Download The prevalence of the metabolic syndrome and its impact on the left

European Review for Medical and Pharmacological Sciences
2012; 16: 90-95
The prevalence of the metabolic syndrome
and its impact on the left ventricular systolic
function in the patients with non-diabetic
first ST elevation myocardial infarction
H.U. YAZICI, F. POYRAZ, M. TURFAN, N. SEN, Y. TAVIL, M. TULMAÇ,
M.A. VATANKULU*, N. AYGÜL*, I. ÖZDOĞRU**, A. ABACI
Department of Cardiology, Gazi University School of Medicine, Ankara (Turkey)
*Department of Cardiology, Selçuk University School of Medicine, Konya (Turkey)
**Department of Cardiology, Erciyes University School of Medicine, Kayseri (Turkey)
Abstract. – Objective: Metabolic syndrome (MS) is common among the patients with
myocardial infarction. The degree of the left ventricular systolic dysfunction is shown to be associated with poor prognosis after myocardial
infarction. The aim of this study was to evaluate
the prevalence of MS and its impact on the left
ventricular systolic function in non-diabetic patients suffering first ST elevation myocardial infarction (STEMI).
Material and Methods: This study was conducted prospectively in three centers. We included patients presenting with non-diabetic first
acute STEMI. The systolic functions of the left
ventricle were assessed through the ejection fraction, the wall motion score index (WMSI) and tissue Doppler myocardial S wave velocities. The diagnosis of MS was done based on the Adult
Treatment Panel III clinical definition of the MS.
Results: Among the 240 patients, 90 patients
(37.5%) had MS but 150 patients (62.5%) were
free of the MS. The patients in the MS group
were older and the prevalence was higher
among the females. Mean myocardial S wave velocities were significantly lower in the patients
with the MS in comparison to the patients without the MS (6.70±1.68 vs. 7.39±1.64; p<0.01).
LVEF and WMSI were similar in two groups.
Conclusions: MS was highly common in nondiabetic patients with acute STEMI and left ventricular systolic function were more severely impaired in these patients. Our observations suggest that more severely impaired left ventricular
systolic function after acute STEMI may contribute to the higher morbidity and mortality
seen in the patients with MS after acute STEMI.
Key Words:
Metabolic syndrome, Acute myocardial infarction,
Left ventricular systolic function.
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Introduction
The metabolic syndrome (MS) is characterized with the clustering of closely associated
interdependent atherosclerotic risk factors, including insulin resistance, high blood pressure,
low level of high-density lipoprotein (HDL)
cholesterol, elevated triglyceride level, increased plasma glucose concentration, and abdominal obesity1. An increased prevalence of
the MS has been showed in the patients with
acute myocardial infarction (AMI). The MS is
a well-known risk factor for the development of
coronary artery disease2-5. In addition, deteriorated prognosis after myocardial infarction that
might be triggered through the unfavorable effect of the MS on the left ventricular function
is presented6,7.
The degree of the left ventricular systolic dysfunction is related with poor prognosis after
acute myocardial infarction8,9. MS has the potential to worsen the myocardial ischemic insult in
setting of AMI. Moreover, it leads to accelerated
atherosclerosis, increased tendency to thrombosis, augmented levels of clotting factors and the
inflammation as well as the inhibition of the fibrinolytic pathway 10. Therefore, the MS may
ground for worsened left ventricular systolic
function by causing recurrent thrombotic events
and aggravating systemic inflammation during
the course of myocardial infarction.
The aim of this study was to evaluate the
prevalence of the MS and its impact on the left
ventricular systolic function in the patients with
non-diabetic first ST elevation myocardial infarction.
Corresponding Author: Hüseyin Uğur Yazici, MD; e-mail: [email protected]
The relationship between metabolic syndrome and myocardial infarction
Materials and Methods
Patient Population
This study was conducted prospectively in
three different Centers. A total of 240 consecutive patients presenting first acute STEMI were
enrolled to the current study between May 2004
and January 2007. The Ethical Committee approval from each Center and informed consent
from each patient were obtained. All the patients
were treated according to the decision of pursuing physician.
