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Cardiovascular, Kidney, and Metabolic Health: American Heart Association Presidential Notice
Summary
Cardiovascular, renal, and metabolic health reflect the interaction between metabolic risk factors, chronic kidney disease, and the cardiovascular system and have profound impacts on morbidity and mortality. Poor cardiovascular, renal, and metabolic health has multisystem consequences , with the most significant clinical impact being the associated high incidence of cardiovascular disease events and cardiovascular mortality. There is a high prevalence of poor cardiovascular, renal and metabolic health in the population, with a disproportionate burden among those with adverse social determinants of health.
However, there is also a growing number of therapeutic options that favorably impact metabolic risk factors, kidney function, or both and that also have cardioprotective effects . To improve cardiovascular, renal, and metabolic health and related outcomes in the population, there is a critical need for: (1) more clarity in the definition of cardiovascular, renal, and metabolic syndrome ; (2) a cardiovascular-kidney-metabolic staging approach that promotes lifelong prevention; (3) prediction algorithms that include the exposures and outcomes most relevant to cardiovascular, renal, and metabolic health; and (4) strategies for the prevention and treatment of cardiovascular disease in relation to cardiovascular, renal, and metabolic health that reflect harmonization between major subspecialty guidelines and emerging scientific evidence.
It is also critical to incorporate social determinants of health considerations into models of care for cardiovascular-kidney-metabolic syndrome and reduce fragmentation of care by facilitating approaches to interdisciplinary patient-centered care. This presidential notice provides guidance on the definition, staging, prediction paradigms, and holistic approaches to the care of patients with cardiovascular-kidney-metabolic syndrome and details a multicomponent vision to effectively and equitably improve cardiovascular-kidney-metabolic health in the population.
Comments
Health experts are redefining cardiovascular disease (CVD) risk, prevention and risk management, according to a new American Association presidential advisor published in the Association’s flagship journal Circulation .
Several aspects of cardiovascular disease that overlap with kidney disease, type 2 diabetes and obesity support the new approach. For the first time, the American Heart Association defines the overlap in these conditions as cardiovascular-renal-metabolic (CKM) syndrome . People who have or are at risk for cardiovascular disease may have cardiovascular-renal-metabolic (CKM) syndrome.
The detailed new approach in presidential advice includes:
- CKM stage stages ranging from 0, or no risk factors and a completely preventive approach, to stage 4, the highest risk stage with established cardiovascular disease. Stage 4 may also include kidney failure. Each stage correlates with specific projections and therapies.
- Addresses social factors that impact health.
- Collaborative care between multiple specialties to treat the entire patient is approaching.
- Suggested updates to the algorithm, or risk calculator, that helps health professionals predict a person’s chance of having a heart attack or stroke. The update adds a risk prediction for heart failure, which estimates the risk of total cardiovascular disease, heart attack, stroke, and/or heart failure.
- The writing group suggests that the updated algorithm provides both 10- and 30-year cardiovascular disease risk estimates.
According to the American Heart Association 2023 Statistical Update , 1 in 3 U.S. adults has three or more risk factors that contribute to cardiovascular disease, metabolic disorders, and/or kidney disease. Cardiovascular-renal-metabolic (CKM) syndrome affects almost all major organs in the body, including the heart, brain, kidney, and liver. However, the greatest impact is on the cardiovascular system, affecting the blood vessels and muscle function of the heart, the rate of fat accumulation in the arteries, electrical impulses in the heart and more.
The advisor addresses the connections between these conditions with a particular focus on identifying people in the early stages of CKM syndrome, said Chiadi E. Ndumele, M.D., Ph.D., MHS, FAHA, chair of the writing committee and professor associate of medicine and director of obesity and cardiometabolic research in the division of cardiology at Johns Hopkins University in Baltimore. Addressing kidney and metabolic diseases will help us start protective therapies sooner to most effectively prevent heart disease and better manage existing heart disease.
