Time to Recognize Cardiovascular-Kidney-Metabolic Syndrome, AHA Says

With the newly dubbed “cardiovascular-kidney-metabolic (CKM) syndrome,” the American Heart Association (AHA) expands concepts of cardiovascular risk, prevention, and management in a framework that touches nearly every major organ system.

In a presidential advisory, the AHA defined CKM syndrome for the first time as a health disorder attributable to overlaps among obesity, diabetes, chronic kidney disease (CKD), and cardiovascular disease (CVD), including heart failure, atrial fibrillation, coronary heart disease, stroke, and peripheral artery disease. CKM syndrome includes those at risk for CVD and those with existing CVD.

“The public health urgency associated with CKM syndrome is a consequence of the historically high prevalence of obesity and diabetes in both adults and youth, with a disproportionate burden in disenfranchised populations,” wrote an AHA writing committee chaired by Chiadi Ndumele, MD, PHD, MHS, of Johns Hopkins University in Baltimore, in the advisory in Circulation.

“There is a need for fundamental changes in how we educate health care professionals and the public, how we organize care and how we reimburse care related to CKM syndrome,” Ndumele said in a press release. “Key partnerships among stakeholders are needed to improve access to therapies, to support new care models and to make it easier for people from diverse communities and circumstances to live healthier lifestyles and to achieve ideal cardiovascular health.”

The AHA group described CKM syndrome by increasing stages of risk with corresponding differences in care goals:

• Stage 0 (no risk factors): An entirely preventive focus based on the AHA Life’s Essential 8 framework. Adults should be screened every 3-5 years to assess blood pressure, triglycerides, HDL cholesterol, and blood sugar.
• Stage 1 (excess body fat and/or impaired glucose tolerance or prediabetes): Healthy lifestyle and a goal of at least 5% weight loss. Screening every 2-3 years is advised.
• Stage 2 (metabolic risk factors present): Prevent progression to CVD and kidney failure by treating type 2 diabetes, high blood pressure, high triglycerides, or kidney disease. Yearly assessment of these risk factors is recommended.
• Stage 3 (early, asymptomatic CVD): Intensify prevention therapies and consider coronary artery calcium screening.
• Stage 4 (CVD with or without kidney failure): Individualized treatment for CVD with consideration for CKM syndrome conditions.

The advisory states that people making healthy lifestyle changes and achieving weight loss may regress to lower CKM syndrome stages, and the best opportunity for this is while they are in Stages 1, 2, and 3.

“Screening for kidney and metabolic disease will help us start protective therapies earlier to most effectively prevent heart disease and best manage existing heart disease,” said Ndumele. “The advisory provides guidance for health care professionals about how and when to use those therapies, and for the medical community and general public about the best ways to prevent and manage CKM syndrome.”

Also announced are plans for a forthcoming CKM risk calculator that expands upon the pooled cohort equations to predict heart attack, stroke, and heart failure in 10 and 30 years — starting as early as age 30. Risk calculations should be amended to include kidney function, type 2 diabetes control, and social determinants of health, the AHA suggested.

Meanwhile, the widely used pooled cohort equations are currently limited to estimating 10-year risk of a heart attack or stroke in people ages 40-75. The tool is known to underestimate risk for Native Americans, South Asians, and Puerto Ricans but overestimate risk for East Asians and Mexican Americans.

The AHA presidential advisory was accompanied by a scientific statement reviewing the landscape of guidelines and studies, and describes where gaps remain in knowledge needed to further improve CKM health.

For now, estimates indicate that one in three U.S. adults have three or more risk factors that contribute to CKM syndrome.

“With the present low rates of control of individual CKM risk factors, there is a need to define optimal strategies for prioritizing and managing multiple risk factors at various stages of CKM syndrome. Real-world effectiveness and implementation studies, with both quantitative and qualitative components, will be needed to refine CKM care models in the population,” wrote Ndumele’s group.

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