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

The impact of the triglyceride-glucose index on the deterioration of kidney function in patients with cardiovascular-kidney-metabolic syndrome: insight from a large cohort study in China

BACKGROUND

The triglyceride-glucose (TyG) index has emerged as a credible surrogate indicator of insulin resistance in recent years. This study aimed to investigate the relationship between the TyG index and the deterioration of kidney function in patients with cardiovascular-kidney-metabolic (CKM) syndrome.

METHODS

In this retrospective cohort study from China, 27,407 hospitalized patients with stage 1-4 CKM syndrome were consecutively included. The participants were categorized into four groups according to TyG index quartiles. The study outcome was the deterioration of kidney function, defined as a decrease in estimated glomerular filtration rate (eGFR) ≥ 40% from baseline. Restricted cubic spline (RCS) curves and multivariate Cox analysis were used for analysis.

RESULTS

3,248 outcome events were recorded during a mean follow-up period of 34 months. The RCS plot displayed a U-shaped curve between the baseline TyG index and the deterioration of kidney function (P for non-linear < 0.001). The baseline TyG index with the lowest hazard ratio (HR) of eGFR decline ranges from 8.65 to 9.15, with an inflection point at 8.88. After fully adjusting for covariates, HRs and 95% confidence intervals (CIs) from the lowest to highest TyG index quartile were 1.00 (reference), 0.82 (0.74, 0.91), 0.78 (0.70, 0.86), and 0.93 (0.83, 1.03), respectively. According to the Kaplan-Meier survival curve, the risk of deterioration of kidney function was elevated in the lowest and highest TyG index quartiles (log-rank test, p < 0.0001).

CONCLUSIONS

In individuals with CKM syndrome, a non-linear U-shaped relationship existed between the baseline TyG index and the deterioration of kidney function.

Stress hyperglycemia ratio as an independent predictor of acute kidney injury in critically ill patients with acute myocardial infarction: a retrospective U.S. cohort study

BACKGROUND

Acute kidney injury (AKI) is a frequent and severe complication in critically ill patients with acute myocardial infarction (AMI), significantly worsening prognosis. Identifying early risk markers for AKI in AMI patients is critical for timely intervention. The stress hyperglycemia ratio (SHR), a marker of acute glycemic response to physiological stress, has been proposed as a predictor of AKI, but its role remains unclear.

OBJECTIVE

This study investigates the association between SHR and AKI development in critically ill patients with AMI, using data from the MIMIC-III and MIMIC-IV databases.

METHODS

A total of 4,663 critically ill AMI patients were analyzed. SHR was evaluated for its association with AKI incidence using logistic regression, restricted cubic splines, and mediation analysis. Subgroup and sensitivity analyses were performed to confirm robustness. Additionally, Cox regression and Kaplan-Meier survival analysis were used to explore SHR's association with in-hospital mortality in the overall cohort and AKI subgroup.

RESULTS

Higher SHR levels were independently associated with an increased risk of AKI, demonstrating a J-shaped relationship. Mediation analysis revealed that neutrophil count and albumin partially mediated this effect. Kaplan-Meier survival curves showed significant differences in in-hospital mortality among SHR quartiles (log-rank p < 0.001). However, Cox regression analysis indicated that SHR was not an independent predictor of in-hospital mortality in either the full cohort or the AKI subgroup.

CONCLUSIONS

SHR serves as an early and independent marker for AKI risk in critically ill AMI patients, offering potential utility in clinical risk stratification. However, its role in predicting in-hospital mortality appears limited. These findings underscore the importance of glycemic monitoring and management in AMI patients at risk of AKI.

Association of cardiovascular-kidney-metabolic syndrome with all-cause and cardiovascular mortality: A prospective cohort study

Background

Given evidence on the cardiovascular disease (CVD) risk conferred by comorbidity risk factors, the American Heart Association (AHA) recently introduced a novel staging construct, named cardiovascular-kidney-metabolic (CKM) syndrome. This study examined the association of CKM syndrome stages with all-cause and cardiovascular mortality among US adults.

Methods

Data were from the National Health and Nutrition Examination Survey (NHANES) 1999-2018 at baseline linked to the 2019 National Death Index records. For each participant, the CKM syndrome was classified into five stages: stage 0 (no CKM risk factors), 1 (excess or dysfunctional adiposity), 2 (metabolic risk factors and chronic kidney disease), 3 (subclinical CVD), or 4 (clinical CVD). The main outcomes were all-cause and cardiovascular mortality.

