Cardiovascular-Kidney-Metabolic Health: A Presidential Advisory From the American Heart Association

Cardiac Troponin to Adjudicate Subclinical Heart Failure in Diabetic Patients and a Murine Model of Metabolic Syndrome

BACKGROUND

Cardiovascular disease, kidney health, and metabolic disease (CKM) syndrome is associated with significant morbidity and mortality, particularly from congestive heart failure (CHF). Guidelines recommend measurement of cardiac troponin (cTn) to identify subclinical heart failure (HF) in diabetics/CKM. However, appropriate thresholds and the impact from routine screening have not been elucidated.

METHODS

cTnI was assessed using the Abbott high sensitivity (hs)-cTnI assay in outpatients with physician-ordered hemoglobin A1c (Hb A1c) and associated with cardiac comorbidities/diagnoses, demographics, and estimated glomerular filtration rate (eGFR). Risk thresholds used in CKM staging guidelines of >10 and >12 ng/L for females and males, respectively, were used. Multivariate logistic regression was applied. hs-cTnI was assessed in a high-fat-diet induced murine model of obesity and diabetes.

RESULTS

Of 1304 patients, 8.0% females and 15.7% males had cTnI concentrations above the risk thresholds. Thirty-one (4.2%) females and 23 (4.1%) males had cTnI above the sex-specific 99% upper reference limit. A correlation between hs-cTnI and Hb A1c (R = 0.2) and eGFR (R = -0.5) was observed. hs-cTnI concentrations increased stepwise based on A1C of <5.7% (median = 1.5, IQR:1.3-1.8), 5.7%-6.4% (2.1, 2.0-2.4), 6.5%-8.0% (2.8, 2.5-3.2), and >8% (2.8, 2.2-4.3). Male sex (P < 0.001), eGFR (P < 0.001), and CHF (P = 0.004) predicted elevated hs-cTnI. Obese and diabetic mice had increased hs-cTnI (7.3 ng/L, 4.2-10.4) relative to chow-fed mice (2.6 ng/L, 1.3-3.8).

CONCLUSION

A high proportion of outpatients with diabetes meet criteria for subclinical HF using hs-cTnI measurements. Glucose control is independently associated with elevated cTnI, a finding replicated in a murine model of metabolic syndrome.

Cardiovascular-Kidney-Metabolic Syndrome Among Healthcare Workers in Chinese Tertiary Hospital

Objective

To determine the prevalence of Cardiovascular-Kidney-Metabolic (CKM) Syndrome and identify risk factors, including occupational factors, lifestyle factors and clinical measurements, and female-specific risk enhancers among healthcare workers in China.

Methods

A cross-sectional study was conducted among healthcare workers at Taizhou People's Hospital between April and May 2024. We collected data through surveys and laboratory results. Univariate and multivariate logistic regression analyses were performed to identify predictors of CKM syndrome and female-specific risk enhancers.

Results

A total of 1110 participants were recruited (197 male; 913 female; mean age 34.8±7.9). Almost 90% of male healthcare workers and 60% of female healthcare workers met the criteria for CKM syndrome (stage 1 or higher). Additionally, most male CKM syndrome patients were in stages 2-3 (53.81%), while most female CKM syndrome patients were in stage 1 (35.82%). Multivariate logistic regression analysis revealed that, compared to those with over 20 years of work duration, a work duration of less than 10 years was a protective factor for CKM Syndrome. Additionally, more than 8 hours of sedentary time was identified as a risk factor compared to less than 2 hours (OR = 1.376, 95% CI 1.027-1.844, P < 0.05). Receiver operating characteristic analysis showed that body mass index (BMI) was superior to fasting plasma glucose, glycated hemoglobin, triglycerides, and the triglyceride glucose product index in predicting CKM Syndrome, with area under the curve values of 0.884 vs 0.638, 0.708, 0.745, and 0.761, respectively (P < 0.05 for all). BMI was identified as an independent risk factor for female-specific risk enhancers.

Conclusion

CKM syndrome is prevalent among healthcare workers in Chinese tertiary hospitals, with males generally presenting at more advanced stages than females. BMI is a key predictor of CKM syndrome and female-specific risk enhancers.

Impact of Visceral and Hepatic Fat on Cardiometabolic Health

PURPOSE OF REVIEW

Body fat distribution plays a significant role in the cardiometabolic consequences of obesity. We review the impact of visceral and hepatic fat and highlight important interventions.

RECENT FINDINGS

Several epidemiologic studies have established a clear association between visceral fat and cardiovascular disease. The association between hepatic fat and cardiovascular disease is less clear with discordant results. Novel evidence demonstrates sodium glucose co-transporter-2 (SGLT2) inhibitors facilitate modest weight loss and reductions in ectopic fat depots in patient with type 2 diabetes. Glucagon-like peptide-1 (GLP-1) receptor agonists have been associated with decreased visceral/hepatic fat and reductions in MACE in populations with type 2 diabetes and with overweight/obesity. Clear associations between visceral fat and cardiometabolic outcomes have been established, whereas the impact of hepatic fat remains less clear. Lifestyle modification and pharmacologic interventions remain the initial therapies, while surgical intervention is associated with improved long-term outcomes. Emerging therapies have demonstrated a profound impact on body fat distribution and cardiometabolic risk.

A novel model of cardiovascular-kidney-metabolic syndrome combining unilateral nephrectomy and high-salt-sugar-fat diet in mice

The aim of this study was to explore biological interaction and pathophysiology mechanisms in a new mouse model of cardiovascular-kidney-metabolic (CKM) syndrome, induced by chronic moderate renal failure in combination with consumption of a customized Western diet rich in carbohydrates, fat and salt. Male C57BL/6J mice were subjected to unilateral nephrectomy, fed a customized Western diet rich not only in sugar and fat but also in salt, and followed for 12 weeks or 20 weeks. Sham-operated mice on a standard chow served as healthy controls. Body composition, weight gain, glucose metabolism, fat distribution, blood pressure, cardiac function, vascular reactivity, renal function, inflammation and mitochondrial function were measured and combined with biochemical and histopathological analyses. The novel triple-hit model of CKM syndrome showed signs and symptoms of metabolic syndrome, disturbed glucose metabolism, impaired adipocyte physiology and fat redistribution, cardiovascular dysfunction, renal damage and dysfunction, systemic inflammation, elevated blood pressure and cardiac remodeling. The pathological changes were more pronounced in mice after prolonged exposure for 20 weeks, but no deaths occurred. In the present mouse model of CKM syndrome, profound and significant metabolic, cardiac, vascular and renal dysfunctions and injuries emerged by using a Western diet rich not only in fat and carbohydrates but also in salt. This multisystem disease model could be used for mechanistic studies and the evaluation of new therapeutic strategies.

Routine measurement of cardiometabolic disease risk factors in primary care in England before, during, and after the COVID-19 pandemic: A population-based cohort study

BACKGROUND

This study estimated to what extent the number of measurements of cardiometabolic risk factors (e.g., blood pressure, cholesterol, glycated haemoglobin) were impacted by the COVID-19 pandemic and whether these have recovered to expected levels.

METHODS AND FINDINGS

A cohort of individuals aged ≥18 years in England with records in the primary care-COVID-19 General Practice Extraction Service Data for Pandemic Planning and Research (GDPPR) were identified. Their records of 12 risk factor measurements were extracted between November 2018 and March 2024. Number of measurements per 1,000 individuals were calculated by age group, sex, ethnicity, and area deprivation quintile. The observed number of measurements were compared to a composite expectation band, derived as the union of the 95% confidence intervals of 2 estimates: (1) a projected trend based on data prior to the COVID-19 pandemic; and (2) an assumed stable trend from before pandemic. Point estimates were calculated as the mid-point of the expectation band. A cohort of 49,303,410 individuals aged ≥18 years were included. There was sharp drop in all measurements in March 2020 to February 2022, but overall recovered to the expected levels during March 2022 to February 2023 except for blood pressure, which had prolonged recovery. In March 2023 to March 2024, blood pressure measurements were below expectation by 16% (-19 per 1,000) overall, in people aged 18 to 39 (-23%; -18 per 1,000), 60 to 79 (-17%; -27 per 1,000), and ≥80 (-31%; -57 per 1,000). There was suggestion that recovery in blood pressure measurements was socioeconomically patterned. The second most deprived quintile had the highest deviation (-20%; -23 per 1,000) from expectation compared to least deprived quintile (-13%; -15 per 1,000).

CONCLUSIONS

There was a substantial reduction in routine measurements of cardiometabolic risk factors following the COVID-19 pandemic, with variable recovery. The implications for missed diagnoses, worse prognosis, and health inequality are a concern.

