2013 Accreditation

Physician Credit
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Medical Education Resources and HealthScience Media, Inc. Medical Education Resources is accredited by the ACCME to provide continuing medical education for physicians.

Credit Designation
Medical Education Resources designates this live activity for a maximum of 27.75 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AAFP (American Academy of Family Physicians) Credit
This live activity, 2013 Cardiometabolic Health Congress, with a beginning date of October 2, 2013, has been reviewed and is acceptable for up to 27.75 Prescribed credit(s) by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Nursing Credit (ANCC)
Medical Education Resources is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

This CE activity provides 27.75 contact hours of continuing nursing education.

Medical Education Resources is a provider of continuing nursing education by the California Board of Registered Nursing, Provider #CEP 12299, for 27.75 contact hours.

AANP (American Academy of Nurse Practitioners) Credit
This program is approved for 27.75 contact hours of continuing education (which includes 23.75 hours of pharmacology) by the American Association of Nurse Practitioners. Program ID 1307294.

Registered Dietitian Credit
Medical Education Resources (Provider Number ME110) is a Continuing Professional Education (CPE) Accredited Provider with the Commission on Dietetic Registration (CDR). Registered dietitians (RDs) and dietetic technicians, registered (DTRs) will receive 27.75 continuing professional education units (CPEUs) for completion of this program/material.

Pharmacy Credit
Medical Education Resources (MER) is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. MER designates this continuing education activity for 27.75 contact hours (2.775 CEUs) of the Accreditation Council for Pharmacy Education. (Universal Program Number - 0816-0000-13-036-L01-P)

Attention Certified Diabetes Educators: The 2013 Cardiometabolic Health Congress (CMHC) is accredited by Medical Education Resources (MER). MER is accredited by the ACCME, ANCC, ACPE, and the CDR to provide continuing medical education. All of these accredited organizations are recognized by the AADE when applying for CDE renewal of certification or for initial certification. For more information please visit Recognized Provider List | NCBDE

Disclosure of Conflicts of Interest
It is the policy of Medical Education Resources to ensure balance, independence, objectivity, and scientific rigor in all of its educational activities. In accordance with this policy, MER identifies conflicts of interest with its instructors, content managers, and other individuals who are in a position to control the content of an activity. Conflicts are resolved by MER to ensure that all scientific research referred to, reported, or used in a CME activity conforms to the generally accepted standards of experimental design, data collection, and analysis. MER is committed to providing its learners with high-quality activities that promote improvements or quality in health care and not the business interest of a commercial interest.

Statement of Need

The ever-increasing presence of cardiometabolic risk continues to be a major challenge for health care professionals in the United States. The prevalence of most cardiometabolic risk factors - especially hypertension, diabetes, and obesity - continues to rise. In the years ahead, American physicians should expect to treat unprecedented numbers of patients at high risk for morbidity and mortality from cardiovascular disease. In 2000, approximately 32% of U.S. adults had the metabolic syndrome, a constellation of cardiometabolic risk factors including excessive abdominal fat, insulin resistance, dyslipidemia, and hypertension.1 In more recent years that figure has climbed to 34%, and it may even be as high as 38%, depending on the criteria used to define the syndrome.2,3

Patients with multiple cardiometabolic risk factors have twice the likelihood of developing and dying from cardiovascular disease and more than seven times the risk of developing diabetes, compared to those with no cardiometabolic risk factors.4-7 As the number of these patients increases, the burden of cardiovascular disease can be expected to increase in the United States as well. Unfortunately, cardiovascular disease already affects approximately 82.6 million U.S. adults and is the leading cause of U.S. deaths. According to the American Heart Association, cardiovascular disease causes more than 800,000 deaths each year - more than cancer and accidents combined. This is an average of more than 2,200 deaths per day, or one death every 39 seconds.8

The Components of Cardiometabolic Risk

Diabetes, another major killer and a leading cardiometabolic risk component, is also on the rise. According to the American Diabetes Association and the Centers for Disease Control and Prevention, approximately 27 million Americans, or nearly 11% of the population, have diabetes.9 By 2050, the prevalence of diabetes could increase to as much as 33% of the population, largely due to the aging of the population and to people with diabetes living longer.10 Approximately 1.9 million new cases of diabetes are diagnosed each year. The disease was the seventh leading cause of death in 2007, directly claiming more than 71,000 lives and contributing to approximately 160,000 additional deaths.9 Patients with diabetes are two to four times more likely than those without it to die from cardiovascular disease, and diabetes is an important cause of blindness, kidney disease, and lower-extremity amputations.9