The patients were diagnosed with acute ST elevation myocardial infarction (STEMI) if new
ST-segment elevation was more than 1 mm in 2
contiguous leads and the increase in the serum
troponin level was at least threefold above the
upper limit of the normal in the setting of the
clinical symptoms11.
The patients having renal dysfunction (creatinine >2,5 mg/dl), history of previous myocardial
infarction, previous percutaneous coronary intervention (PCI) or coronary artery bypass surgery,
presence of significant valvular disease, inadequate echocardiographic image quality, known
malignancy, previous stroke, or diabetes mellitus
were excluded from the study.
The diagnostic criteria for MS were based on
the Adult Treatment Panel III (ATP III) clinical
definition of the MS. This requires the presence
of ≥3 of the followings: (1) abdominal obesity
(waist circumference >102 cm in men and >88
cm in women); (2) a high triglyceride level (>150
mg/dl); (3) and a low HDL-cholesterol level (<40
mg/dl for men and <50 mg/dl for women); (4)
high blood pressure (systolic >130 mm Hg or diastolic >85 mm Hg, or being on an antihypertensive medication); and (5) a high fasting plasma
glucose concentration (>110 mg/dl).
Biochemical Analysis
Automated analyzers were used for the biochemical measurements. The blood samples for
the biochemical measurements were drawn without stasis at 7-8 o’clock in the morning after 20
min of supine rest following a fasting period of
12 h within 48 hours after admission to the cardiac intensive care unit (ICU). Glucose, creatinine, and lipid levels were determined by standard methods.
Echocardiography Analysis
The echocardiographic examination was done
as soon as clinical stability of the patients was
achieved after the admission to the coronary ICU
(mean 2.4 days). All the patients were evaluated
by two-dimensional and pulsed wave tissue
Doppler echocardiography using the Vivid 7 or 5
echocardiography machine (General ElectricVingmed, Horten, Norway) with a 2.5-5 MHz
transducer. The left ventricular ejection fraction
was determined with Simpson’s modified biplane
formula. End-systolic and end-diastolic LV cavity volumes were computed from the area measurement obtained from apical 2- and 4-chamber
views at end-systole and end-diastole, respectively and averaged.
The wall motion score index (WMSI) was calculated according to American Echocardiography Association Model that takes 16 left ventricular segments into account. Regional wall motion
in each segment was graded visually, using a
four-point scoring system: 1 = normal, normal
wall motion; 2 = hypokinesia, marked decrease
in endocardial motion; 3 = akinesia, absence of
inward wall motion; 4 = dyskinesia, paradoxical
wall motion away from the left ventricular lumen
in systole. If more than two segments in the infarct zone or 4 or more of all 16 segments were
not visualized, the study was considered inadequate and these patients were not included in the
study. The WMSI was obtained by dividing the
sum of all the scores by the number of the segments visualized.
Pulsed tissue Doppler samples were recorded
from four different locations by the 2.0-4.0 Mhz
sample volume placed at the level of mitral annulus (anterior, inferior, lateral, posterior septum),
using the apical two- and four-chamber and longaxis views. The mean of peak systolic myocardial annular (Sm) velocity of waves for the above
four sites was used to assess global systolic function12,13.
All of the echocardiographic examinations
were done in each Center by one cardiologist
who was blind to the laboratory and clinical data
of the patients.
Statistical Analysis
Continuous variables were expressed as
mean±SD, categorical variables were defined as
percentages. To compare continuous variables,
we used Student’s t-test or the Mann-Whitney Utest, where appropriate. Categorical variables
were compared via the chi-square test. Since we
considered that mean Sm velocity might be affected by age and gender, we performed covariance analysis for the variants. For all the tests, a
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H.U. Yazici, F. Poyraz, M. Turfan, N. Sen, Y. Tavil, M. Tulmaç, et al.
value of p < 0.05 was considered to be statistically significant. The SPSS statistical software
package (SPSS, version 16.0 for windows; SPSS
Inc., Chicago, IL, USA) was used to perform all
the statistical calculations.
