How PCPs should care for each stage of cardiovascular-kidney-metabolic syndrome

Key takeaways:

• Cardiovascular-kidney-metabolic syndrome, a recent term coined by the American Heart Association, is a growing cause of concern in the U.S.
• Experts described how PCPs should care for patients during each stage.

Primary care providers play a critical role in detecting and managing cardiovascular-kidney-metabolic syndrome, according to experts.

In October, the American Heart Association (AHA) released a presidential advisory on cardiovascular-kidney-metabolic (CKM) syndrome, which “defines the collective health condition caused by connections among CVD, kidney disease, type 2 diabetes and obesity,” Joshua J. Joseph, MD, MPH, FAHA, a member of the AHA’s CKM science advisory group, told Healio.

Chiadi E. Ndumele, MD, PhD, FAHA, associate professor of medicine and director of obesity and cardiometabolic research at Johns Hopkins University, chair of the AHA’s CKM science advisory group and lead author of the advisory, said “due to the increasing burden of the inter-related risk factors of obesity, diabetes and chronic kidney disease,” CKM health “is a growing cause of heart disease risk in the population.”

“Individuals with CKM syndrome suffer from premature cardiovascular mortality, and CKM syndrome is responsible for worsening trends in cardiovascular mortality in the population,” he said.

The AHA has estimated that one-third of adults in the United States have at least three risk factors contributing to CVD, kidney disease or metabolic disorders, Joseph said.

“CKM affects nearly every major organ in the body, including the heart, brain, kidney and liver,” Joseph, who is also an associate professor of internal medicine, endowed professor for research in internal medicine and investigator at the Diabetes & Metabolism Research Center at The Ohio State University Wexner Medical Center, told Healio. “However, the biggest impact is on the cardiovascular system, affecting blood vessels and heart muscle function, the rate of fatty buildup in arteries, electrical impulses in the heart and more.”

Ndumele said seeking health care can be challenging for patients with CKM syndrome.

“They often experience fragmented care and difficulties navigating multiple subspecialists,” Ndumele said. “Like other health care providers, I commonly take care of patients with overlapping metabolic risk factors, [chronic kidney disease] and heart disease, and there is a clear need for more holistic and interdisciplinary approaches to supporting their care and improving long-term outcomes.”

A major part of the AHA’s October 2023 presidential advisory focused on defining CKM syndrome. Because CKM syndrome is a relatively new concept, awareness and understanding is still a key issue.

What is CKM syndrome?

The historically high prevalence of type 2 diabetes and obesity is largely responsible for CKM syndrome.

“Type 2 diabetes and obesity are metabolic conditions — the ‘M’ in CKM — that are also risk factors for cardiovascular disease,” Joseph said. “Moreover, the most common cause of death for people with type 2 diabetes and chronic kidney disease is cardiovascular disease.”

The presidential advisory also emphasized identifying patients at the early stages of CKM syndrome “so interventions can begin quickly and progression to later stages may be prevented or delayed,” Joseph said.

“Screening for CKM is intended to detect cardiovascular, metabolic and kidney health changes early and throughout the life course; identify social and structural barriers to care; and prevent progression to the next stage of CKM syndrome,” Joseph added. “Screenings should be tailored to each individual based on the CKM stage of each patient.”

The stages of CKM range from 0 (prevention) to 4 (the highest risk), and each is associated with specific care recommendations:

• stage 0: no risk factors, symptoms or measures of any CKM conditions;
• stage 1: excess and/or an unhealthy distribution of body fat (like abdominal obesity), and/or prediabetes or impaired glucose tolerance;
• stage 2: metabolic and renal risk factors such as hypertension, type 2 diabetes, kidney disease or high triglycerides;
• stage 3, subclinical atherosclerosis CVD or subclinical heart failure; and
• stage 4, clinical CVD.

At stage 0, Joseph said providers should counsel patients to follow the AHA’s Life’s Essential 8 strategy for optimal cardiovascular health and to prevent progressing to any CKM stage.

At stage 1, the AHA recommends support for healthy lifestyle changes like diet and exercise and a goal of 5% weight loss. If needed, treatment for glucose intolerance is also recommended. Every 2 to 3 years, the patient should be screened to assess blood glucose, BP, cholesterol and triglycerides.

Stage 2 indicates a higher risk for worsening heart and kidney disease, Joseph said. As providers attempt to address risk factors and prevent disease progression, treatments can include medications to control cholesterol, blood glucose and BP. For certain patients, SGLT2 inhibitors and GLP-1 receptor agonists can also be helpful. Suggested screening is a yearly evaluation of kidney function, BP, blood sugar, triglycerides and cholesterol.

