Journal of Atherosclerosis and Thrombosis Vol. 21, No.1

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1 Committee Report 8 Journal of Atherosclerosis and Thrombosis Vol. 21, No.1 1 Executive Summary of the Japan Atherosclerosis Society (JAS) Guidelines for the Diagnosis and Prevention of Atherosclerotic Cardiovascular Diseases in Japan 2012 Version Tamio Teramoto, Jun Sasaki, Shun Ishibashi, Sadatoshi Birou, Hiroyuki Daida, Seitaro Dohi, Genshi Egusa, Takafumi Hiro, Kazuhiko Hirobe, Mami Iida, Shinji Kihara, Makoto Kinoshita, Chizuko Maruyama, Takao Ohta, Tomonori Okamura, Shizuya Yamashita, Masayuki Yokode and Koutaro Yokote Committee for Epidemiology and Clinical Management of Atherosclerosis Japanese eating habits and dietary components have clearly changed in recent years 1). Lifestyles that include overnutrition and physical inactivity are threatening to increase the incidence of coronary artery disease (CAD) and stroke. Among the conditions underlying the development of atherosclerotic cardiovascular diseases (CVD), particular importance is ascribed to a cluster of multiple risk factors, including hyperglycemia, dyslipidemia, and elevated blood pressure, which are closely related to lifestyle. This pathologic condition used to be called Syndrome X, 2) the deadly quartet, 3) visceral fat syndrome, 4), or insulin resistance syndrome, ) but those terms were unified as metabolic syndrome 6) in Metabolic syndrome is recognized as a condition in which the risk factors of atherosclerosis cluster on the basis of obesity, particularly visceral fat accumulation, due to overnutrition and physical inactivity 7, 8). 1. Importance of Accumulated Risk Factors The Group of The Research for the Association between Host Origin and Atherosclerotic Diseases under the Preventive Measure for Work-related Diseases of the Japanese Ministry of Labour performed a case-control study in approximately 120,000 office workers 9, 10). The records of annual medical health checkups performed 10 years prior to the onset of CAD were reviewed for 94 individuals who developed CAD during a 3-year observation period and were compared to those of age- and gender-matched controls who were randomly selected from the same workplace of the patient. The surveys revealed that the Received: March 12, 2013 Accepted for publication: March 26, 2013 blood pressure, fasting blood glucose, total cholesterol (TC), triglyceride (TG), and uric acid levels were significantly higher in cases compared with those in controls for the evaluated 10-year period, even though these abnormalities were mild or moderate. It was of particular interest that the body mass index (BMI) remained higher in cases compared to controls for a long period of time. The NIPPON DATA80 also showed that the relative risk of death due to CAD and stroke increased with the number of combined risk factors (Fig. 1) 9-12). These results clearly indicate the importance of a cluster of multiple risk factors in the development of CAD in Japan, even if the severity of each risk factor is mild. According to a survey of middle-aged and elderly Japanese, the odds ratio of having any one risk factor (hypertension, impaired glucose tolerance/diabetes mellitus, hypertriglyceridemia, or hypo-hdl-cholesterolemia) and the frequency of having multiple risk factors were high in both obese and non-obese subjects with visceral fat accumulation compared with non-obese subjects without visceral fat accumulation 13). The odds ratio was not significant in obese subjects without visceral fat accumulation. The Japan Society for the Study of Obesity proposed a definition of obesity disease based on susceptibility to the clustering of obesity-associated risk factors 14, 1). The fat distribution in CAD patients (observed using CT) revealed that approximately half of the patients had excess visceral fat accumulation with multiple risk factors 16). A 10-year follow-up study of middle-aged and elderly Japanese-American men revealed that approximately 30% of subjects developed CAD and that the accumulation of visceral fat, hypertension, and hyperglycemia were important risk factors 17).