Results
Of 307 patients admitted with first acute STEMI, 67 of them were excluded from the study
since they did not meet to inclusion criteria. The
remaining 240 patients were included in the final
analysis. The mean age of the patients (212 men,
28 women) was 55±10.6 years (ranged from 33
to 80). Among the 240 patients enrolled, 90 patients (37.5%) had MS. The main characteristics
of study population are presented in Table I. The
patients in the MS group were older and the
prevalence was higher among the females.
The echocardiographic parameters are presented
in Table II. LVEF and WMSI were similar in two
groups. However, the mean Sm velocities were significantly lower in the patients with the MS in
comparison to the patients without the MS.
The covariance analysis performed for the
possible effect of age and gender showed that
statistical significance of mean Sm velocity still
continued to be existed (7.3±1.63 vs. 6.72±1.61,
p = 0.02).
Discussion
In the present study, we evaluated the prevalence of MS and its impact on the left ventricular
systolic function in patients with non-diabetic
first STEMI using conventional and tissue
Doppler echocardiographic methods. The prevalence of MS was 37.5% in patients with non-diabetic first acute STEMI. The results of the present study are consistent with the previous investigations showing marked prevalence of MS in
the patients with MI2-4.
We found that the mitral annulus S velocities
in patients with MS was significantly lower than
those patients with MS, but the mean ejection
fraction (EF) and WMSI of both groups were
similar. In a previous study, a correlation between LV ejection fraction and tissue Doppler
peak mitral annulus systolic velocity is clearly
shown14. The average of tissue Doppler peak systolic velocities attained from four different locations at the level of mitral annulus (anterior, inferior, lateral, posterior septum) reflects the global
systolic function of the left ventricle12,13. Furthermore, peak mitral annulus S velocities detected
by tissue Doppler imaging (TDI) are also a more
sensitive marker than conventional echocardiographic methods for detecting mildly impaired
LV systolic function15. A similar previous study
examining the patients with first myocardial infarction shows that the patients with normal LV
Table I. The main characteristics of patients with and without MS.
Age (years)
Sex (men), No. (%)
Hypertension, No. (%)
Family history of CAD, No. (%)
Current smoker, No. (%)
Time between AMI and
echocardiography (day)
Waist circumference (cm)
Total cholesterol (mg/dl)
LDL-cholesterol (mg/dl)
HDL-cholesterol (mg/dl)
Triglyceride (mg/dl)
Glucose (mg/dl)
Creatinine (mg/dl)
Patient without
metabolic syndrome
(n = 150)
Patient with
metabolic syndrome
(n = 90)
p value
53.3 ± 10.5
142 (94.7%)
20 (13.3%)
28 (18.7%)
113 (75.3%)
2.2 ± 1.3
57.8±10.4
70 (77.8%)
53 (58.9%)
24 (26.7%)
55 (61.1%)
2.4 ±1.4
0.001
< 0.001
< 0.001
0.11
0.01
0.30
93 ± 9
195.8 ± 42
130.2 ± 37
42.7 ± 9.1
110.4 ± 60.8
116 ± 42
1.02 ± 0.21
98.3 ± 14
195.7 ± 35
126.3 ± 29
38.1 ± 7.9
154.8 ± 82.8
127 ± 25
1.05 ± 0.26
0.002
0.99
0.40
< 0.001
< 0.001
0.002
0.35
CAD: Coronary artery disease, AMI: Acute myocardial infarction, LDL: Low density lipoprotein, HDL: High density lipoprotein.
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The relationship between metabolic syndrome and myocardial infarction
Table II. The echocardiographic parameters of patients with and without MS.
