Aside from obesity and smoking, diabetes, hypertension, or dyslipidemia may not be known until the appropriate diagnostic tests have been performed. Thus, control of these risk factors may not be obvious. Patients may become impatient regarding the benefit of any management strategy. A performance measure to suggest functional capacity improvement is clinically relevant both to patients and physicians. The New York Heart Association classification indicating fatigue even at rest, on mild, moderate or severe exertion are subjective assessments with inter-and intra-observer variability. The Framingham criteria are applicable for heart failure evaluation that includes major and minor criteria with HF physical examination findings. The Boston, Gotemberg and European Society of Cardiology criteria in addition include chest x-ray findings. Treadmill or bicycle ergometer functional capacity examinations are equipment dependent. What is a practical and inexpensive functional capacity determination?

The 6 minutes walk has been significantly correlated with the New York Heart Association functional capacity test among HF case. (Eur Heart J ’05;26:778) The distance in meters covered during a six minutes level walk can provide baseline data. Subsequently, monitored information regarding individual performance can be done. This objective test should be a useful motivator for anyone to assess improvement or deterioration of ones function. A PASOO study shows that a marching band can cover 400 meters in 6 minutes. As a guide, a USA data among class III NYHA criteria has a 300 meters average distance. Thus, metabolic syndrome risk particularly among obese cases may monitor effects of life style modification or pharmaceutical interventions.

The earliest manifestation of atherosclerosis is endothelial dysfunction. The usual diagnostic procedure is the hyperemic test using Doppler Vascular changes. Blood pressure is influenced by blood vessel flow and resistance. At raised arm, BP component of flow is reduced leaving vascular resistance as the major BP determinant. Such raised arm maneuver (RAM) correlated with the BP changes following sublingual NTG use due to preload reduction of venous retum. Inflating the cuff at RAM and then taking the BP after the arm is lowered (post RAM) can reflect flow mediated dilation effect. Thus, normal BP will show lower SBP at RAM and post-RAM compared to usual BP recording. On the other hand, hypertensive cases will have similar RAM and control SBP. Higher post RAM SBP is due to flow mediated constriction rather than the expected dilation. The RAM test correlated with the hyperemic Doppler scan testing. Increasing pulse pressure (SBP-DBP) monitored changes greater than 40 mmHg is also an indicator of endothelial dysfunction.

Since the Metabolic Syndrome of Smoking, over Eating, eXercise lack, Hypertension, Diabetes, dysLipidemia (SEX-HDL) may not necessarily kill until target organ damage exist, determination of endothelial dysfunction and functional capacity may provide prognostic implication. Small caliber vessels can dilate much more than the larger caliber vessels. Endothelial dysfunction can manifest more in microvessels leading microvascular disease (MVD). The role of MVD is in LVH as a marker of cardiac remodeling is in response to risk factors enumerated above. Diastolic ventricular dysfunction is a compliance problem. Insufficiency lusitrophy can result in acute pulmonary congestion in 50%. A recent study, OPTIMIZED-HF registry shows that < 40%, 40-50%, > 50% ejection fraction (EF) have similar in- hospital death, post-hospital mortality and re-hospitalization for HF (JACC ’07; 50:768). Thus, preserved or depressed LVF can have similar morbidity and mortality risks. Despite a positive treadmill stress test for ischemia among hypertensives with echo evidence of LVH and hypokinesia and typical angina, coronary angiogram is significant in only 46% suggesting wall stress and MVD components in the ischemic burden. Retinopathy and micro-albuminuria are manifestations of extra-cardiac MVD. MVD can limit infarct size regression or reduce survival rates in post MI treatment.

In summary, obesity is not a stand-alone clinical problem. Co-morbidities comprising the metabolic syndrome can result in endothelial dysfunction that can be suspected following a RAM test. Such patho-physiology can result in MVD that has prognostic implications. Metabolic syndrome components are asymptomatic and may required diagnostic methodologies for confirmation. At risk or treated patient may utilize the 6-minute walk to objectively measure life style modification or pharmacologic treatment outcome. Finally, it is difficult to quit smoking, eat properly, lose weight, or exercise if other members will no do the same. Being a matriarchal culture, the boss in the home, the wife or mother should lead the way. And since genetic may play a significant role in obesity or the metabolic syndrome, early detection of family member of consulting patients can provide a household primordial or primary preventive strategy.