An additional 79 million Americans have prediabetes.9 Individuals with prediabetes have blood glucose levels that are higher than normal but not high enough to be classified as diabetes.11 Without intervention, most people with prediabetes will develop diabetes within ten years.12 In addition, studies have shown that these individuals are at increased risk for cardiovascular disease, including a heart attack or stroke.13-15 Individuals with prediabetes are also likely to have additional cardiovascular risk factors such as elevated cholesterol and high blood pressure.13 The medical community is increasingly recognizing the importance of identifying individuals with prediabetes and acting promptly to reduce blood glucose levels and any additional cardiovascular risk factors in this patient population to prevent the onset of diabetes and cardiovascular disease.14,15/

Diabetes and prediabetes are strongly linked to obesity and overweight.16 Nearly 50% of people with diabetes are obese, and 90% are overweight.16,17 A chief risk factor for prediabetes is excess abdominal fat.11,12 Obesity increases one’s risk for a variety of other medical problems, including hypertension, stroke, other forms of cardiovascular disease, arthritis, and several forms of cancer.18,19 In fact, obese people are at twice the risk of dying from any cause than normal-weight individuals.8 The prevalence of obesity and overweight have risen to epidemic proportions in the United States, where 67% of adults are overweight and, of these, approximately half are obese.8,19 The prevalence of hypertension, another cardiometabolic risk component, has been increasing for the last decade. In 1994, 24% of U.S. adults had hypertension. Today, that figure has risen to 29%, according to data from the National Health and Nutrition Examination Survey.8,20 In addition, nearly 30% of U.S. adults have prehypertension.8 Hypertension increases one’s risk of suffering a stroke, developing end-stage renal disease, and dying from cardiovascular disease. In recent years, hypertension has directly claimed more than 61,000 U.S. lives and has contributed to approximately 347,000 deaths each year.8 Of the components of cardiometabolic risk, only the prevalence of dyslipidemia has declined. Between 1999 and 2010, the percentage of U.S. adults with high total cholesterol declined from approximately 18% to 13%.21 However, according to the American Heart Association, nearly half of U.S. adults today (44%) are still at increased risk for atherosclerotic disease because their levels of total cholesterol are elevated (200 mg/dL or higher).8 Of these 98.8 million individuals with elevated cholesterol, 33.6 million have high cholesterol (240 mg/dL or above), and 71.3 million have low-density lipoprotein (LDL) cholesterol levels of 130 mg/dL or higher.8 In addition, approximately 19% of U.S. adults have low levels of high-density lipoprotein (HDL) cholesterol,7 and one-third have elevated triglycerides.22 Finally, dyslipidemia affects the vast majority (up to 97%) of individuals with diabetes and contributes to their elevated risk for cardiovascular disease.23

The Comorbidities of Cardiometabolic Risk

Not only do patients with multiple cardiometabolic risk factors face the aforementioned health problems, but they also commonly suffer certain comorbidities that can exacerbate cardiovascular risk and severely affect quality of life. These comorbidities include the following:

• Depression: Growing evidence suggests a link between the metabolic syndrome and depression.24 Patients with the syndrome tend to score higher than the general population on clinical measures of depression.25 One recent study of elderly men and women found that those with the metabolic syndrome were 73% more likely to develop depression compared to those without.26

• Obstructive sleep apnea (OSA): There is increasing evidence that OSA is linked to the metabolic syndrome and is itself an independent risk factor for cardiovascular disease.27-31 A disproportionately large percentage of individuals with the metabolic syndrome also have OSA. OSA has been linked with obesity, insulin resistance, and increased risk for cardiovascular disease and diabetes.29-31

• Polycystic ovary syndrome (PCOS): Women with PCOS have a three- to fivefold increase in risk for the metabolic syndrome, according to recent studies, suggesting that PCOS may be an independent cardiometabolic risk factor.32,33

• Hypogonadism:Low testosterone is associated with cardiometabolic risk factors, including overweight and obesity, hypertension, and diabetes, as well as cardiovascular morbidity and mortality.34 Conversely, high testosterone levels have been linked with a more favorable cardiovascular risk profile, with one analysis finding that men with the highest testosterone levels were 47% less likely to die of cardiovascular disease compared to men with the lowest levels.35

• Erectile dysfunction: ED is strongly associated with cardiovascular risk. A recent meta-analysis found that men with ED were at significantly increased risk for cardiovascular disease, coronary heart disease, stroke, and all-cause mortality compared to men without ED.36 Because symptoms of ED often precede those of cardiovascular disease by several years, clinicians are increasingly recognizing that ED may be a signal of asymptomatic, or “silent,” cardiovascular disease, and that it is logical to look for cardiometabolic risk factors in patients with ED.37,38

• Diabetic neuropathic pain: Neuropathic pain affects half of all patients with diabetes.39 Of these, more than one million suffer chronic pain that diminishes their quality of life, disrupts sleep, and can lead to depression.40