2 2 Teramoto et al. Hazard ratio for death CAD Stroke Number of risk factors Fig. 1. Relationship between the number of concurrent risk factors and death due to coronary artery disease and stroke (NIPPON DATA80: ) 11) Risk factors: Obesity, hypertension, hyperglycemia, hypercholesterolemia (Nakamura Y, et al: Circ J, 2006; 70: ) 2. Diagnostic Criteria for The definition of metabolic syndrome in Japan, which is characterized by the accumulation of visceral fat accompanied by the concurrence of multiple risk factors including elevated blood pressure, dyslipidemia, and hyperglycemia, was established in 200 (Table 1). In the diagnostic criteria, waist circumference is used as an index of visceral fat accumulation for practical convenience, and individuals with metabolic syndrome are defined as those having visceral fat accumulation demonstrated by increased waist circumference and 2 or more risk factors 7). The International Diabetes Federation also published diagnostic criteria for metabolic syndrome based on the same concept 8). The joint statement of NCEP-ATP Ⅲ and several societies in Western countries proposed that individuals with three of the five risk factors, including abdominal obesity, hypertriglyceridemia, hypo-hdlcholesterolemia, high blood pressure, and high blood glucose, should be diagnosed as having metabolic syndrome 18). The Western diagnostic criteria consider the absolute risk for the development of cardiovascular events and type 2 diabetes. In contrast to the Western criteria, the Japanese criteria emphasize that the syndrome develops based on visceral fat accumulation. The purpose of the Japanese criteria is to decrease risk factors through interventions to reduce visceral fat. The compulsory measurement of waist circumference in workplace annual health checkups and the specific health examination began in 2008; this action was intended to prevent Table 1. Japanese diagnostic criteria for metabolic syndrome 7 Visceral fat accumulation Waist circumference Men 8 cm Women 90 cm (The values for both men and women correspond to visceral fat 100 cm 2.) Two or more of the items mentioned below in addition to the above Hypertriglyceridemia and/or Hypo-HDL-cholesterolemia Systolic blood pressure and/or Diastolic blood pressure Fasting hyperglycemia 10 mg/dl <40 mg/dl for both men and women 130 mmhg 8 mmhg 110 mg/dl Measurement of visceral fat by methods such as CT scanning is recommended. The waist circumference is measured at the umbilical level in the standing position during light breathing. If the umbilicus is displaced due to marked fat accumulation, measurement is performed at the level of the midpoint between the lower costal margin and iliac crest. If a diagnosis of metabolic syndrome has been made, a glucose tolerance test is recommended, but it is not essential for the diagnosis. If the examinee is undergoing drug treatments for hypertriglyceridemia, hypo-hdl-cholesterolemia, hypertension, and/or diabetes mellitus, each item is considered to be positive. (Evaluation Committee on Diagnostic Criteria for : Internal Medicine, 200; 94: ) diabetes and atherosclerotic CVD based on the concept of metabolic syndrome. According to a recent large-scale cross-sectional study conducted in Japan on visceral fat area and accumulated risk factors, the average number of obesity-related cardiovascular risk factors (dyslipidemia, high blood pressure, and high blood glucose) was more than 1.0 at 100 cm 2 for visceral fat area in both men and women 19, 20). The criteria for waist circumference in Japan were determined by the absolute visceral fat area of 100 cm 2 ; this differs from the Western criteria, which are based on the value corresponding to the obesity criteria in each country. 3. Disease Concept of and its Significance Conditions, such as metabolic syndrome, that involve the clustering of multiple risk factors (using WHO or NCEP-ATP Ⅲ definition) have been shown to increase the risk of CVD in comparison to a single risk factor in epidemiological studies in Japan, includ-

3 3 Per 1,000 persons/year Incidence CAD Cerebral infarction p 0.0 vs. no risk factors multiple risk factors were treated for each of the concurrent factors using multiple pharmaceutical regimens. Through the establishment of the concept of metabolic syndrome, the significance of visceral fat reduction by lifestyle modification (e.g., guidance based on lifestyle characteristics; diet and exercise therapy in accordance with the guidance; and behavior therapy for effective continuance) has become strengthened as the first step in the management of individuals with visceral fat accumulation 28) Number of concurrent risk factors Fig. 2. Relationship between the number of concurrent risk factors and incidences of coronary artery disease and cerebral infarction 12) Components of metabolic syndome: Obesity, impaired glucose