Cardiovascular-renal-metabolic (CKM) syndrome is a consequence of the historically high prevalence of obesity and type 2 diabetes in both adults and young people, according to the advisory. Type 2 diabetes and obesity are metabolic conditions, the M in CKM , that are also risk factors for cardiovascular disease. Additionally, the most common cause of death for people with type 2 diabetes and chronic kidney disease is cardiovascular disease.
We now have several therapies that prevent both kidney and heart disease from worsening, Ndumele said. The advice provides guidance for healthcare professionals on how and when to use such therapies, and for the medical community and the general public on the best ways to prevent and manage CKM syndrome.
With multiple conditions to manage, Ndumele noted that fragmented care is a concern in the treatment of patients with CKM syndrome, particularly for those with barriers to care. The advice suggests ways in which professionals from different specialties can better work together as part of a unified team to treat the whole patient. Additionally, the counselor emphasizes the importance of systematic screening for social factors that act as determinants, or drivers, of health, such as nutritional insecurity and exercise opportunities, as key aspects of optimal CKM syndrome care.
A companion article published with the presidential advisor, a new scientific statement from the American Heart Association documents the evidence for the approach proposed by the writing committee. The scientific statement brings together evidence from current guidelines and large research studies and describes where gaps remain in the knowledge needed to continue improving CKM health.
CKM screening, stages and treatment
Screening related to cardiovascular-renal-metabolic (CKM) syndrome is intended to detect early cardiovascular, metabolic, and kidney health changes; identify social and structural barriers to care; and prevent progression to the next stage of CKM syndrome.
The advice is aimed at caring for adults. However, studies suggest that MRC syndrome is progressive and begins early in life. Therefore, the advice aligns with the American Academy of Pediatrics’ recommendations for children and youth to have annual weight, blood pressure, and mental and behavioral health screenings, starting at age 3 .
Stage 0 – No CKM risk factors . The goal at this stage is to prevent CKM syndrome by achieving and maintaining ideal health based on the American Heart Association’s Essential Living 8 recommendations. Recommendations include healthy eating, physical activity, and sleep habits; avoid nicotine; and maintain optimal weight, blood pressure, blood sugar and cholesterol levels. The council suggests screening Stage 0 adults every three to five years to assess blood pressure, triglycerides, HDL (good) cholesterol and blood sugar.
Preventing unhealthy weight gain is important for preventing CKM syndrome because of obesity’s connection to type 2 diabetes, high blood pressure, and high triglycerides. At all stages, the council proposes annual measurement of waist circumference and body mass index . Healthy lifestyle behaviors are also encouraged at all stages.
Stage 1 – Addressing body fat and/or an unhealthy distribution of body fat, such as abdominal obesity, and/or impaired glucose tolerance or prediabetes. Support for healthy lifestyle changes (healthy eating and regular physical activity) and a goal of at least 5% weight loss is suggested in people with Stage 1, with treatment for glucose intolerance if necessary . It is advisable to examine blood pressure, triglycerides, cholesterol and blood sugar every two or three years.
Stage 2 – Metabolic risk factors and kidney disease. Stage 2 includes people with type 2 diabetes, high blood pressure, high triglycerides, or kidney disease, and indicates an increased risk of worsening kidney disease and heart disease. The goal of care at this stage is to address risk factors to prevent progression to cardiovascular disease and kidney failure. Treatment may include medications to control blood pressure, blood sugar, and cholesterol . In those with chronic kidney disease and in some people with type 2 diabetes, SGLT2 inhibitors are advised to protect kidney function and reduce the risk of heart failure. SGLT2 inhibitors are a class of prescription medications that are approved by the FDA for use with diet and exercise to lower blood sugar in adults with type 2 diabetes. Glucagon-like peptide 1 receptor agonists are also suggested ( GLP-1) for consideration in people with type 2 diabetes to help reduce high glucose, facilitate weight loss, and reduce the risk of CVD. Other therapies are also advised to prevent worsening of kidney function. Screening suggestions for stage 2 CKM syndrome align with AHA/ACC guidelines, including annual evaluation of blood pressure, triglycerides, cholesterol, blood sugar, and kidney function. For those at higher risk of kidney failure based on kidney function assessments, more frequent kidney screening is recommended.