• Chronic kidney disease: Kidney disease is most often the result of diabetes or hypertension. Approximately one-third of patients with diabetes develop chronic kidney disease.41 In addition, hypertension causes more than 25,000 new cases of kidney failure in the United States each year.42

Cardiometabolic Risk Factors Are Undertreated and Difficult to Manage

Despite the well-documented risks of unchecked diabetes, obesity, hypertension, and dyslipidemia, these conditions are commonly undertreated. Even when treated, they remain stubbornly difficult to manage:

• Half or more of treated patients with diabetes fail to meet recommended target HbA1c goals. Analyses of data from National Health and Nutrition Examination surveys found that only one-half to one-third of treated patients achieve the American Diabetes Association’s recommended HbA1c target of 7% or less.8,43 In addition, a report released by the American Association of Clinical Endocrinologists stated that two out of three patients with type 2 diabetes were not achieving the association’s recommended HbA1c goal of 6.5% or less.44

• When it comes to first-line therapy for obesity - diet and exercise - few patients succeed. Those who do achieve significant weight loss tend to gain the weight back within a year or two.45 Many clinicians do not address diet and exercise for weight loss with their patients, citing a lack of belief that lifestyle changes can work, lack of understanding of how to counsel patients about lifestyle change, and inadequate amounts of time and personnel.46 Until recently, pharmacotherapy options for treating obesity have been limited. However, new anti-obesity drugs have recently been approved and others are in late-stage development.47 In order to more successfully manage obesity in the United States, clinicians will need to understand how to integrate these new strategies into an overall weight-loss program.47

• Only 73% of patients with hypertension are receiving any form of treatment. Of these treated patients, only half have their blood pressure under control.8

• Less than half of those who qualify for any kind of lipid-modifying treatment to reduce their risk of coronary heart disease are receiving it. In fact, less than half of even the highest-risk individuals - those with symptomatic coronary heart disease - are receiving lipid-lowering treatment. Of those being treated, only about one-third are achieving target goals.8

One important reason that cardiometabolic risk factors are poorly controlled has been clinicians’ traditional reliance on single-drug therapy.48-51 In the treatment of diabetes, for example, patients are traditionally started on a single anti-diabetic agent (usually metformin), and additional agents are added only if the first fails to adequately control glucose levels.48 The problem is that diabetes is a progressive disease and that most patients will not achieve sustained glucose control on a single agent.50,51 Additional agents are added only after a sustained period of poor glucose control during which patients are at increased cardiovascular risk.50,51

Thought leaders in the field of diabetes treatment, therefore, are increasingly recognizing the importance of early and aggressive treatment with combination therapies in order to achieve prompt and sustained glucose control and reduce cardiovascular risk.52-56 Newer, incretin-based therapies are proving especially useful in this regard, and treatment algorithms are being revised to reflect this new state of knowledge.56-58 For example, a joint position statement released by the American Diabetes Association and the European Association for the Study of Diabetes in 2012 recommends that clinicians consider initial combination therapy in patients with an HbA1c of 9% or greater, including combination therapy with a GLP-1 receptor agonist or DPP-4 inhibitor.57 It is critical that clinicians who treat patients with diabetes have current information on updated treatment algorithms and clinical trial data evaluating combination therapy for patients with diabetes.

Similarly, thought leaders in the field of hypertension management have concluded that, for most patients, it is difficult or impossible to control blood pressure with a single agent.59 Current guidelines therefore recommend combination therapy for high-risk patients whose hypertension needs to be controlled quickly, such as those with diabetes.59 Clinical evidence has shown that combination therapy targeting two or more blood-pressure regulatory systems simultaneously reduces hypertension more effectively than does monotherapy.60,61 A variety of fixed-dose combination therapies for hypertension are becoming available in the marketplace.60,61 It is important for clinicians to understand current treatment recommendations concerning combination therapy and to appropriately integrate this strategy into the management of patients with hypertension.

In addition, leaders in the field of dyslipidemia management are also recognizing the potential benefits of combination therapy.62-65 LDL cholesterol is still the primary target of therapy, but clinical evidence is gathering about the importance of targeting HDL cholesterol and triglycerides as well to further reduce cardiovascular risk.62,63 Combination therapies designed to improve all these lipid parameters are also becoming available in the marketplace, and it is important that clinicians understand their appropriate use.64,65

Another important development in the field of dyslipidemia management is the emergence of novel classes of drugs that not only have more potent LDL-cholesterol-lowering effects than current options but also have favorable effects on other atherogenic lipoproteins.66 These experimental drugs include inhibitors of apolipoprotein B (Apo B), microsomal transfer protein (MTP), and proprotein convertase subtilisin/kexin type 9 (PCSK9).66 As these newer options become available, clinicians will need to understand how to integrate them into lipid management programs.