tolerance, lipidosis, hypertension, hyperinsulinemia After adjustment for age, -year ( ) follow-up of 1097 men and women aged 60 years in Hisayama-machi (Reproduced from Ken Okubo, et al: Rinsho to Kenkyu 2004; 81: with partial modification) ing the Tanno and Sobetu Study 21) and the Hisayama Study 12), as well as in foreign epidemiological studies, including NHANES Ⅱ 22) and SAHS 23) in the United States, the Botnia study 24) and the KIHD study 2) in Finland and Sweden, respectively and a meta-analysis that included Japanese epidemiological studies 26) (Fig. 2). Concerning the secondary prevention of CAD, it was also reported that the presence of metabolic syndrome increased the incidence of subsequent cardiac events in a study of long-term outcomes in 748 patients who underwent percutaneous coronary intervention 27). Metabolic syndrome develops due to visceral fat accumulation and subsequent insulin resistance. The accumulation of visceral fat leads to the dysregulation of adipocyte-derived biologically active products (adipocytokines), resulting in pathologic conditions such as impaired glucose metabolism, dyslipidemia, and hypertension. Metabolic syndrome is significant because the accumulation of visceral fat is related not only to the development of each risk factor but also to the clustering of risk factors, which substantially increases the risk of CVD, even though the severity of each risk factor is not particularly high. Inevitably, without visceral fat accumulation, patients with hyperglycemia, hypertension, and dyslipidemia are at high risk for atherosclerotic CVD. Conventionally, some patients with 4. Relationship to Hyper-LDL-Cholesterolemia A global consensus has been reached that high- LDL-cholesterolemia is a major risk factor for atherosclerotic CVD, and its management protocol has been established. Metabolic syndrome has been proposed as a high-risk condition for CVD independent of high- LDL-cholesterolemia 7). Therefore, the diagnostic criteria of metabolic syndrome include no criterion concerning the LDL-C level. However, subjects with metabolic syndrome sometimes also present an elevated level of plasma LDL-C. The combination of metabolic syndrome and high-ldl-cholesterolemia will further increase the risk of CVD. Therefore, strong recommendations to reduce visceral fat and a comprehensive approach for multiple risk factor control, including high-ldl-cholesterolemia, are necessary in such cases. Footnotes This is an English version of the guideline from the Japan Atherosclerosis Society (chapter 8) published in Japanese in June, Acknowledgements We are grateful to the following societies for their collaboration and valuable contributions: Dr. Hidenori Arai (The Japan Geriatrics Society), Dr. Kiminori Hosoda (Japan Society for the Study of Obesity), Dr. Hiroyasu Iso (Japan Epidemiological Association), Dr. Atsunori Kashiwagi (Japan Diabetes Society), Masayasu Matsumoto (The Japan Stroke Society), Dr. Hiromi Rakugi (The Japanese Society of Hypertension), Tetsuo Shoji (Japanese Society of Nephrology) and Hiroaki Tanaka (Japanese Society of Physical Fitness and Sports Medicine). We also thank Dr. Shinji Koba, Dr. Manabu Minami, Dr. Tetsuro Miyazaki, Dr. Hirotoshi Ohmura, Dr. Mariko Harada-Shiba, Dr. Hideaki Shima, Dr. Daisuke Sugiyama, Dr. Minoru Takemoto and Dr. Kazuhisa Tsukamoto for supporting this work.

4 4 Teramoto et al. References 1) Society for the study of health and nutrition information, ed: The national health and nutrition survey (2004). Ministry of Health, Labour and Welfare, ) Reaven GM: Banting lecture Role of insulin resistance in human disease. Diabetes, 1988; 37: ) Kaplan NM: The deadly quartet. Upper-body obesity, glucose intolerance, hypertriglyceridemia, and hypertension. Arch Intern Med, 1989; 149: ) Fujioka S, Matsuzawa Y, Tokunaga K, Tarui S: Contribution of intra-abdominal fat accumulation to the impairment of glucose and lipid metabolism in human obesity. Metabolism, 1987; 36: 4-9 ) DeFronzo RA, Ferrannini E: Insulin resistance. A multifaceted syndrome responsible for NIDDM, obesity, hypertension, dyslipidemia, and atherosclerotic cardiovascular disease. Diabetes Care, 1991; 14: ) World Health Organization, Department of Noncommunicable Disease Surveillance: Definition, diagnosis and classification of diabetes mellitus and its complications: report of a WHO consultation. Part 1: Diagnosis and classification of diabetes mellitus. World Health Organization, Geneva, ) Committee on Diagnostic Criteria for : Definition and diagnostic criteria of metabolic syndrome. J Jpn Soc Intern Med, 200; 94: ) Alberti KG, Zimmet P, Shaw J; IDF Epidemiology Task Force Consensus Group: The metabolic syndrome-a new worldwide definition. Lancet, 200; 366: ) Nakamura T, Tsubono Y, Kameda-Takemura K, Funahashi T, Yamashita S, Hisamichi S, Kita T, Yamamura T, Matsuzawa