Cardiovascular-kidney-metabolic syndrome - An integrative review

The American Heart Association recently defined the complex interactions among the cardiovascular, renal, and metabolic systems as CKM syndrome. To promote better patient outcomes, having a more profound understanding of CKM pathophysiology and pursuing holistic preventative and therapy strategies is critical. Despite many gaps in understanding CKM syndrome, this study attempts to elucidate two of these gaps: the new emerging biomarkers for screening and the role of inflammation in its pathophysiology. For this review, an extensive search for specific terms was conducted in the following databases: PubMed, Scopus, Web of Science, and Google Scholar. Studies were first assessed by title, abstract, keywords, and selected for portfolio according to eligibility criteria, which led to 38 studies. They provided background information about CKM syndrome; data suggested that serum uric acid, leptin, aldosterone, bilirubin, soluble neprilysin, lipocalin-type-prostaglandin-D-synthase, and endocan could be valuable biomarkers for CKM screening; and finally, the inflammation role in CKM.

Cardiovascular-kidney-metabolic syndrome definition and its role in the prevention, risk staging, and treatment. An opportunity for the Nephrology

The recent conceptualization of the cardiovascular-kidney-metabolic (CKM) syndrome by the American Heart Association (AHA) opens an opportunity for a multidisciplinary and lifelong approach in the risk stratification, early prevention, and treatment of the vicious circle generated by the interaction of cardiovascular, renal and metabolic risk factors and aggravated by the development of cardiovascular diseases (including their full spectrum: heart failure, atrial fibrillation, coronary heart disease, stroke, and peripheral arterial disease), chronic kidney disease or type 2 diabetes mellitus, with the excess or dysfunctional adiposity as the trigger. Three publications offer the rational basis of a conceptual decalogue and action plan and a new cardiovascular risk stratification equation since the age of 30 that includes measures of renal function/damage, among others, to promote effective cardiovascular, renal, and metabolic prevention. In Spain, we must leverage this momentum to adapt these new concepts to our reality with greater and improved collaboration between primary care and the specialties involved in CKM syndrome, including the formation of multidisciplinary units for the optimal management using a patient-centred approach.

Cardiovascular and non-renal complications of chronic kidney disease: Managing risk

Chronic kidney disease (CKD) currently affects approximately 850 million people globally and is continuing to increase in prevalence as well as in importance as a cause of death. The excess mortality related to CKD is mostly caused by an increase in cardiovascular disease. This includes atherosclerotic cardiovascular disease as many promoters of atherosclerosis, such as blood pressure, lipid levels and hypercoagulation, are increased in people with CKD. Diabetes is a leading cause of CKD contributing to the risk of CVD, and obesity is also increasingly prevalent. Management of these risk factors is therefore very important in CKD, and to reduce risk of CKD progression. Heart failure is also more prevalent in CKD and, again, many risk factors are shared. The concept of foundational pillars in the management of heart failure has been adapted to the treatment of CKD, with many organ-protective interventions, such renin-angiotensin system blockade, sodium-glucose cotransporter-2 inhibition and mineralocorticoid receptor antagonism, reducing the risk for mortality in heart failure with reduced ejection fraction, but also for progression of CKD. Atrial fibrillation is also more common with CKD and affects the management of the former. In this review these non-renal complications of CKD are discussed, along with how the risk of these complications should be managed. Many new opportunities have demonstrated heart and kidney organ protection, but implementation is a challenge.

Software-driven chronic disease management: Algorithm design and implementation in a community-based blood pressure control pilot

Background

Optimal guideline-directed medical therapy is rarely attained in practice, resulting in inadequate control of diseases such as hypertension, with poorer results in under-resourced communities. Technology, including artificial intelligence-driven decision support and software-driven workflow transformation, can potentially improve disease outcomes at a reduced cost, although it must be integrated with a holistic approach.

Methods

We describe the design of a software platform that enables rapid iterative remote management of >20 conditions across cardiac-kidney-metabolic disease. The platform distributes work across a care team of providers and care navigators, automates decision-making, ordering, and documentation, supports rapid incorporation of new evidence, and launches pragmatic trials. We describe software used in a 500-person community-based blood pressure control implemented as a single-arm quality improvement program. The primary endpoint was the proportion of patients meeting the Healthcare Effectiveness Data and Information Set quality measure blood pressure goal (<140/90) at 12 weeks.

Results

A total of 1609 patients were screened, 945 (59%) were found to have uncontrolled hypertension, and 512 patients consented to join the program. The average age was 61 ± 11 years; 59% were female, and 99% self-identified as Black. Blood pressure distribution was: 10% Stage 1 (SBP 130-139 mmHg or DBP 80-89 mmHg), 69% Stage 2 (SBP 140-179 mmHg or DBP 90-119 mmHg), and 21% Stage 3 (SBP >180 mmHg or DBP >120 mmHg). Two hundred four patients (39%) proceeded to a provider encounter, and 160 of these (78%) completed the program. The Healthcare Effectiveness Data and Information Set blood pressure goal was achieved in <12 weeks of enrollment for 141 participants (69% of those enrolled, 88% of those who completed the program).

Conclusion

Software-driven remote blood pressure is feasible, although strategies to improve patient enrollment will be needed to achieve maximum impact. Future work will be required to compare outcomes to usual care and evaluate concurrent management of multiple cardiac-kidney-metabolic conditions.

Integrated Cardiorespiratory Rehabilitation and Its Impact on Cardio-Renal-Metabolic Profile After Cardiac Surgery

BACKGROUND

Cardiovascular diseases (CVDs) and chronic kidney disease (CKD) are common causes of morbidity and mortality. However, the impact of changes in lifestyle and rehabilitation programs on the progression of cardiovascular, renal, and metabolic (CRM) conditions, remains unclear.

METHODS

In a retrospective manner, we analyzed charts of 200 patients admitted for cardiorespiratory rehabilitation at our facility in 2023. A 6 min walk test, echocardiographic features, and laboratory values were investigated to evaluate the impact of cardiorespiratory rehabilitation in patients post cardiac surgery. This study examined the impact of combined lifestyle and exercise scores (diet, alcohol consumption, smoking, aerobic physical activity, sedentary behavior, sleep duration, and social connection) on cardio-renal-metabolic profiles and on a quality-of-life score measured by the Borg Scale.

RESULTS

During the rehabilitation program, left ventricular ejection fraction (LVEF) significantly increased (51.2 vs. 54.3%, SEM 0.51 p = 0.001). The six-minute walk test (6 MWT) significantly improved in terms of meters (133 vs. 373 m, SEM 6.41, p < 0.001) and Borg scale (6.6 vs. 2.5, SEM 0.06, p < 0.001). Glycemia levels reduced significantly (114.5± vs. 107.4± mg/dL, SEM 2.45, p = 0.001). While total cholesterol levels (119.4 vs. 129.6 mg/dL, SEM 2.4, p < 0.001) as well as HDL levels (29.9 vs. 40 mg/dL, SEM 0.62, p < 0.001) significantly increased, triglyceride levels significantly decreased (128.5 vs. 122.1 mg/dL, SEM 3.8, p = 0.048). There was no change in LDL levels. Creatinine levels remained stable throughout the period of rehabilitation.

CONCLUSIONS

Cardiorespiratory rehabilitation has a significant impact on myocardial function, quality of life in terms of exercise capacity and symptoms (6 MWT) as well as laboratory levels relevant for cardiovascular prevention such as glycemia and lipid profile.

CMR to characterize myocardial structure and function in heart failure with preserved left ventricular ejection fraction

Despite remarkable progress in therapeutic drugs, morbidity, and mortality for heart failure (HF) remains high in developed countries. HF with preserved ejection fraction (HFpEF) now accounts for around half of all HF cases. It is a heterogeneous disease, with multiple aetiologies, and as such poses a significant diagnostic challenge. Cardiac magnetic resonance (CMR) has become a valuable non-invasive modality to assess cardiac morphology and function, but beyond that, the multi-parametric nature of CMR allows novel approaches to characterize haemodynamics and with magnetic resonance spectroscopy (MRS), the study of metabolism. Furthermore, exercise CMR, when combined with lung water imaging provides an in-depth understanding of the underlying pathophysiological and mechanistic processes in HFpEF. Thus, CMR provides a comprehensive phenotyping tool for HFpEF, which points towards a targeted and personalized therapy with improved diagnostics and prevention.

Impact of metabolic abnormalities on the association between normal-range urinary albumin-to-creatinine ratio and cardiovascular mortality: evidence from the NHANES 1999-2018

BACKGROUND

The urinary albumin to creatinine ratio (UACR) is associated with adverse cardiovascular outcomes, even when within the normal range. However, the potential modification of this effect by metabolic abnormalities remains unclear. This study explored whether metabolic abnormalities modify the association between normal-range UACR and cardiovascular mortality.