LVEF (%)
WMSI
Sm (cm/sn)
Patient without
metabolic syndrome
(n=150)
Patient with
metabolic syndrome
(n=90)
p value
49 ± 8.5
1.58 ± 0.35
7.39 ± 1.64
47.5 ± 9.1
1.60 ± 0.44
6.70 ± 1.68
0.21
0.71
< 0.01
LVEF: Left ventricular ejection fraction, WMSI: Wall motion score index, Sm: Systolic miyocardial annular velocity.
systolic function assessed using the conventional
echocardiography have reduced left ventricular
systolic function when evaluated with TDI16. In
addition, TDI has been used to detect subclinical
LV dysfunction in a number of diseases. Reduced
Sm velocities have been shown in patients with
mutations of hypertrophic cardiomyopathy at the
time of subclinical disease when cardiac hypertrophy is not present17. In asymptomatic patients
with severe mitral regurgitation and normal LV
ejection fraction, reduced Sm velocity can help
to predict those who would develop LV ejection
fraction reduction after mitral valve surgery18.
Earlier studies investigating the impact of MS
on LV functions have deposited conflicting results. Zeller et al3 found that MS is associated
with a higher incidence of severe heart failure
following acute myocardial infarction (AMI) although LV systolic function evaluated with conventional echocardiography were similar between patients who had MS and without MS.
Ya ar et al19 have found that MS is not associated with LV ejection fraction in patients with
AMI. Grandi et al20 found that MS is only associated with LV diastolic function. In contrast,
Gong et al21 describe that LV systolic and diastolic functions are impaired in the patients with
MS when evaluated by strain rate echocardiography even if they have normal LVEF. Moreover,
Wong et al7 demonstrate that MS is associated
with LV systolic dysfunction, even in the absence
of apparent cardiovascular disease. Using TDI
we found that LV systolic function is more severely impaired in patients with MS than patients
without MS in case of first acute STEMI.
Left ventricular contraction occurs along both
the long and the short axes of heart. Shortening
along the atrioventricular long axis can be used
in the evaluation of left ventricular regional and
global systolic functions. Longitudinal fibers,
which are responsible in LV shortening along the
long axis, are denser in the subendocardial and
subepicardial areas. The subendocardium is the
most vulnerable portion of the myocardium to ischemia. The wall motions along the longitudinal
axis are affected more severely during ischemia.
Consequently, deterioration in the left ventricular
systolic function is expected first in the longitudinal axis in the patients with AMI. Therefore,
mitral annular velocity recordings are probably
more sensitive than conventional methods to
identify decreased left ventricular systolic function in the case of AMI15,16,22.
The most important factor that determines the
left ventricle systolic function after acute myocardial infarction is the success of reperfusion
therapy23,24. Thus, we investigated the effect of
MS on the success rate of reperfusion therapy.
There was no significant difference between patients with MS and patients without MS in successful reperfusion rate according to ECG findings. MS may lead worsened left ventricular systolic function by causing recurrent thrombotic
events through aggravating systemic inflammation in the course of AMI. In addition, the components of MS may lead to the left ventricular
structural and functional disorders25,26.
We are aware of the presence of some limitations with the present study. First of all, acute
metabolic stress owing to MI may affect blood
glucose and lipid levels. However, it is known
that fasting glucose levels measured 4-5 days after an AMI accurately predicts glucose metabolism. A gradual decrease in mean HDL cholesterol and triglyceride levels during the in-hospital
stay has been reported but is only minor during
the first 24 hours of an AMI. All of the biochemical measurements in the present study were performed within 48 hours after the admission of the
patients to the cardiac ICU. All of these factors
could, therefore, only weakly influence the calculation of the prevalence of MS in the setting of
acute myocardial infarction27-29. Secondly, we
didn’t have a core laboratory for evaluating the
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H.U. Yazici, F. Poyraz, M. Turfan, N. Sen, Y. Tavil, M. Tulmaç, et al.
biochemical and echocardiographic measurements. Thirdly, medications of the patients were
not recorded but all the patients included in the
study were treated according to the updated international guidelines.
Conclusion
Our results demonstrated that the MS was
highly common in non-diabetic patients with
acute STEMI and LV systolic function assessed
by TDI were more severely impaired in this patients. Our observations suggest that more severely impaired LV systolic function after acute
STEMI may contribute to the higher morbidity
and mortality seen in the patients with MS after
acute STEMI.
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