Results

Among 34,809 participants (mean age: 46.7 years; male: 49.2 %), the prevalence of CKM stages 0 to 4 was 13.2 %, 20.8 %, 53.1 %, 5.0 %, and 7.8 %, respectively. During a median follow-up of 8.3 years, compared to participants with CKM stage 0, those with higher stages had increased risks of all-cause mortality (stage 2: HR 1.43, 95 % 1.13-1.80; stage 3, HR 2.75, 95 % CI 2.12-3.57; stage 4, HR 3.02, 95 % CI 2.35-3.89). The corresponding hazard ratios (95 % confidence interval) of cardiovascular mortality risks were 2.96 (1.39-6.30), 7.60 (3.50-16.5), and 10.5 (5.01-22.2). The population-attributable fractions for advanced (stages 3 or 4) vs. CKM syndrome stages (stages 0, 1, or 2) were 25.3 % for all-cause mortality and 45.3 % for cardiovascular mortality.

Conclusion

Higher CKM syndrome stages were associated with increased risks of all-cause and cardiovascular mortality. These findings emphasize that primordial and primary prevention efforts on promoting CKM health should be strengthened to reduce mortality risk.

Cardiovascular-Kidney-Metabolic (CKM) Syndrome: A Case-Based Narrative Review

These 4 hypothetical cases highlight new features of the American Heart Association cardiovascular-kidney-metabolic (CKM) health construct. The cases incorporate the CKM staging system, estimates from the PREVENT risk calculator, and clinical approaches related to CKM stages and individual risk profiles. Topics include management considerations for (1) a patient with stage 1 obesity and impaired glucose tolerance, (2) a patient with metabolic risk factors and moderate-risk chronic kidney disease (CKD), (3) a patient with subclinical atherosclerotic cardiovascular disease and multiple comorbid conditions, and (4) a patient with metabolic risk factors, prior myocardial infarction, new-onset heart failure, atrial fibrillation, and CKD.

Risk-directed management of chronic kidney disease

The timely and rational institution of therapy is a key step towards reducing the global burden of chronic kidney disease (CKD). CKD is a heterogeneous entity with varied aetiologies and diverse trajectories, which include risk of kidney failure but also cardiovascular events and death. Developments in the past decade include substantial progress in CKD risk prediction, driven in part by the accumulation of electronic health records data. In addition, large randomized clinical trials have demonstrated the effectiveness of sodium-glucose co-transporter 2 inhibitors, glucagon-like peptide 1 receptor agonists and mineralocorticoid receptor antagonists in reducing adverse events in CKD, greatly expanding the options for effective therapy. Alongside angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, these classes of medication have been proposed to be the four pillars of CKD pharmacotherapy. However, all of these drug classes are underutilized, even in individuals at high risk. Leveraging prognostic estimates to guide therapy could help clinicians to prescribe CKD-related therapies to those who are most likely to benefit from their use. Risk-based CKD management thus aligns patient risk and care, allowing the prioritization of absolute benefit in determining therapeutic selection and timing. Here, we discuss CKD prognosis tools, evidence-based management and prognosis-guided therapies.

The prevention and management of chronic kidney disease among patients with metabolic syndrome

Treatment of patients with chronic kidney disease (CKD) requires implementation of prevention and management strategies that reduce the risk of kidney failure and CKD-associated cardiovascular risk. Metabolic syndrome is characterized by obesity, high blood pressure, dyslipidemia, and hyperglycemia, and it is common among patients with CKD. Large-scale randomized trials have led to significant advances in the management of CKD, with 5 pharmacotherapies now proven to be nephroprotective and/or cardioprotective in certain types of patients. Renin-angiotensin system inhibitors and sodium-glucose cotransporter 2 inhibitors slow kidney disease progression and reduce heart failure complications for most patients with CKD. In addition, statin-based regimens reduce low-density lipoprotein cholesterol and lower the risk of atherosclerotic disease (with no clinically meaningful effect on kidney outcomes). For patients with type 2 diabetes and albuminuric CKD, the nonsteroidal mineralocorticoid receptor antagonist finerenone and the glucagon-like peptide-1 receptor agonist semaglutide also confer cardiorenal benefits, with semaglutide additionally effective at reducing weight. Together, these randomized data strongly suggest that metabolic syndrome mediates some of the cardiorenal risk observed in CKD. Considered separately, the trials help elucidate which components of metabolic syndrome influence the pathophysiology of kidney disease progression and which separately modify risk of atherosclerotic and nonatherosclerotic cardiovascular outcomes. As we predict complementary and different mechanisms of nephroprotection and cardioprotection for these different interventions, it seems logical that they should be deployed together to maximize benefits. Even when combined, however, these therapies are not a cure, so further trials remain important to reduce the residual cardiorenal risks associated with CKD.

Diet quality and cardiometabolic health in breast cancer survivors: the Pathways Study

PURPOSE

Breast cancer (BC) survivors experience higher rates of cardiometabolic conditions, partly due to treatment. While healthy eating decreases the risk of these conditions in the general population, its association in BC survivors is unclear.