Cardiometabolic Risk on the Rise in Children and Adolescents

Cardiometabolic risk is becoming so common in the United States that it is affecting our children, suggesting that future generations will bear a greater burden of cardiovascular disease if adequate treatments cannot be found. According to estimates from the American Heart Association, more than 9% of U.S. children and adolescents aged 12-19, or nearly three million individuals, have the metabolic syndrome.8 Among overweight and obese adolescents, this prevalence rate rises to 44%. Two-thirds of adolescents have at least one metabolic abnormality.8

Preliminary prospective studies report that children and adolescents with the metabolic syndrome are at high risk of developing cardiovascular disease and diabetes as adults. One 25-year prospective study found that, compared with children without the syndrome, those with the metabolic syndrome are 14 times more likely to suffer from cardiovascular disease and 11 times more likely to develop diabetes when they reach adulthood.67

Cardiometabolic risk among children and adolescents is fueled by the rising prevalence of obesity in this age group. From 1980 to 2008, rates of obesity have increased from 5% to 10% among preschool children aged 2-5. During the same time period, obesity increased from 6.5% to nearly 20% among 6-11year-olds and from 5% to 18% among adolescents aged 12-19.68 Hypertension among children and adolescents has increased by 1% since 1999 and is estimated to affect 3.6% of those aged 3-18.8 This increase is attributed to the rising number of overweight and obese children.8 The prevalence of lipid abnormalities among children and adolescents is also tied to obesity and overweight. Approximately 14% of normal-weight youths aged 12-19 have lipid abnormalities.8 That figure rises to 22% of overweight youths and nearly 43% of obese youths.8

Obesity is also tied to the rise of type 2 diabetes among U.S. children. Until recently, diabetes in children was typically assumed to be type 1, formerly known as juvenile-onset diabetes.69 However, according to the Centers for Disease Control and Prevention, recent clinical evidence indicates that the prevalence of type 2 diabetes, formerly known as adult-onset diabetes, is increasing among American children and adolescents.69 This increase is most notable among Blacks, Asian/Pacific Islanders, Hispanics, and American Indians. Children who develop type 2 diabetes are typically overweight or obese. “Type 2 diabetes in children and adolescents already appears to be a sizable and growing problem,” the CDC says. “Better physician awareness and monitoring of the disease’s magnitude will be necessary.”69

Conclusion

Health care professionals play a major role in stemming the future burden of cardiovascular disease, diabetes, and associated comorbidities by employing aggressive strategies for the early identification and comprehensive management of patients presenting with multiple cardiometabolic risk factors. The 2013 Cardiometabolic Health Congress will translate the latest cutting-edge medical research into practical, clinical approaches for preventing, delaying, and managing cardiovascular and metabolic risk. The goal is to provide the medical community with evidence-based interventions to improve health outcomes and quality of life for the growing numbers of patients at increased cardiometabolic risk.

Purpose Statement

To improve patient outcomes through early identification and intervention strategies for patients with, or at risk of developing, diabetes and cardiovascular disease.

Target Audience & Learning Objectives

The CMHC is designed for advanced-level clinicians responsible for the prevention, diagnosis, and management of cardiometabolic risk.
At the end of the congress, participants will be able to:

1. Explain the interrelationships among the various cardiometabolic risk factors, their impact on cardiovascular health, and their common comorbidities.
2. Translate evidence-based strategies for prevention, screening, and treatment of cardiometabolic risk factors and their comorbidities to their clinical practice.
3. Identify which interventions, including lifestyle changes and various drugs in combination, are most appropriate for particular patients based on their risk profiles.
4. Identify how novel and emerging therapies can be integrated into clinical practice to reduce morbidity and mortality from cardiovascular and metabolic disease.

Disclaimer

The content and views presented in this educational activity are those of the authors and do not necessarily reflect those of Medical Education Resources, HealthScience Media, Inc and/or the various industry supporters. The authors have disclosed if there is any discussion of published and/or investigational uses of agents that are not indicated by the FDA in their presentations. The opinions expressed in this educational activity are those of the faculty and do not necessarily represent the views of Medical Education Resources, HealthScience Media, Inc. and/or the various industry supporters. MER’s ANCC accreditation status does not imply endorsement by MER or ANCC of any commercial products displayed in conjunction with this activity. Before prescribing any medicine, primary references and full prescribing information should be consulted. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities. The information presented in this activity is not meant to serve as a guideline for patient management.

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64. Farnier M. Safety review of combination drugs for hyperlipidemia. Expert Opin Drug Saf. 2011;10:363-371.
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The 2013 Cardiometabolic Health Congress is jointly sponsored by HealthScience Media, Inc. and Medical Education Resources, Inc.