METHODS

This cohort study included 27,298 U.S. adults from the National Health and Nutrition Examination Survey 1999-2018, with mortality follow-up through December 31, 2019. Normal UACR (< 30 mg/g) was considered. Metabolic abnormalities were categorized into three groups based on the number of metabolic abnormality components: metabolic health (0 components), pre-metabolic syndrome (Pre-MetS, 1-2 components), and metabolic syndrome (MetS, 3-5 components). Multivariable Cox proportional hazards regression was used to estimate the association between normal UACR and cardiovascular mortality, stratified by metabolic abnormality groups.

RESULTS

Over a median follow-up of 9.67 years, 764 cardiovascular deaths occurred. In the fully adjusted model, higher normal UACR was associated with an increased risk of cardiovascular death in metabolically abnormal individuals, but not in metabolically healthy individuals. When UACR was divided into tertiles, the highest tertile was associated with a 60% and 79% higher risk of cardiovascular mortality in the Pre-MetS and MetS groups, respectively, compared with the lowest tertile (Pre-MetS: HR, 1.60 [95% CI: 1.19-2.15]; MetS: HR, 1.79 [95% CI: 1.34-2.41]).

CONCLUSION

A higher normal UACR was associated with an increased risk of cardiovascular death in metabolically abnormal individuals, underscoring the need for early renal risk management in this population.

Metabolic syndrome

The metabolic syndrome (MetS) is a multiplex modifiable risk factor for cardiovascular disease, type 2 diabetes mellitus and other health outcomes, and is a major challenge to clinical practice and public health. The rising global prevalence of MetS, driven by urbanization, sedentary lifestyles and dietary changes, underlines the urgency of addressing this syndrome. We explore the complex underlying mechanisms, including genetic predisposition, insulin resistance, accumulation of dysfunctional adipose tissue and ectopic lipids in abdominal obesity, systemic inflammation and dyslipidaemia, and how they contribute to the clinical manifestations of MetS. Diagnostic approaches vary but commonly focus on abdominal obesity (assessed using waist circumference), hyperglycaemia, dyslipidaemia and hypertension, highlighting the need for population-specific and phenotype-specific diagnostic strategies. Management of MetS prioritizes lifestyle modifications, such as healthy dietary patterns, physical activity and management of excess visceral and ectopic adiposity, as foundational interventions. We also discuss emerging therapies, including new pharmacological treatments and surgical options, providing a forward-looking perspective on MetS research and care. This Primer aims to inform clinicians, researchers and policymakers about MetS complexities, advocating for a cohesive, patient-centred management and prevention strategy. Emphasizing the multifactorial nature of MetS, this Primer calls for integrated public health efforts, personalized care and innovative research to address this escalating health issue.

Early metabolic and hemodynamic indicators of kidney dysfunction in mice offspring from parental low protein diet

BACKGROUND

Parental malnutrition, particularly a low-protein diet (LPD), causes oligonephropathy at birth and predisposes offspring to hypertension and chronic kidney disease later in life. The onset of adult kidney disease varies based on genetics and environmental factors, often with subclinical alterations in kidney function being overlooked. This study aimed to examine changes in kidney morphology before significant kidney function decline in the offspring of mice fed a low-protein diet.

METHODS

Using a combination of histological analysis, kidney metabolic and hemodynamic panel assessments, and advanced statistical techniques such as Linear Discriminant Analysis (LDA) and Principal Component Analysis (PCA), we investigated the initial impact of a maternal low-protein diet (LPD) on kidney development and function. Our study utilized 12-week-old F1 mice from F0 parents fed either a low-protein diet (LPD) or a normal-protein diet (NPD) before the onset of hypertension.

RESULTS

The offspring (F1 generation) of parents (F0 generation) fed an LPD show reduced body weight from birth to P20. The kidney weight was also reduced compared to F1 offspring from parents fed an NPD. At 12 weeks of age, body weight normalized, but kidney weight remained low. Offspring of parents fed an LPD displayed abnormal kidney morphology, including dilated tubules, oligonephropathy, and fluid-filled cysts which had worsened with age. A kidney metabolic panel analysis at 12 weeks revealed a slight but consistent increase in urine albumin, plasma creatinine, mean urea, and BUN concentrations. Although no significant changes in hemodynamic variables were observed, 2/12 mice, both males, showed alterations in systolic blood pressure, suggesting sex-specific effects when comparing F1 mice from F0 fed either diet. Overall, kidney metabolic changes were strongly correlated to parental LPD.

CONCLUSION

Our findings indicate that significant kidney damage must accumulate in the F1 generation from parents fed an LPD before any detectable changes in blood pressure occur. Our study suggests that small variations in kidney metabolic function may point to early kidney damage and should not be overlooked in the offspring of these malnourished mice and likely humans.

Preterm Birth and Kidney Health: From the Womb to the Rest of Life

Chronic kidney disease (CKD) is a widespread condition often resulting from multiple factors, including maternal influences. These risk factors not only heighten the likelihood of developing CKD but increase the risk of a preterm birth. Adverse events during nephrogenesis can disrupt kidney development, leading to a reduced number of nephrons. As survival rates for preterm infants improve, more individuals are living into adulthood, thereby elevating their risk of CKD later in life. This review aims to explore the connections between preterm birth, kidney development, and the increased risk of CKD, while proposing practical solutions for the future through a multidisciplinary approach. We examine human studies linking preterm birth to negative kidney outcomes, summarize animal models demonstrating kidney programming and reduced nephron numbers, and consolidate knowledge on common mechanisms driving kidney programming. Additionally, we discuss factors in the postnatal care environment that may act as secondary insults contributing to CKD risk, such as acute kidney injury (AKI), the use of nephrotoxic drugs, preterm nutrition, and catch-up growth. Finally, we outline recommendations for action, emphasizing the importance of avoiding modifiable risk factors and implementing early CKD screening for children born preterm. Together, we can ensure that advancements in kidney health keep pace with improvements in preterm care.

Association between different stages of cardiovascular-kidney-metabolic syndrome and the risk of all-cause mortality

BACKGROUND AND AIMS

Poor cardiovascular-kidney-metabolic (CKM) health is a major determinant of all-cause mortality, which poses a significant burden on global public health systems and socio-economics. However, the association between different stages of CKM syndrome and the risk of all-cause mortality remains unclear. This study aimed to evaluate the association between different stages of CKM syndrome and risk of all-cause mortality.

METHODS

A total of 97,777 adults from the Kailuan Study were included. Cox proportional hazards regression models were applied to estimate hazard ratios (HRs) and 95 % confidence intervals (CIs) of all-cause mortality according to different stages of CKM syndrome.

RESULTS

Over a median follow-up of 15.0 (14.7-15.2) years, we identified 14,805 all-cause mortality cases. The stage of CKM syndrome was positively associated with the risk of all-cause mortality (p-trend <0.001). Compared with Stage 0, the multivariable-adjusted HRs (95 % CIs) of all-cause mortality were 1.24 (1.06-1.45) for Stage 1, 1.72 (1.48-2.00) for Stage 2, 2.58 (2.22-3.01) for Stage 3 and 3.73 (3.19-4.37) for Stage 4. Moreover, the observed associations were more pronounced in younger adults (aged <60 years) compared with older adults (p for interaction <0.001).

CONCLUSIONS

Our data showed that a higher stage of CKM syndrome was associated with a higher risk of all-cause mortality, with a particularly pronounced association observed in younger adults. The study emphasized the need for targeted public health strategies and clinical management tailored to the stages of CKM syndrome, aiming to alleviate its burden on individuals and healthcare systems.

Sodium-glucose cotransporter 2 inhibitors reduce the risk of incident type 2 diabetes in people with heart failure without diabetes: An analysis of real-world, cohort data

AIM

Sodium-glucose cotransporter 2 inhibitors (SGLT2is), used as a glucose-lowering therapy in people with type 2 diabetes (T2D), have significant cardiorenal benefits, reducing hospitalization for heart failure (HF) and cardiovascular mortality in patients with and without T2D. Recent clinical trial evidence suggests their potential utility in preventing incident T2D among the high-risk HF populations. Therefore, we aimed to assess whether this finding was reproducible in a real-world setting.

METHODS

We performed a retrospective cohort analysis of 484 643 patients with HF, without baseline diabetes, prescribed either angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers with/without SGLT2is (treatment, n = 42 018; reference, n = 442 625) across 95 global health care organizations, using a large real-world ecosystem. Propensity score matching balanced arms 1:1 for confounders (n = 39 168 each arm). Subgroup analysis further evaluated the impact on patients with prediabetes and the efficacy of dapagliflozin/empagliflozin, specifically, on incident T2D and secondary outcomes, including all-cause mortality, acute pulmonary oedema and hospitalization.