Y; Group of the Research for the Association between Host Origin and Atherosclerotic Diseases under the Preventive Measure for Work-related Diseases of the Japanese Labour Ministry: Magnitude of sustained multiple risk factors for ischemic heart disease in Japanese employees: a casecontrol study. Circ J, 2001; 6: ) The 1994 Report of the Group of the Research for the Association between Host Origin and Atherosclerotic Diseases under Preventive Measure for Work-related Diseases of the Japanese Labour Ministry: Significance of host factors contributing to the development of atherosclerosis 11) Nakamura Y, Yamamoto T, Okamura T, Kadowaki T, Hayakawa T, Kita Y, Saitoh S, Okayama A, Ueshima H; NIPPON DATA 80 Research Group: Combined cardiovascular risk factors and outcome-nippon DATA80, Circ J, 2006; 70: ) Okubo K, Kiyohara Y: Frequency of the metaboric syndrome in the general inhabitant. Jpn J Clin Exp Med, 2004; 81: ) Matsuzawa Y: Multicenter follow-up study of insulin resistance and the lifestyle basis in patients at high risk of diabetes mellitus-establishment of significance of abdominal obesity for intervention. Health Science Research Report of the Ministry of Health and Welfare. Ministry of Welfare, ) The Examination Committee of Criteria for Obesity Disease in Japan; Japan Society for the Study of Obesity: A new diagnosis for obesity and obesity as a disease in Japanese. J Jpn Soc Study of Obesity, 2000; 6: ) Japan Society for the Study of Obesity, ed: 2006 Diagnostic guidelines for obesity. J Jpn Soc Study of Obesity, 2011; 12: ) Nakamura T, Tokunaga K, Shimomura I, Nishida M, Yoshida S, Kotani K, Islam AH, Keno Y, Kobatake T, Nagai Y, Fujioka S, Tarui S, Matsuzawa Y: Contribution of visceral fat accumulation to the development of coronary artery disease in non-obese men. Atherosclerosis, 1994; 107: ) Fujimoto WY, Bergstrom RW, Boyko EJ, Chen KW, Leonetti DL, Newell-Morris L, Shofer JB, Wahl PW: Visceral adiposity and incident coronary heart disease in Japanese-American men. The 10-year follow-up results of the Seattle Japanese-American community diabetes study. diabetes Care, 1999; 22: ) Alberti KG, Eckel RH, Grundy SM, Zimmet PZ, Cleeman JI, Donato KA, Fruchart JC, James WP, Loria CM, Smith SC Jr; International Diabetes Federation Task Force on Epidemiology and Prevention; Hational Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; International Association for the Study of Obesity: Harmonizing the metabolic syndrome: a joint interim statement of the 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. Circulation, 2009; 120: ) Wen C-P, Gershoff SN: Changes in serum cholesterol and coronary heart disease mortality associated with changes in the postwar Japanese diet. Am J Clin Nutr, 1973; 26: ) Hiuge-Shimizu A, Kishida K, Funahashi T, Okutsu M, Kametani R, Kobayashi H, Nozaki Y, Nomura A, Yokoi H, Yoshizumi T, Ohira T, Nakamura T, Matsuzawa Y, Sumitsuji S, Shimomura I. Absolute value of visceral fat area measured on computed tomography scans and obesity-related cardiovascular risk factors in large-scale Japanese general population (the VACATION-J study). Ann Med Oct 22 Early Online 21) Takeuchi H, Saitoh S, Takagi S, Ohnishi H, Ohhata J, Isobe T, Shimamoto K ncept of metabolic syndrome defined by the national cholesterol education programadult treatment panel Ⅲ to Japanese men-the Tanno and Sobetsu Study. Hypertens Res, 200; 28: ) Malik S, Wong ND, Franklin SS, Kamath TV, L'Italien GJ, Pio JR, Williams GR: Impact of the metabolic syndrome on mortality from coronary heart disease, cardiovascular disease, and all causes in United States adults. Circulation, 2004; 110: ) Hunt KJ, Resendez RG, Williams K, Haffner SM, Stern MP; San Antonio Heart Study: National cholesterol education program versus world health organization metabolic syndrome in relation to all-cause and cardiovascular mortality in the san antonio heart study. Circulation, 2004; 110: ) Isomaa B, Almgren P, Tuomi T, Forsén B, Lahti K, Nissén

5 M, Taskinen MR, Groop L: Cardiovascular morbidity and mortality associated with the metabolic syndrome. Diabetes Care, 2001; 24: ) Lakka HM, Laaksonen DE, Lakka TA, Niskanen LK, Kumpusalo E, Tuomilehto J, Salonen JT: The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men. JAMA, 2002; 288: ) Mottillo S, Filion KB, Genest J, Joseph L, Pilote L, Poirier P, Rinfret S, Schiffrin EL, Eisenberg MJ: The metabolic syndrome and cardiovascular risk: a systematic review and meta-analysis. J Am Coll Cardiol, 2010; 6: ) Kasai T, Miyauchi K, Kurata T, Ohta H, Okazaki S, Miyazaki T, Kajimoto K, Kubota N, Daida H: Prognostic value of the metabolic syndrome for long-term outcomes in patients undergoing percutaneous coronary intervention. Circ J, 2006; 70: ) Japan Society for the Study of Obesity, ed.: 2006 Diagnostic guidelines for obesity. J Jpn Soc Study of Obesity, 2006; 12 (Extra Edition)