The first cardiovascular-kidney-metabolic syndrome guidelines are urging clinicians to identify risks sooner and take early action with pharmacotherapy to protect against long-term heart, metabolic and kidney complications.

Led by the American Heart Association and the American College of Cardiology, the multisociety guidelines emphasise CKM syndrome staging for preventing progression, tailoring therapy, reducing cardiovascular events and loss of kidney function, and promoting CKM stage regression through lifestyle changes.

The authors, who also represent the American Diabetes Association and the American Society of Nephrology, recommend quantitative risk assessments to guide clinician-patient discussion around risk-reducing strategies. There are also calls to assess and address social determinants of health as a key risk factor for developing CKM syndrome and to introduce a “CKM Coordination Point Person” to coordinate care across kidney, diabetes and cardiovascular diseases.

Top take-home messages highlighted in a societal statement include:

• Routine assessments for metabolic risk factors and kidney function for all adults, and select assessments for pre-HF, metabolic dysfunction–associated steatotic liver disease (MASLD), and obstructive sleep apnoea in subsets of individuals. The guidelines provide advice on timeframes.

• Patients at risk for CVD should have their 10- and 30-year risk estimated for ASCVD, HF and total CVD using the PREVENT equations, with the results to inform CKM staging and decisions around pharmacotherapy prioritisation.

• Cardioprotective antihyperglycaemic therapies should be used for patients with T2D and CVD or at increased risk for CVD to improve CVD and kidney outcomes. These include SGLT2 inhibitors, GLP-1RAs or both depending on comorbidities such as CKD, ASCVD, HF, obesity, severe hyperglycaemia and MASLD.

• Glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR) should be used to characterise CKD and guide the use of kidney-protective agents. For patients with CKD and T2D or CKD and albuminuria:
  • Renin-angiotensin system inhibitors (RASi) and SGLT2i should be used as first-line therapy.
  • If albuminuria persists among patients with CKD and T2D, nonsteroidal mineralocorticoid receptor antagonist (MRA) or a GLP-1–based therapy should be added for further kidney and cardiovascular protection.

“A common challenge for individuals with CKM syndrome is the delayed recognition of risk factors and conditions that confer substantial risk for adverse outcomes. Earlier identification of these conditions and timely initiation of proven therapies are associated with improved outcomes,” the authors wrote in the 100-page document.

They added that their proposed CKM syndrome care model reflected a “paradigm-shift to less siloed, more integrated clinical care”  for those with multiple interconnected clinical conditions, and education and training would need to be reconsidered and adapted to reflect this shift in clinical approach.

Will the CKM guidelines change Aussie practice?

Associate Professor Adam Nelson.

Speaking to the limbic, Associate Professor Adam Nelson, an interventional and general cardiologist at the Royal Adelaide Hospital, said the guidelines were a positive step towards providing a ‘one-stop shop’ for the CKM patient.

“Organ-based specialists tend to be focused on their disease without addressing related pathology elsewhere. This leads to untreated elements of the CKM syndrome and ultimately promotes potentially preventable multimorbidity,” he said.

“Each of our professional societies have incorporated specific CKM guidance (Heart Foundation for cardiology and now more recently the obesity consensus statement, KDIGO for kidney guidance) although some of it isn’t necessarily aligned with each other and still requires generalist-aspiring doctors to look at each guideline for relevant disease or organ-specific elements.”

He also highlighted some challenges around implementation locally.

Regarding the American Heart Association’s PREVENT equations, Associate Professor Nelson said the assessment was analogous to, but more expansive than, Australia’s CVD risk equation, and how accurately it translated locally would need to be evaluated. It also potentially added confusion with yet another risk score to the mix of available tools.

“The elevation of 30-year risk assessment I think is helpful when undertaking conversations with younger patients where 5-year risk is simply too proximate,” he said.

He also pointed out that implementing the recommendations around pharmacotherapy, which aligned with Australian guidance, would be challenging considering GLP1-based therapy was not reimbursed for those with obesity with complications, which created “an evidence to practice gap for many patients”.

“Indeed those patients most vulnerable to CKM conditions through lower socioeconomic status are most likely to benefit from GLP-1RA based therapy but least likely to be able to access,” he said.

Associate Professor Nelson also said the concept of health promotion in the earlier stages aligned with Australia’s health promotion strategy, but “actually implementing this in current culture and care models is going to be a big effort”.

He said GP specialists were ideally placed to scaffold the care for patients with, or at risk of, CKM syndrome.

The guidelines were published in the American Heart Association’s flagship peer-reviewed journal Circulation [link here], with a societal statement and at-a-glance guide available in the Journal of the American College of Cardiology [link here].