RESULTS

Treatment with SGLT2is significantly reduced incident T2D {hazard ratio (HR) 0.71 [95% confidence interval (CI) 0.63, 0.75]} in patients with HF. The analysis of patients with prediabetes found that SGLT2is further reduced incident T2D [HR 0.62 (95% CI 0.45, 0.80)]. The magnitude of reduction in incident T2D was higher in patients prescribed dapagliflozin [HR 0.47 (95% CI 0.39, 0.56)] versus empagliflozin [HR 0.81 (95% CI 0.70, 0.93)].

CONCLUSION

Treatment with SGLT2is in patients with HF was associated with a reduced risk of incident T2D, most strikingly in people with prediabetes.

Projected Changes in Statin and Antihypertensive Therapy Eligibility With the AHA PREVENT Cardiovascular Risk Equations

Importance

Since 2013, the American College of Cardiology (ACC) and American Heart Association (AHA) have recommended the pooled cohort equations (PCEs) for estimating the 10-year risk of atherosclerotic cardiovascular disease (ASCVD). An AHA scientific advisory group recently developed the Predicting Risk of cardiovascular disease EVENTs (PREVENT) equations, which incorporated kidney measures, removed race as an input, and improved calibration in contemporary populations. PREVENT is known to produce ASCVD risk predictions that are lower than those produced by the PCEs, but the potential clinical implications have not been quantified.

Objective

To estimate the number of US adults who would experience changes in risk categorization, treatment eligibility, or clinical outcomes when applying PREVENT equations to existing ACC and AHA guidelines.

Design, Setting, and Participants

Nationally representative cross-sectional sample of 7765 US adults aged 30 to 79 years who participated in the National Health and Nutrition Examination Surveys of 2011 to March 2020, which had response rates ranging from 47% to 70%.

Main Outcomes and Measures

Differences in predicted 10-year ASCVD risk, ACC and AHA risk categorization, eligibility for statin or antihypertensive therapy, and projected occurrences of myocardial infarction or stroke.

Results

In a nationally representative sample of 7765 US adults aged 30 to 79 years (median age, 53 years; 51.3% women), it was estimated that using PREVENT equations would reclassify approximately half of US adults to lower ACC and AHA risk categories (53.0% [95% CI, 51.2%-54.8%]) and very few US adults to higher risk categories (0.41% [95% CI, 0.25%-0.62%]). The number of US adults receiving or recommended for preventive treatment would decrease by an estimated 14.3 million (95% CI, 12.6 million-15.9 million) for statin therapy and 2.62 million (95% CI, 2.02 million-3.21 million) for antihypertensive therapy. The study estimated that, over 10 years, these decreases in treatment eligibility could result in 107 000 additional occurrences of myocardial infarction or stroke. Eligibility changes would affect twice as many men as women and a greater proportion of Black adults than White adults.

Conclusion and Relevance

By assigning lower ASCVD risk predictions, application of the PREVENT equations to existing treatment thresholds could reduce eligibility for statin and antihypertensive therapy among 15.8 million US adults.

A comprehensive review of finerenone-a third-generation non-steroidal mineralocorticoid receptor antagonist

Multiple studies have shown that finerenone (BAY 94-8862), a third-generation non-steroidal mineralocorticoid receptor antagonist (MRA), possesses different or superior mechanisms of action to traditional MRAs. Specifically, animal and cell-based experiments have demonstrated that this compound exerts multiple effects including fibrosis inhibition, reduced pulmonary artery pressure, improved diabetic retinopathy, enhanced endothelial functions, metabolic optimization as well as reduced oxidative stress, thereby exerting overall positive effects on renal and cardiovascular diseases. Consequently, clinical research, such as the FIGARO-DKD and FIDELIO-DKD trials, has demonstrated dual benefits for patients with type 2 diabetes mellitus and chronic kidney disease (T2DM-CKD), especially by validating MRAs' potential in reducing risks of renal and cardiovascular composite endpoints. Currently, cardiovascular indications for finerenone are limited to patients with T2DM-CKD, while its use in non-T2DM CKD patients remains at clinical trial stages. Despite showing good safety and efficacy in T2DM-CKD patients, there are insufficient corresponding data for those presenting chronic kidney disease without diabetes (ndCKD). Furthermore, the application of this compound in diseases such as primary aldosteronism and its association with cancer risk need to be further validated through larger-scale and longer-term clinical studies. Nevertheless, the development of finerenone provides an additional option for treating cardiovascular and renal diseases. With further research, it is expected that finerenone will be relevant to a broader range of CKD patient populations by addressing current knowledge gaps to comprehensively evaluate its clinical value and potentially alter existing treatment strategies. The current review aims to comprehensively analyze the basic research and clinical advancements involving finerenone in order to explore its prospects for treating cardiovascular and renal diseases, while addressing unmet needs in current treatment strategies. Additionally, through a comprehensive analysis of relevant research findings, a deeper understanding of finerenone's drug characteristics will be provided alongside scientific guidance for future treatment strategies and their clinical significance.

Maternal Polyphenols and Offspring Cardiovascular-Kidney-Metabolic Health

BACKGROUND

The convergence of cardiovascular, kidney, and metabolic disorders at the pathophysiological level has led to the recognition of cardiovascular-kidney-metabolic (CKM) syndrome, which represents a significant global health challenge. Polyphenols, a group of phytochemicals, have demonstrated potential health-promoting effects.

METHODS

This review highlights the impact of maternal polyphenol supplementation on the CKM health of offspring.

RESULTS

Initially, we summarize the interconnections between polyphenols and each aspect of CKM syndrome. We then discuss in vivo studies that have investigated the use of polyphenols during pregnancy and breastfeeding, focusing on their role in preventing CKM syndrome in offspring. Additionally, we explore the common mechanisms underlying the protective effects of maternal polyphenol supplementation.

CONCLUSIONS

Overall, this review underscores the potential of early-life polyphenol interventions in safeguarding against CKM syndrome in offspring. It emphasizes the importance of continued research to advance our understanding and facilitate the clinical translation of these interventions.

International Initiatives of the American Heart Association: Original Concepts, Present Programs, and Future Focus: A Science Advisory From the American Heart Association

The American Heart Association (AHA), founded in 1924, is anchored in the core belief that scientific research can lead the way to better prevention, treatment, recovery, and ultimately a cure for cardiovascular disease. Historically, the association's involvement in international efforts centered on scientific cooperation. Activities mostly involved AHA leadership presenting at international scientific meetings and leaders from other countries sharing scientific and medical information at AHA meetings. Although the AHA's and American Stroke Association's international efforts have expanded substantially since those early days, global knowledge exchange remains the bedrock of its international endeavors. As the AHA turns 100, we reflect on the successful global efforts in prevention, resuscitation, global advocacy, quality improvement, and health equity that have guided the organization to a place of readiness for "advancing health and hope, for everyone, everywhere." Motivated by the enormous potential for population health gains in an aging world, the AHA is entering its second century with redoubled commitment to improving global cardiovascular and cerebrovascular health for all.

Advancements in Incident Heart Failure Risk Prediction and Screening Tools

Heart failure (HF) is a major cause of mortality and morbidity in the United States that carries substantial healthcare costs. Multiple risk prediction models and strategies have been developed over the past 30 years with the aim of identifying those at high risk of developing HF and of implementing preventive therapies effectively. This review highlights recent developments in HF risk prediction tools including emerging risk factors, innovative risk prediction models, and novel screening strategies from artificial intelligence to biomarkers. These developments allow more accurate prediction, but their impact on clinical outcomes remains to be investigated. Implementation of these risk models in clinical practice is a considerable challenge, but HF risk prediction tools offer a promising opportunity to improve outcomes while maintaining value.

Maternal Dietary Strategies for Improving Offspring Cardiovascular-Kidney-Metabolic Health: A Scoping Review

Dietary regulation has been recognized for its profound impact on human health. The convergence of cardiovascular, kidney, and metabolic disorders at the pathophysiological level has given rise to cardiovascular-kidney-metabolic (CKM) syndrome, which constitutes a significant global health burden. Maternal dietary nutrients play a crucial role in fetal development, influencing various programmed processes. This review emphasizes the effects of different types of dietary interventions on each component of CKM syndrome in both preclinical and clinical settings. We also provide an overview of potential maternal dietary strategies, including amino acid supplementation, lipid-associated diets, micronutrients, gut microbiota-targeted diets, and plant polyphenols, aimed at preventing CKM syndrome in offspring. Additionally, we discuss the mechanisms mediated by nutrient-sensing signals that contribute to CKM programming. Altogether, we underscore the interaction between maternal dietary interventions and the risk of CKM syndrome in offspring, emphasizing the need for continued research to facilitate their clinical translation.