METHODS

We included 3415 participants from the Pathways Study, a prospective cohort of women diagnosed with invasive BC between 2005 and 2013 and followed through 2021. Concordance of food intakes from food frequency questionnaires was estimated for five healthy eating patterns at BC diagnosis: Dietary Approaches to Stop Hypertension (DASH), healthy Plant-based Dietary Index (hPDI), 2020 Healthy Eating Index (HEI), American Cancer Society nutrition guidelines (ACS), and the alternate Mediterranean Diet Index (aMED). Incident hypertension, diabetes, and dyslipidemia were identified through electronic health records. Cumulative incidence rates (CIRs) were estimated accounting for the competing risk of death. Covariate-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Fine and Gray regression models, stratified by BC treatment status.

RESULTS

Over an average 11.5 years (range = 0.3-16.3) of follow-up, 554 (16.2%) participants developed hypertension, 362 (10.6%) developed diabetes, and 652 (19.1%) developed dyslipidemia. CIRs for any cardiometabolic condition 15 years after BC diagnosis were 39.2% for women in the highest HEI quartile compared to 49.3% in the lowest. After adjustment, women in the highest HEI quartile had lower risks of any cardiometabolic condition (HR = 0.70, 95% CI 0.54-0.91, Ptrend = 0.006), including hypertension (HR = 0.71, 95% CI 0.54-0.94, Ptrend = 0.007), diabetes (HR = 0.57, 95% CI 0.41-0.79, Ptrend < 0.001), and dyslipidemia (HR = 0.77, 95% CI 0.59-0.99, Ptrend = 0.04). Similar associations were observed for DASH, hPDI, and ACS with diabetes incidence.

CONCLUSION

Healthier diets at BC diagnosis, particularly those aligned with the HEI, were associated with lower cardiometabolic risks.

Cardiometabolic disease management: influences from epigenetics

Epigenomics is a rapidly emerging field that has gathered significant attention as a "non-genetic determinant" implicated in the manifestation of non-communicable diseases. Exploring epigenetic modifications provides novel insights into the management of cardiometabolic disease (CMD). Epigenetics signatures are influenced by environmental stressors such as air pollution, toxins, and urban noises as well as by established cardiovascular risk factors including smoking, sedentary lifestyle, obesity, and diabetes. Understanding how epigenetic alterations lead to CMD as well as inter-individual differences in epigenetic makeup could unveil new molecular targets and new epi-drugs to be employed for precision medicine approaches in the growing population of patients with cardiometabolic disease to reduce cardiovascular risk. Herein, we provide an overview of the latest advancements in epigenetic mechanisms implicated in CMD and possible therapeutic opportunities.

Glucagon-like peptide-1 receptor agonists to improve cardiorenal outcomes: data from FLOW and beyond

PURPOSE OF REVIEW

Glucagon-like peptide-1 receptor agonists (GLP1RA), initially approved for glycemic control in type 2 diabetes mellitus (T2DM), have emerged as agents for weight loss, cardiovascular and kidney protection. This review summarizes the evidence supporting the benefits of these therapies on cardiorenal outcomes.

RECENT FINDINGS

Clinical trials have consistently demonstrated reductions in major adverse cardiovascular events with GLP1RA treatments. Recently, the FLOW trial revealed that semaglutide reduced the composite outcome of kidney failure, at least 50% decline in estimated glomerular filtration rate, kidney or cardiovascular mortality by 24% in patients with T2DM, thereby establishing GLP1RA as a pillar of therapy in this population. New evidence suggests favorable effects on kidney endpoints in nondiabetic individuals with overweight or obesity. Dedicated trials have also provided evidence for reduction in the risk for heart failure hospitalization and improvement in symptoms in individuals with heart failure with preserved ejection fraction. Subgroup analyses have suggested that GLP1RAs confer additive cardiorenal benefits irrespective of background medication use.

SUMMARY

There is increasing evidence that GLP1RA reduces the risk for cardiovascular events, chronic kidney disease progression, and heart failure hospitalizations. Further data on the effect of dual and triple GLP1-based therapies on cardiorenal outcomes is required.

Aortic valve calcium as a novel risk marker for kidney function deterioration: The MESA study

BACKGROUND

Aortic valve calcium (AVC) is associated with increased risk of mortality, cardiovascular disease (CVD), non-CVD such as dementia. Traditional atherosclerotic CVD risk factors are associated with both AVC and chronic kidney disease (CKD), but whether there is an association between AVC and CKD is unknown.

OBJECTIVES

To ascertain whether AVC quantified by cardiac CT scanning is independently associated with the long-term risk of incident CKD among individuals without a previous history of CVD.