In stage 3, the goal of care “is to intensify efforts to prevent people who are at high risk of progressing to symptomatic cardiovascular disease and kidney failure,” Joseph said. That includes additional focus on lifestyle changes and adjusting medications. In some cases, when treatment decisions are unclear, coronary artery calcium measurement to assess narrowing of the arteries can help guide decisions on cholesterol-lowering statin therapy.

Stage 4 encompasses two subcategories: 4a for patients without kidney failure and 4b for patients who have it. Joseph said, at this point, patients may have already had a stroke, myocardial infarction or heart failure, and “may have additional cardiovascular conditions such as peripheral artery disease or atrial fibrillation.” Here, he said, “the goal of care is individualized treatment for cardiovascular disease with consideration for CKM syndrome conditions.”

Ndumele said most patients with CKM syndrome in stages 0, 1 and 2 will exclusively see their PCPs for care, “so it is critical that we support PCPs in helping their patients understand where they are along the CKM syndrome spectrum, and that we help to optimize their care.”

Implications for PCPs

PCPs “are key to early detection and referral for treatment for CKM-related health conditions,” Joseph said.

“The 2023 presidential advisory suggests the multidisciplinary team includes a primary care clinician in addition to professionals in cardiology, endocrinology, obesity and kidney disease,” Joseph added. “PCPs play an important role in supporting routine weight monitoring and counseling to improve lifestyle and health.”

Ndumele said because CKM syndrome “is a multisystem challenge,” several different specialties are often involved in its care.

“PCPs have long been at the center of coordinating care for patients with multisystem disease, so the journey to optimizing CKM health will often start with them,” he said. “It’s important that the approach to care for CKM syndrome is harmonized across these various health care professionals, and that care is collaborative and coordinated.”

Considering the critical part PCPs play in early diagnosis and treatment, “we encourage them to learn about CKM health and urge an active role in developing and sustaining a multidisciplinary health care team for their patients with CKM syndrome or suspected CKM syndrome,” Joseph said. “With early intervention, we have the opportunity to reduce risk, slow progression and hopefully promote longer, healthier lives for our patients.”

Resources

Joseph said “a plethora of resources are available” for PCPs to learn more about CKM syndrome, its diagnosis and management. For example, the AHA’s presidential advisory statement offers various materials to help educate health care professionals.

“At this time, the most important new tool for clinicians is the new CKM risk calculator called PREVENT,” he said. “It includes health measures of kidney function, type 2 diabetes control (using blood test results instead of a yes/no response) and social determinants of health to produce a more comprehensive risk estimate.”

Joseph said the calculator quantifies CKM risk score based on a patient’s health measures and their demographic information and “is able to estimate 10-year and 30-year total CKM risk.” Additionally, it can be used for patients as young as 30 years. This represents a major improvement over the limitations of the previous risk calculator, which Joseph said “could estimate only 10-year risk and was valid only for adults aged 40 to 79 years.”

Alongside the PREVENT calculator, Ndumele also mentioned CKM coordinators, who “partner with PCPs and other health care professionals to help patients in their journey to optimizing CKM health.”

“The focus here should be on strategies to help individuals in the population to optimize their health, which will have substantial long-term benefits for preventing cardiovascular and kidney disease,” he said.

Additionally, the AHA recently announced a 4-year long initiative “to implement a person-centered approach to awareness, professional and patient education, and treatment of CKM syndrome,” according to a press release from the organization. In collaboration with several other national organizations and nonprofits, the initiative will reach more than 265,000 patients at 150 health care sites across the U.S.

Ndumele said he is “very excited by the AHA’s new initiative,” and that it will “take the principles of holistic care described in the CKM health presidential advisory, including facilitating interdisciplinary care and addressing social determinants of health, and make sure they are being applied to real-world populations.”

“This initiative should help to bring hope to the many individuals in the population suffering from clusters of interconnected conditions within CKM syndrome,” he said. “By focusing on systematic screening, risk assessments, coordinated care, addressing social determinants of health and the use of powerful evidence-based therapies for addressing metabolic risk factors, [chronic kidney disease] and heart disease risk, this initiative has the potential to have a powerful impact on the health of individuals with CKM syndrome.”

References:

• Cardiovascular-Kidney-Metabolic health: A presidential advisory from the American Heart Association. https://professional.heart.org/en/guidelines-statements/cardiovascularkidneymetabolic-health-a-presidential-advisory-from-the-americancir0000000000001184. Accessed July 11, 2024.
• New opportunity to improve diagnosis, care for people with cardiovascular-kidney-metabolic syndrome. https://newsroom.heart.org/news/new-opportunity-to-improve-diagnosis-care-for-people-with-cardiovascular-kidney-metabolic-syndrome. Published July 17, 2024. Accessed July 17, 2024.