Preclinical modeling of metabolic syndrome to study the pleiotropic effects of novel antidiabetic therapy independent of obesity

Cardiovascular-kidney-metabolic health reflects the interactions between metabolic risk factors, chronic kidney disease, and the cardiovascular system. A growing body of literature suggests that metabolic syndrome (MetS) in individuals of normal weight is associated with a high prevalence of cardiovascular diseases and an increased mortality. The aim of this study was to establish a non-invasive preclinical model of MetS in support of future research focusing on the effects of novel antidiabetic therapies beyond glucose reduction, independent of obesity. Eighteen healthy adult Beagle dogs were fed an isocaloric Western diet (WD) for ten weeks. Biospecimens were collected at baseline (BAS1) and after ten weeks of WD feeding (BAS2) for measurement of blood pressure (BP), serum chemistry, lipoprotein profiling, blood glucose, glucagon, insulin secretion, NT-proBNP, angiotensins, oxidative stress biomarkers, serum, urine, and fecal metabolomics. Differences between BAS1 and BAS2 were analyzed using non-parametric Wilcoxon signed-rank testing. The isocaloric WD model induced significant variations in several markers of MetS, including elevated BP, increased glucose concentrations, and reduced HDL-cholesterol. It also caused an increase in circulating NT-proBNP levels, a decrease in serum bicarbonate, and significant changes in general metabolism, lipids, and biogenic amines. Short-term, isocaloric feeding with a WD in dogs replicated key biological features of MetS while also causing low-grade metabolic acidosis and elevating natriuretic peptides. These findings support the use of the WD canine model for studying the metabolic effects of new antidiabetic therapies independent of obesity.

Social and Environmental Determinants of Health and Cardio-Kidney-Metabolic Syndrome-Related Mortality

Importance

It is not well understood if and how various social and environmental determinants of health (SEDoH) are associated with mortality rates related to cardio-kidney-metabolic syndrome (CKM) across the US.

Objective

To study the magnitude of the association strength of SEDoH with CKM-related mortality at the county level across the US.

Design, Setting, and Participants

This cross-sectional, retrospective, population-based study used aggregate county-level data from the US Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (WONDER) data portal from 2010-2019. Data analysis occurred from September 2023 to January 2024.

Exposures

A total of 7 diverse SEDoH were chosen, including median annual household income, percentage of racial and ethnic minority residents per county, fine particulate air pollution (PM2.5) concentrations, high-school completion rate, primary health care access, food insecurity, and rurality rate.

Main Outcomes and Measures

The primary outcome was county-level age-adjusted mortality rate (aaMR) attributable to CKM. The association of county-level CKM-related aaMR with the 7 SEDoH was analyzed using geographically weighted models and the model median coefficients for each covariate studied.

Results

Data from 3101 of 3243 counties (95.6%) were analyzed. There was substantial variation in SEDoH between states and counties. The overall pooled median (IQR) aaMR (2010-2019) in the US was 505.5 (441.3-578.9) per 100 000 residents. Most counties in the lower half of the US had rates much higher than the pooled median (eg, Southern US median [IQR] aaMR, 537.3 [466.0-615.9] per 100 000 residents). CKM-related mortality was positively associated with the food insecurity rate (median [IQR] β = 6.78 [2.78-11.56]) and PM2.5 concentrations (median [IQR] β = 5.52 [-11.06 to 19.70]), while it was negatively associated with median annual household income (median [IQR] β = -0.002 [-0.003 to -0.001]), rurality (median [IQR] β = -0.32 [-0.67 to 0.02]), high school completion rate (median [IQR] β = -1.89 [-4.54 to 0.10]), racial and ethnic minority rate (median [IQR] β = -0.66 [-1.85 to 0.89]), and primary health care access rate (median [IQR] β = -0.18 [-0.35 to 0.07]).

Conclusions and Relevance

In this cross-sectional study of county-level data across the US, there were substantial geographical differences in the magnitude of the association of SEDoH with CKM-related aaMR. These findings may provide guidance for deciding local health care policy.

Metabolically "extremely unhealthy" obese and non-obese people with diabetes and the risk of cardiovascular adverse events: the Silesia Diabetes - Heart Project

BACKGROUND

There is a growing burden of non-obese people with diabetes mellitus (DM). However, their cardiovascular risk (CV), especially in the presence of cardiovascular-kidney-metabolic (CKM) comorbidities is poorly characterised. The aim of this study was to analyse the risk of major CV adverse events in people with DM according to the presence of obesity and comorbidities (hypertension, chronic kidney disease, and dyslipidaemia).

METHODS

We analysed persons who were enrolled in the prospective Silesia Diabetes Heart Project (NCT05626413). Individuals were divided into 6 categories according to the presence of different clinical risk factors (obesity and CKM comorbidities): (i) Group 1: non-obese with 0 CKM comorbidities; (ii) Group 2: non-obese with 1-2 CKM comorbidities; (iii) Group 3: non-obese with 3 CKM comorbidities (non-obese "extremely unhealthy"); (iv) Group 4: obese with 0 CKM comorbidities; (v) Group 5: obese with 1-2 CKM comorbidities; and (vi) Group 6: obese with 3 CKM comorbidities (obese "extremely unhealthy"). The primary outcome was a composite of CV death, myocardial infarction (MI), new onset of heart failure (HF), and ischemic stroke.

RESULTS

2105 people with DM were included [median age 60 (IQR 45-70), 48.8% females]. Both Group 1 and Group 6 were associated with a higher risk of events of the primary composite outcome (aHR 4.50, 95% CI 1.20-16.88; and aHR 3.78, 95% CI 1.06-13.47, respectively). On interaction analysis, in "extremely unhealthy" persons the impact of CKM comorbidities in determining the risk of adverse events was consistent in obese and non-obese ones (Pint=0.824), but more pronounced in individuals aged < 65 years compared to older adults (Pint= 0.028).

CONCLUSION

Both non-obese and obese people with DM and 3 associated CKM comorbidities represent an "extremely unhealthy" phenotype which are at the highest risk of CV adverse events. These results highlight the importance of risk stratification of people with DM for risk factor management utilising an interdisciplinary approach.

Research hotspots and future trends in lipid metabolism in chronic kidney disease: a bibliometric and visualization analysis from 2004 to 2023

Background

Disorders of lipid metabolism play a key role in the initiation and progression of chronic kidney disease (CKD). Recently, research on lipid metabolism in CKD has rapidly increased worldwide. However, comprehensive bibliometric analyses in this field are lacking. Therefore, this study aimed to evaluate publications in the field of lipid metabolism in CKD over the past 20 years based on bibliometric analysis methods to understand the important achievements, popular research topics, and emerging thematic trends.

Methods

Literature on lipid metabolism in CKD, published between 2004 and 2023, was retrieved from the Web of Science Core Collection. The VOSviewer (v.1.6.19), CiteSpace (v.6.3 R1), R language (v.4.3.2), and Bibliometrix (v.4.1.4) packages (https://www.bibliometrix.org) were used for the bibliometric analysis and visualization. Annual output, author, country, institution, journal, cited literature, co-cited literature, and keywords were also included. The citation frequency and H-index were used to evaluate quality and influence.

Results

In total, 1,285 publications in the field of lipid metabolism in CKD were identified in this study. A total of 7,615 authors from 1,885 institutions in 69 countries and regions published articles in 466 journals. Among them, China was the most productive (368 articles), and the United States had the most citations (17,880 times) and the highest H-index (75). Vaziri Nosratola D, Levi Moshe, Fornoni Alessia, Zhao Yingyong, and Merscher Sandra emerged as core authors. Levi Moshe (2,247 times) and Vaziri Nosratola D (1,969 times) were also authors of the top two most cited publications. The International Journal of Molecular Sciences and Kidney International are the most published and cited journals in this field, respectively. Cardiovascular disease (CVD) and diabetic kidney disease (DKD) have attracted significant attention in the field of lipid metabolism. Oxidative stress, inflammation, insulin resistance, autophagy, and cell death are the key research topics in this field.

Conclusion

Through bibliometric analysis, the current status and global trends in lipid metabolism in CKD were demonstrated. CVD and DKD are closely associated with the lipid metabolism of patients with CKD. Future studies should focus on effective CKD treatments using lipid-lowering targets.

