MEet al. Mediterranean-style dietary pattern, reduced risk of metabolic syndrome traits, and
incidence in the Framingham Offspring Cohort. Am J Clin Nutr 2009; 90:16081614.
Aizawa K, Shoemaker JK, Overend TJ, Petrella RJ. Effects of lifestyle modification
on central artery stiffness in metabolic syndrome subjects with prehypertension
and/or prediabetes. Diab Res Clin Pract 2009; 83:249256.
DeLorgeril M, et al.Mediterranean diet, traditional risk factors, and the rate of cardiovascular
complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation 1999;
99:779785.


30 min
45-60 min. 5

AHA 2 ( )
.
( ) , HbA1c

( )
,HDL, LDL .


?
.
.
. -
ACEIs ARBs
. (-Blockers)

2013 ESH, ESC Guidelines:

Treatment strategies in hypertensive patients with
metabolic syndrome or prediabetes

G. Mancia et al EHJ June 2013



:
LDL <70 mg/dl
LDL<100 mg/dl
:
LDL TG>200 mg/dl
Non-HDL (ATP)
: HDL
>40 mg/dl >50 mg/dl

(/)

( ,
).

.
Bader Ted Am J Gastroenterol 2010; 105: 978-980



. J Hepatol
2012; 56: 305-7
,

10-30%


NAFLD

CVD

The Greek Atorvastatin and

Coronary Heart Disease
Evaluation (GREACE)
CHD, <75ys, Tg<400mg/dL, LDL>100mg/dL

437 <3
( NAFLD)

vs placebo 3ys

10% VS 30% (p<0.0001)
Lancet. 2010 ;376:1916-22

TG:
- ,
-

TG
-
-
- -3
TG:
-
- ( )
- (
- )
TG
(>500mg/dl)

:
-

(TG, HDL-C)
-

- TG (LDL-C)

ESC GUIDELINES 2012

Recommendations on antithrombotic therapy

EHJ 2012;33(12):1635-1701

 ADA EASD

,
,

..

.

Statement ADA and EASD

Diabetes Care 2005; 28: 2289 -2304

Kahn R. Diabetes Care 2006; 29:1693-1696




300 mgr
E 40 mgr

(kg)

Mean
Change
Sib
(n=397)
-6.4

Mean
change
Placebo
(n=200)
0.2

-2.3

0.0

P
value

<0.00
1
<0.00
1
<0.00
1
<0.00
1
<0.00

BMI (kg/m2)
WC (cm)
TG (mg/dL)
HDL (mg/dL)
SBP (mmHg)

-9.6

-3.9

-69.1

-24.2

+6.7

+3.8

+0.4

-1.5

1
0.206

DBP (mmHg)

+0.3

-0.4

0.103

Fujioka K et al Obesity Research 2003, 452 P

.
( LDL)
.
.
( LDL)

National Lipid Associations Safety Task Force:

Cohen DE, et al. Am J Cardiol. 2006;97(8 suppl 1):S77-S81.

(kg)

Mean
Change
Sib
(n=397)
-6.4

Mean
change
Placebo
(n=200)
0.2

-2.3

0.0

P
value

<0.00
1
<0.00
1
<0.00
1
<0.00
1
<0.00

BMI (kg/m2)
WC (cm)
TG (mg/dL)
HDL (mg/dL)
SBP (mmHg)

-9.6

-3.9

-69.1

-24.2

+6.7

+3.8

+0.4

-1.5

1
0.206

DBP (mmHg)

+0.3

-0.4

0.103

Fujioka K et al Obesity Research 2003, 452 P



/


.
Atherosclerosis 2007; 191 : 235240

: ALT, AST
Usu <4 x
78% NAFLD ..

Hepatology

2004:40:13871395

Gastroenterology 2008:134;16821698

AST/ALT<1 : AST/ALT>1
Hepatology 1999:30;13561362

GT ,
Hepatology 2009; 50:14031411
Gastroenterology 2009;136:477485

GT>96.5 U/L
83%
69%

Hepato-Gastroenterology 2008;55:1433-8

 LDL-C:
ESC/EAS 2011

EHJ 2011;32:1769-1818

2013 ESH, ESC Guidelines:

Treatment strategies in hypertensive patients with
metabolic syndrome or prediabetes

G. Mancia et al EHJ June 2013

.
Bader Ted Am J Gastroenterol 2010; 105: 978-980



. J Hepatol
2012; 56: 305-7
,

10-30%


(Consensus definition)
:

(population and ethnicity specific)

150 mg/dl
HDL-C <40 mg/dl <50 mg/dl
130/85mmHg
100 mg/dl

International Diabetes Federation Task Force on Epidemiology and Prevention;

National Heart, Lung, and Blood Institute; American Heart Association; World Heart
Federation; International Atherosclerosis Society; and International Association for
the Study of Obesity.

.
/


.
Framingham scoring 45
55 .
.

 &
Physical activity is negatively related to the presence of
metabolic syndrome

Mohan V, et al. (CUPS n 15). Diabet Met 2005;22:1206-1211.

-

300 mgr
E 40 mgr
E 2



Statement AHA -NHLBI

:
:
: LDL

High risk <100 mg/dl

Very high risk + <70 mg/dl
high risk+ <130 mg/dl

: non HDL Very high risk + <100 mg/dl

high risk + < 130 mg/dl
: HDL

Lifestyle . HDL

.:

<140/ 90 mmHg & <130/ 80

. .
.

IFG lifestyle .
. . . 1C <7%.

-
..
CVD clopidogrel
.
Circulation 2008; 112: 2735

 LDL-C:
ESC/EAS 2011

EHJ 2011;32:1769-1818


( LDL-C
> 500 mg/dl nonHDL-C
> 200 mg/dl)
(
10
> 20%)
Athyros
(
):
VG et al. Metabolism 2005;54:1065-74
HbA1c < 7%Athyros VG et al. Curr Med Res Opin 2009;25:971-80


ALT

Dallas Heart Study

Hepatology 2006;44:466-471

J Hepatol 2007:47:135-141
Hepatology 2007;46:1453-63

Atherosclerosis 2004;174:193-6

J Gastrointest Liv Dis 2007;16:39-46

J
Gastroenterol 2010;45:750-7

16 NASH 12



-
=

77%

McCullough AJ. J Clin Gastroenterol. 2002:34:255-262.

AST
50%
<200 U/L
ALT,

<1
AST/ALT

AST/ALT
>1

ALP,
-GT =2-3 50%

( )

50%,




National Lipid Associations Safety Task Force:

Cohen DE, et al. Am J Cardiol. 2006;97(8 suppl 1):S77-S81.

.
Bader Ted Am J Gastroenterol 2010; 105: 978-980



. J Hepatol
2012; 56: 305-7
,

10-30%

ALT

Horlander

12

Nair

13

Kiyici

27

Rallidis

10%

2

4.3 (V)
APRI (AST to Platelet Ratio Index)
HCV

<0.3
0.5
1.5 .

6. ()
NAFLD vs NASH gold
standard