Stage 3 – Early cardiovascular disease without symptoms in people with metabolic risk factors or kidney disease or in those at high risk for cardiovascular disease. The goal of Stage 3 care is to intensify efforts to prevent people who are at high risk from progressing to symptomatic cardiovascular disease and kidney failure. This may involve increasing or changing medications, and additional focus on lifestyle changes. The writing committee advises measuring coronary artery calcium (CAC) in some adults to evaluate narrowing of the arteries when treatment decisions are unclear. CAC screening is used to guide decisions about cholesterol-lowering statin therapy. Test results indicating asymptomatic heart failure should lead to intensified therapy to prevent heart failure symptoms.
The advisor also describes CKM syndrome regression , an important concept and public health message in which people who make healthy lifestyle changes and achieve weight loss can regress into lower stages of CKM syndrome and a better state of health. The best chance for patients to experience regression is in stages 1, 2, and 3. Some may see improvements in glucose control, cholesterol and blood pressure levels, weight, kidney function, and types of cardiac dysfunction. .
Stage 4 Symptomatic cardiovascular disease in people with excess body fat, metabolic risk factors, or kidney disease. Stage 4 syndrome is divided into two subcategories: (4a) for those without kidney failure or (4b) for those with kidney failure . At this stage, people may have had a heart attack or stroke or may already have heart failure. They may also have additional cardiovascular conditions such as peripheral artery disease or atrial fibrillation. The goal of care is individualized treatment for cardiovascular disease with consideration for CKM syndrome conditions.
Predict risk
A critical step in assessing risk and managing CKM syndrome is to update the risk prediction algorithm to help healthcare professionals predict cardiovascular disease in a way that includes components of CKM: cardiovascular disease, chronic kidney disease and metabolic disorders.
The Pooled Cohort Equation , the current atherosclerotic cardiovascular disease risk calculator, established in 2013, estimates the risk of a heart attack or stroke in the next 10 years for people ages 40-75. It includes health and demographic factors about a person and is used to guide lifestyle recommendations and treatment decisions for people at risk for cardiovascular disease. Risk factors are age, sex, and race (such as white, black, and other); cholesterol levels; and systolic blood pressure. The equation also includes yes/no responses to whether a person is receiving treatment for high blood pressure, Type 2 Diabetes, or smokes cigarettes.
The advisor proposes updating the risk calculator to include measures of kidney function, type 2 diabetes management (using blood test results instead of a yes/no answer), and social determinants of health for an estimate more complete risk assessment. Kidney function assessments include a measure of how well the kidneys filter albumin levels in blood and urine, a measure of how well the kidneys reabsorb protein. Individual health measures in addition to demographic information will allow the calculator to produce a total CVD risk estimate.
The writing group recommends that updates to the risk calculator be expanded to assess risk in people as young as 30 years old and to calculate 10- and 30-year CVD risk. More comprehensive cardiovascular risk assessment at younger ages will allow for earlier preventative strategies to mitigate progression to advanced stages of CKM syndrome. In the long term, this will help reduce gaps in treatment and health equity and improve outcomes.
Calls to action
The advice calls for systemic changes to optimize CKM health.
There is a need for fundamental changes in the way we educate healthcare professionals and the public, how we organize care, and how we reimburse for care related to CKM syndrome, Ndumele said. Partnerships between stakeholders are needed to improve access to therapies, to support new models of care and to make it easier for people from diverse communities and circumstances to live healthier lifestyles and achieve ideal cardiovascular health.
Investing in research is important to advance CKM care. The main gaps in the research include:
Better understand the pathways that lead to heart disease in CKM syndrome.
A better understanding of why some people may progress more quickly through the stages of CM, while others may progress more slowly.
Understand how best to use newer therapies with multiple effects on CKM syndrome, including to improve metabolic factors such as obesity and type 2 diabetes, and reduce worsening of kidney disease and prevent heart disease.