The impact of population ageing on the burden of chronic kidney disease

The burden of chronic kidney disease (CKD) and its risk factors are projected to rise in parallel with the rapidly ageing global population. By 2050, the prevalence of CKD category G3-G5 may exceed 10% in some regions, resulting in substantial health and economic burdens that will disproportionately affect lower-income countries. The extent to which the CKD epidemic can be mitigated depends largely on the uptake of prevention efforts to address modifiable risk factors, the implementation of cost-effective screening programmes for early detection of CKD in high-risk individuals and widespread access and affordability of new-generation kidney-protective drugs to prevent the development and delay the progression of CKD. Older patients require a multidisciplinary integrated approach to manage their multimorbidity, polypharmacy, high rates of adverse outcomes, mental health, fatigue and other age-related symptoms. In those who progress to kidney failure, comprehensive conservative management should be offered as a viable option during the shared decision-making process to collaboratively determine a treatment approach that respects the values and wishes of the patient. Interventions that maintain or improve quality of life, including pain management and palliative care services when appropriate, should also be made available.

Trends in Glucagon-Like Peptide-1 Receptor Agonist Social Media Posts Using Artificial Intelligence

Background

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have surged in popularity in recent years, with discussions about their on-label and off-label use spilling into the public forum. No study has analyzed online discussions about GLP-1RAs.

Objectives

The purpose of this study was to analyze perceptions of GLP-1RAs on social media.

Methods

We analyzed GLP-1RA-related posts on Reddit between May 28, 2013, and June 1, 2023. All posts were identified that included generic or brand names of GLP-1RAs. Post volume on Reddit was compared to search interest on Google over time. An artificial intelligence (AI) pipeline consisting of a semi-supervised natural language processing model (Bidirectional Encoder Representations from Transformers [BERT]), a dimensionality reduction technique, and a clustering algorithm was used to cluster posts into related topics. Discussion sentiment was classified using a pretrained BERT model and assessed qualitatively.

Results

14,390 GLP-1RA-related Reddit posts by 8,412 authors were identified. Ninety-four percent of posts were created after 2021, consistent with search interest trend on Google. We used the AI model to categorize posts into 30 topics which were hierarchically grouped by the model based on shared content. Posts were identified among communities for individuals with diabetes and obesity, as well as for diseases without a Food and Drug Administration-approved indication. Most posts had a negative sentiment using the pretrained model, acknowledging the pretrained model is at risk for misclassifying posts.

Conclusions

AI can generate insights on perceptions of GLP-1RAs on social media. Common themes included success stories of improving diabetes and obesity management, struggles with insurance coverage, and questions regarding diet, side effects, and medication administration.

Exploring the nexus: The place of kidney diseases within the cardiovascular-kidney-metabolic syndrome spectrum

Cardiovascular-kidney-metabolic (CKM) syndrome and chronic kidney disease (CKD) are two significant comorbidities affecting a large proportion of the general population with considerable crosstalk. In addition to substantial co-incidence of CKD and CKM syndrome in epidemiological studies, clinical and pre-clinical studies have identified similar pathophysiological pathways leading to both entities. Patients with CKM syndrome are more prone to develop acute kidney injury and CKD, while therapeutic alternatives and their success rates are considerably lower in such patient groups. Nevertheless, the association between CKM syndrome and CKD or ESKD is bidirectional rather than being a cause-effect relationship as patients with CKD are also prone to develop peripheral insulin resistance, high blood pressure, and dyslipidemia. Furthermore, such patients are less likely to receive kidney transplantation in addition to the higher allograft dysfunction risk. We hereby aim to evaluate the association in-between kidney diseases and CKM syndrome, including epidemiological data, pre-clinical studies with pathophysiological pathways, and potential therapeutic perspectives.

Curbing the Obesity Epidemic: Should GLP-1 Receptor Agonists Be the Standard of Care for Obesity?

PURPOSE OF REVIEW

This article summarizes the medical management of obesity with an emphasis on incretin-based therapeutics that target the neuro-hormonal basis of obesity.

RECENT FINDINGS

Medications that mimic the effect of incretins, a group of peptide hormones released in response to nutrient intake that regulate appetite, result in potent and durable weight loss. Glucagon-like peptide 1 (GLP-1) agonists and glucose-dependent insulinotropic polypeptide (GIP) agonists such as semaglutide and tirzepatide are approved by the United States Food and Drug Administration (FDA) for the management of obesity. The SELECT trial demonstrated that semaglutide led to a reduction in major adverse cardiovascular events in patients without diabetes who were either overweight and had preexisting cardiovascular disease or obese.

SUMMARY

The treatment of obesity is critical to prevent the progression of cardiovascular-kidney-metabolic syndrome. Incretin-based therapies offer remarkable weight loss and reduce major cardiovascular adverse events.

Combination of Cardiovascular, Kidney, and Metabolic Diseases in a Syndrome Named Cardiovascular-Kidney-Metabolic, With New Risk Prediction Equations

Associations of chronic kidney disease (CKD) with metabolic syndrome and cardiovascular disease (CVD) have long been recognized. Until recently, such associations were mainly limited to interrelationships between either heart and kidney, heart and metabolic syndrome, or metabolic syndrome and kidney. It is the merit of the American Heart Association (AHA) to have set up a work group of cardiologists, endocrinologists, and nephrologists for the purpose of combining all 3 disorders in a single entity, as an appreciation of their pathophysiological interrelatedness. To this end, they proposed the term cardiovascular-kidney-metabolic (CKM) syndrome, which reflects multidirectional relationships among metabolic risk factors, CKD, and the cardiovascular system. Following a consensus approach in defining CKM with 5 stages, the work group subsequently developed new risk prediction equations, named predicting risk of CVD events (PREVENT) equations, which included estimated glomerular filtration rate (eGFR) and albuminuria as variables in addition to traditional cardiovascular and metabolic factors. Despite several limitations, this development is a major step forward in cardiovascular risk prediction. Its clinical application should translate into earlier, more appropriate treatment and prevention of CKM syndrome.

Cardiovascular-Kidney-Metabolic Syndrome: Association with Adverse Events After Major Noncardiac Surgery

BACKGROUND

The American Heart Association (AHA) recently defined the cardiovascular-kidney-metabolic syndrome (CKM) as a new entity to address the complex interactions between heart, kidneys, and metabolism. The aim of this study was to assess the outcome impact of CKM syndrome in patients undergoing noncardiac surgery.

METHODS

This is a secondary analysis of a prospective international cohort study including patients aged ≥45 years with increased cardiovascular risk undergoing noncardiac surgery. Main exposure was CKM syndrome according to the AHA definition. The primary end point was a composite of major adverse cardiovascular events (MACE) 30 days after surgery. Secondary end points included all-cause mortality and non-MACE complications (Clavien-Dindo class ≥3).

RESULTS

This analysis included 14,634 patients (60.8% male, mean age = 72±8 years). MACE occurred in 308 patients (2.1%), and 335 patients (2.3%) died. MACE incidence by CKM stage was as follows: CKM 0: 5/367 = 1.4% (95% confidence interval [CI], 0.4%-3.2%); CKM 1: 3/367 = 0.8% (95% CI, 0.2%-2.4%); CKM 2: 102/7440 = 1.4% (95% CI, 1.1%-1.7%); CKM 3: 27/953 = 2.8% (95% CI, 1.9%-4.1%); CKM 4a: 164/5357 = 3.1% (95% CI, 2.6%-3.6%); CKM 4b: 7/150 = 4.7% (95% CI, 1.9%-9.4%). In multivariate logistic regression, CKM stage ≥3 was independently associated with MACE, mortality, and non-MACE complications, respectively (MACE: OR 2.26 [95% CI, 1.78-2.87]; mortality: OR 1.42 [95% CI: 1.13 -1.78]; non-MACE complications: OR 1.11 [95% CI: 1.03-1.20]).

CONCLUSION

The newly defined CKM syndrome is associated with increased morbidity and mortality after non-cardiac surgery. Thus, cardiovascular, renal, and metabolic disorders should be regarded in mutual context in this setting.

Machine Learning-Assisted Analysis of Sublingual Microcirculatory Dysfunction for Early Cardiovascular Risk Evaluation and Cardiovascular-Kidney-Metabolic Syndrome Stage in Patients With Type 2 Diabetes Mellitus

AIMS

To examine whether sublingual microcirculation can be used as an effective and noninvasive method for assessing cardiovascular, kidney, and metabolic risks in patients with type 2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

This cross-sectional observational study enrolled 186 patients with T2DM. All patients were evaluated using the Framingham General Cardiovascular Risk Score (FGCRS) and cardiovascular-kidney-metabolic (CKM) syndrome stage. Side-stream dark-field microscopy was used for sublingual microcirculation, including total and perfused vessel density (TVD and PVD). Multiple machine-learning prediction models have been developed for CKM risk and stage assessment in T2DM patients. Receiver operating characteristic (ROC) curves were generated to determine cutoff points.

RESULTS

Compared to patients with T2DM, diabetic patients with subclinical atherosclerosis (SA) had a greater CV risk, as measured by the FGCRS, accompanied by markedly decreased microcirculation perfusion. Microcirculatory parameters (TVD and PVD), including carotid intima-media thickness (IMT), brachial-ankle pulse wave velocity (ba-PWV), and FGCRS, were closely associated with SA incidence. Microcirculatory parameters, Index (DMSA screen), and cut-off points were used to screen for SA in patients with T2DM. Furthermore, a new set of four factors identified through machine learning showed optimal sensitivity and specificity for detecting CKM risk in patients with T2DM. Decreased microcirculatory perfusion served as a useful early marker for CKM syndrome risk stratification in patients with T2DM without SA.

CONCLUSIONS

Sublingual microcirculatory dysfunction is closely correlated with the risk of SA and CKM risk in T2DM patients. Sublingual microcirculation could be a novel tool for assessing the CKM syndrome stage in patients with T2DM.

Physical exercise: a polypill against chronic kidney disease

We are currently facing a pandemic of physical inactivity that might contribute to the growing prevalence of chronic kidney disease (CKD). Here, we summarize currently available evidence on the association between physical activity and CKD, and also review the effects of exercise intervention in affected patients. Physical activity/exercise might act as a polypill against CKD, preventing its development or even exerting beneficial effects once it is established (i.e. improvements in patients' physical fitness and cardiovascular risk, as well as in kidney function). Exercise benefits are also found at advanced CKD stages or in patients under hemodialysis. The biological mechanisms behind the clinical evidence are also discussed. An active lifestyle appears as a cornerstone in CKD prevention and management.

Gender Disparities in the Association Between Educational Attainment and Cardiovascular-Kidney-Metabolic Syndrome: Cross-Sectional Study

Background

Cardiovascular-kidney-metabolic (CKM) health is affected by social determinants of health, especially education. CKM syndrome has not been evaluated in Chinese population, and the association of education with CKM syndrome in different sexes and its intertwined relation with lifestyles have not been explored.

Objective

We aimed to explore the association between educational attainment and the prevalence of CKM syndrome stages in middle-aged and older Chinese men and women as well as the potential role of health behavior based on Life's Essential 8 construct.

Methods

This study used data from the nationwide, community-based REACTION (Risk Evaluation of Cancers in Chinese diabetic individuals: a longitudinal study). A total of 132,085 participants with complete information to determine CKM syndrome stage and education level were included. Educational attainment was assessed by the self-reported highest educational level achieved by the participants and recategorized as low (elementary school or no formal education) or high (middle school, high school, technical school/college, or above). CKM syndrome was ascertained and classified into 5 stages according to the American Heart Association presidential advisory released in 2023.

Results

Among 132,085 participants (mean age 56.95, SD 9.19 years; n=86,675, 65.62% women) included, most had moderate-risk CKM syndrome (stages 1 and 2), and a lower proportion were at higher risk of CKM (stages 3 and 4). Along the CKM continuum, low education was associated with 34% increased odds of moderate-risk CKM syndrome for women (odds ratio 1.36, 95% CI 1.23-1.49) with a significant sex disparity, but was positively correlated with high-risk CKM for both sexes. The association between low education and high-risk CKM was more evident in women with poor health behavior but not in men, which was also interactive with and partly mediated by behavior.

Conclusions

Low education was associated with adverse CKM health for both sexes but was especially detrimental to women. Such sex-specific educational disparity was closely correlated with health behavior but could not be completely attenuated by behavior modification. These findings highlight the disadvantage faced by women in CKM health ascribed to low education, underscoring the need for public health support to address this inequality.

Global Community Health Screening and Educational Intervention for Early Detection of Cardiometabolic Renal Disease

The global burden of cardiometabolic renal disease is increasing, particularly in underserved communities. Twinepidemic Inc.'s Galvanize Healthy Living program conducts community screenings, risk assessments, and educational interventions globally. We screened 1209 subjects for cardiovascular-kidney-metabolic syndrome, assessing their disease knowledge and self-confidence. Mean age was 50, with 65% females and 35% males. Imaging post-risk assessment revealed abnormalities: EKG (16%), echocardiogram (10%), carotid plaque (9%), ABI (2.5%), and eye exam (3.6%, including 8 retinopathies, 14 cataracts). New onset DM was found in 8%, prediabetes in 18.5%, High LDL in 4.2%, low HDL in 40.2%, high triglycerides in 13.1%, and abnormal BP in 38%. In addition, 18.2% were reclassified to a higher category of risk levels after imaging. Significant improvements in knowledge and self-empowerment (all p < 0.001) were seen after educational interventions. This study underscores early risk assessment's potential to enhance health outcomes globally for underserved populations, validating POC imaging and emphasizing the role of accessible care and education in patient engagement and empowerment.

Social Risk Profile and Cardiovascular-Kidney-Metabolic Syndrome in US Adults

BACKGROUND

Poor cardiovascular-kidney-metabolic (CKM) health is associated with premature mortality and excess morbidity in the United States. Adverse social conditions have a prominent impact on cardiometabolic diseases during the life course. We aim to examine the association between social risk profile (SRP) and CKM multimorbidity among US adults.

METHODS AND RESULTS

We used data from the National Health and Nutrition Examination Survey from 1999 to 2018. The definition of CKM syndrome is the coexistence of subclinical or clinical cardiovascular disease, chronic kidney disease, and metabolic disorders. We classified participants by 4 CKM stages according to the different clinical severity of different forms of CKM syndrome. We calculated the summed number of positive SRP measures, including employed, high-income level, food secure, high education attainment, private insurance, owning a house, and married, as SRP scores and classified them into 4 levels by quartiles: low (0-2), lower-middle (3-4), upper-middle (5-6), and high (7-8). A total of 18 373 US adults, aged 20 to 79 years, were included in our analyses. There were 2567 (9.4%) participants with low SRP score level. Most individual SRP measures and a combined SRP score were associated with CKM stages. Compared with high SRP score level, low SRP level was associated with higher odds of having CKM stage 1 (odds ratio [OR], 1.34 [95% CI, 1.06-1.70]), CKM stage 2 (OR, 2.03 [95% CI, 1.59-2.58]), CKM stage 3 (OR, 5.28 [95% CI, 3.29-8.47]), and CKM stage 4 (OR, 5.97 [95% CI, 4.20-8.49]).

CONCLUSIONS

Cumulative social disadvantage, denoted by higher SRP burden, was associated with higher odds of CKM multimorbidity, independent of demographic and lifestyle factors.

Association between systemic immune-inflammation index and cardiovascular-kidney-metabolic syndrome

This study aims to explore the relationship between the Systemic Immune-Inflammation Index (SII) and Cardiovascular-Kidney-Metabolic (CKM) Syndrome and its components. Data from the National Health and Nutrition Examination Survey (NHANES) from 2001 to 2018 were analyzed. CKM Syndrome is defined as the coexistence of Cardiometabolic Syndrome (CMS) and Chronic Kidney Disease (CKD). The SII is calculated using the formula: SII = (Platelet count × Neutrophil count)/Lymphocyte count. Weighted logistic regression models were used to examine the associations between SII and CKM, as well as its specific components. Restricted cubic splines explored non-linear relationships, and piecewise linear regression models assessed threshold effects. A consistent positive correlation was observed between elevated SII levels and the likelihood of CKM and its related diseases. In the fully adjusted Model 3, an increase of 1000 units in SII was associated with a 1.48-fold increase in the odds of CKM (95% CI 1.20-1.81, p < 0.001). Quartile analysis revealed a dose-response relationship, with the highest quartile of SII (Q4) showing the strongest association with CKM and its components. Nonlinear analyses revealed inflection points for waist circumference, triglycerides, low HDL-C, and cardiometabolic syndrome at specific SII levels, indicating a change in the direction or strength of associations beyond these points. Conversely, a linear relationship was observed between SII and chronic kidney disease. The SII is positively correlated with the risk of CKM Syndrome and its individual components, with evidence of non-linear relationships and threshold effects for some components.

Hyperuricaemia Prevalence Rates According to Their Physiochemical and Epidemiological Diagnostic Criteria and Their Associations with Cardio-Renal-Metabolic Factors: SIMETAP-HU Study

Background: Scientific societies disagree on serum uric acid (SUA) thresholds for the diagnosis of hyperuricaemia (HU) according to epidemiological or physiochemical criteria (SUA ≥ 7.0 mg/dL for men and ≥6.0 mg/dL for women [HU-7/6]; SUA ≥ 7.0 mg/dL for both genders [HU-7/7], respectively). HU is not included among the diagnostic criteria for metabolic syndrome or cardiovascular-renal-metabolic syndrome (CKM), although it promotes atherosclerosis and is associated with renal and cardiometabolic diseases. Both issues are of utmost importance and need to be clarified, hence the present study aims to assess the prevalence rates of HU and their associations with CKM factors. Methods: A cross-sectional observational study was conducted on a random population-based sample of 6489 adults. Bivariate and multivariate analyses were performed on the most well-known renal and cardiometabolic variables of the populations with and without HU-7/7 and HU-7/6. Results: The adjusted prevalence rates for HU-7/6 were 13.4% in adult population (18.4% in men; 9.6% in women) and 10.2% (18.4% in men; 3.8% in women) for HU-7/7. The main factors associated independently with HU for both genders were low estimated glomerular filtration rate, hypertension, hypertriglyceridaemia, and alcoholism, regardless of the criteria chosen, as well as albuminuria in women and central obesity in men. Conclusions: The prevalence rates of HU increase linearly with age for both genders. The associations of CKM factors with HU diagnosed according to physiochemical criterion are more similar between men and women than those using epidemiological criteria.

Atrial Fibrillation Prevalence Rates and Its Association with Cardiovascular-Kidney-Metabolic Factors: SIMETAP-AF Study

Background and Objectives: Atrial fibrillation (AF) is the most frequent arrhythmia and the main cause of hospital admissions for cardioembolic stroke. The SIMETAP research project aims to update the prevalence rates of cardiovascular, renal, or metabolic factors and to evaluate their respective associations with factors that could be related. The present study aims to assess the AF prevalence rates in an adult population and its association with cardiovascular-kidney-metabolic (CKM) factors. Materials and Methods: This cross-sectional observational study was conducted in a primary care setting, with a population-based random sample of 6588 people aged 18.0-102.8 years. Crude and adjusted prevalence rates of AF were calculated. The associations of CKM factors with AF were assessed using bivariate and multivariate analysis. Results: The age- and sex-adjusted prevalence rates of AF were 2.9% in the overall adult population, 6.1% in the population aged ≥50 years, and 12.9% in the population aged ≥70 years, with no significant differences by sex. AF prevalence in the population under 50 years of age barely reached 1‰. Heart failure (HF), hypertension, chronic kidney disease (CKD), stroke, low HDL-cholesterol, and prediabetes were independent CKM factors associated with AF in the overall population, as were the same factors, except prediabetes, in the population ≥50 years old (p < 0.001). High or very high vascular risk was present in 92.4% [95% CI: 89.1-95.7]) of the population with AF. Conclusions: The adjusted prevalence rate of AF in the population aged 50 years or older was 6.1%, twice that of the overall adult population and half that of the population aged 70 years or older. The main independent CKM factors associated with AF were HF, stroke, CKD, hypertension, and low HDL-cholesterol.

Association between the triglyceride glucose-body mass index and future cardiovascular disease risk in a population with Cardiovascular-Kidney-Metabolic syndrome stage 0-3: a nationwide prospective cohort study

BACKGROUND

The American Heart Association (AHA) has recently introduced the concept of Cardiovascular-Kidney-Metabolic (CKM) syndrome, which is the result of an increasing emphasis on the interplay of metabolic, renal and cardiovascular diseases (CVD). Furthermore, there is substantial evidence of a correlation between the triglyceride glucose-body mass index (TyG-BMI ) and CVD as an assessment of insulin resistance (IR). However, it remains unknown whether this correlation exists in population with CKM syndrome.

METHODS

All data for this study were obtained from the China Health and Retirement Longitudinal Study (CHARLS). The exposure was the participants' TyG-BMI at baseline, which was calculated using a combination of triglycerides (TG), fasting blood glucose (FBG) and body mass index (BMI). The primary outcome was CVD, which were determined by the use of a standardised questionnaire during follow-up. To examine the relationship between TyG-BMI and CVD incidence in population with CKM syndrome, both Cox regression analyses and restricted cubic spline (RCS) regression analyses were performed.

RESULTS

A total of 7376 participants were included in the final analysis. Of these, 1139, 1515, 1839, and 2883 were in CKM syndrome stages 0, 1, 2, and 3, respectively, at baseline. The gender distribution was 52.62% female, and the mean age was 59.17 ± 9.28 (years). The results of the fully adjusted COX regression analyses indicated that there was a 6.5% increase in the risk of developing CVD for each 10-unit increase in TyG-BMI,95% confidence interval (CI):1.041-1.090. The RCS regression analyses demonstrated a positive linear association between TyG-BMI and the incidence of CVD in the CKM syndrome population (P for overall < 0.001, P for nonlinear = 0.355).

CONCLUSIONS

This cohort study demonstrated a positive linear association between TyG-BMI index and increased CVD incidence in a population with CKM syndrome stage 0-3. This finding suggests that enhanced assessment of TyG-BMI index may provide a more convenient and effective tool for individuals at risk for CVD in CKM syndrome stage 0-3.

Cost Offset of Dapagliflozin in the US Medicare Population with Cardio-Kidney Metabolic Syndrome

INTRODUCTION

Cardiovascular-kidney-metabolic (CKM) syndrome is highly prevalent in the US Medicare population and is projected to increase further. Sodium-glucose co-transporter 2 inhibitors have indications in chronic kidney disease (CKD), heart failure (HF), and type 2 diabetes (T2D), providing protective efficacy across conditions within CKM syndrome. The objective of this study was to develop a model to extrapolate key outcomes observed in pivotal clinical trials to the US Medicare population, and to assess the potential direct cost offsets associated with dapagliflozin therapy.

METHODS

All US 2022 Medicare beneficiaries (≥ 65 years of age) eligible to receive dapagliflozin were estimated according to drug label indication and Medicare enrollment and claims data. Incidence of key outcomes from the dapagliflozin clinical program were modelled over a 4-year time horizon based on patient-level data with CKD, HF, and T2D. Published cost data of relevant clinical outcomes were used to calculate direct medical care cost-offset associated with treatment with dapagliflozin.

RESULTS

In a population of 13.1 million patients with CKM syndrome, treatment with dapagliflozin in addition to historical standard of care (hSoC) versus hSoC alone led to fewer incidents of HF-related events (hospitalization for HF, 613,545; urgent HF visit, 98,896), renal events (kidney failure, 285,041; ≥ 50% sustained decline in kidney function, 375,137), and 450,355 fewer deaths (of which 225,346 and 13,206 incidences of cardiovascular and renal death were avoided). In total this led to medical care cost offsets of $99.3 billion versus treatment with hSoC only (dapagliflozin plus hSoC, $310.3 billion; hSoC, $211.0 billion).

CONCLUSION

By extrapolating data from trials across multiple indications within CKM syndrome, this broader perspective shows that considerable medical care cost offsets may result through attenuated incidence of clinical events in CKD, T2D, and HF populations if treated with dapagliflozin in addition to hSoC over a 4-year time horizon. Graphical abstract available for this article.

Inclisiran in individuals with diabetes or obesity: Post hoc pooled analyses of the ORION-9, ORION-10 and ORION-11 Phase 3 randomized trials

AIMS

To conduct a pooled analysis of Phase 3 trials investigating the efficacy and safety of inclisiran across glycaemic and body mass index (BMI) strata.

MATERIALS AND METHODS

Participants were randomized 1:1 to receive 300 mg inclisiran sodium or placebo twice yearly, after initial and 3-month doses up to 18 months, with background oral lipid-lowering therapy. Analyses were stratified by glycaemic status (normoglycaemia, prediabetes, and diabetes) or BMI (<25, ≥25 to <30, ≥30 to <35, and ≥35 kg/m2). Co-primary endpoints were percentage and time-adjusted percentage change in low-density lipoprotein (LDL) cholesterol from baseline. Safety was also assessed.

RESULTS

Baseline characteristics were balanced between treatment arms and across strata. Percent LDL cholesterol change (placebo-corrected) with inclisiran from baseline to Day 510 ranged from -47.6% to -51.9% and from -48.8% to -54.4% across glycaemic/BMI strata, respectively. Similarly, time-adjusted percentage changes after Day 90 and up to Day 540 ranged from -46.8% to -52.0% and from -48.6% to -53.3% across glycaemic/BMI strata, respectively. Inclisiran led to significant reductions in proprotein convertase subtilisin/kexin type 9 and other atherogenic lipids and lipoproteins versus placebo across the glycaemic/BMI strata. The proportions of individuals achieving LDL cholesterol thresholds of <1.8 mmol/L and <1.4 mmol/L with inclisiran increased with increasing glycaemic and BMI strata. Across the glycaemic/BMI strata, a higher proportion of individuals had mild/moderate treatment-emergent adverse events (TEAEs) at the injection site with inclisiran (2.8%-7.7%) versus placebo (0.2%-2.1%).

CONCLUSION

Inclisiran provided substantial and sustained LDL cholesterol lowering across glycaemic/BMI strata, with a modest excess of transient mild-to-moderate TEAEs at the injection site.