METHODS

We examined 6346 Multi-Ethnic Study of Atherosclerosis (MESA) participants who underwent cardiac CT scanning at Visit 1 (2000-02) and had an eGFR of ≥ 60 mL/min/1.73 m2. AVC was quantified using the Agatston method and categorized as 0, 1-99, and ≥100. Incident CKD was defined as an eGFR < 60 mL/min/1.73 m2 accompanied with an at least 40 % decline in eGFR from baseline, and/or a diagnosis of CKD and indicators of end stage renal disease extracted from hospital records using the International Classification of Disease (ICD) codes. We performed Kaplan-Meier survival curve analyses along with multivariable adjusted Cox proportional hazard regression models to examine the association between AVC (categorical and log-transformed) and incident CKD.

RESULTS

Participants had a mean age 62.2 ± 10.1 years, 53 % were women, and AVC >0 was present in 795 (12 %) participants. During a median follow-up time of 16.9 years, 982 (15 %) participants developed incident CKD. AVC examined as a continuous variable was associated with a significantly increased risk of developing CKD (per log-unit [AVC+1] HR 1.06 [95 % CI: 1.02-1.10]; p = 0.005). Kaplan-Meier models showed a higher cumulative incidence for CKD with higher AVC levels. In the multivariable adjusted Cox models, participants with AVC ≥100 had a higher risk of incident CKD, compared with the AVC=0 group (HR 1.48 [95 % CI: 1.15-1.89]; p = 0.002). The observed associations remained after further adjusting for CAC score (p = 0.024), Lp(a) (p = 0.004), and the APOE-ε4 genotype (p = 0.004).

CONCLUSIONS

In a multi-ethnic cohort of participants free of CKD at baseline, AVC was independently associated with a higher risk of incident CKD. Further work is needed to understand the multidirectional relationship between AVC, CKD, and atherosclerosis.

Association between atherogenic index of plasma and new-onset stroke in a population with cardiovascular-kidney-metabolic syndrome stages 0-3: insights from CHARLS

BACKGROUND

The associations between atherogenic index of plasma (AIP) and cardiovascular disease (CVD) have been widely reported; However, such association to the incidence of stroke in the population with Cardiovascular-Kidney-Metabolic (CKM) syndrome remains ambiguous.

METHODS

A total of 7754 participants with CKM syndrome stages 0-3 from the China Health and Retirement Longitudinal Study were enrolled in this study. The incidence of new-onset stroke events was the primary outcome of this study. We used Kaplan-Meier survival curves and Cox proportional hazards models to explore the association between baseline AIP levels and the risk of stroke in the population with CKM syndrome stages 0-3. Additionally, we utilized restricted cubic spline plots to analyze the form of this association.

RESULTS

During a median follow-up of 6.8 years, 455 participants (5.9%) with CKM syndrome experienced their first stroke events. AIP was positively associated with the risk of stroke in the population with CKM syndrome stages 0-3. Kaplan-Meier curves analysis demonstrated a significant difference in stroke incidence across the AIP groups among the entire cohort. In the fully adjusted Model 3, the results revealed a significantly elevated risk of stroke for participants in the Q2, Q3, and Q4 groups compared to those in the Q1 group, with respective HR (95% CI) value of 1.352 (1.009-1.811), 1.421 (1.064-1.897), and 1.414 (1.052-1.900). Restricted cubic spline plots revealed the association of AIP and stroke risk was nonlinear (P-overall < 0.05, P-non-linear < 0.05), with inflection points of 0.32.

CONCLUSION

This study provides evidence that baseline AIP levels were significantly positively associated with the risk of stroke in individuals with CKM syndrome stages 0-3, and AIP may serve as an effective risk marker for early identification of high-risk individuals prone to stroke within the CKM stages syndrome 0-3 population.

Estimated glucose disposal rate outperforms other insulin resistance surrogates in predicting incident cardiovascular diseases in cardiovascular-kidney-metabolic syndrome stages 0-3 and the development of a machine learning prediction model: a nationwide prospective cohort study

BACKGROUND

The American Heart Association recently introduced the concept of cardiovascular-kidney-metabolic (CKM) syndrome, highlighting the increasing importance of the complex interplay between metabolic, renal, and cardiovascular diseases (CVD). While substantial evidence supports a correlation between the estimated glucose disposal rate (eGDR) and CVD events, its predictive value compared with other insulin resistance (IR) indices, such as triglyceride-glucose (TyG) index, TyG-waist circumference, TyG-body mass index, TyG-waist-to-height ratio, triglyceride-to-high density lipoprotein cholesterol ratio, and the metabolic score for insulin resistance, remains unclear.

METHODS

This prospective cohort study utilized data from the China Health and Retirement Longitudinal Study (CHARLS). The individuals were categorized into four subgroups based on the quartiles of eGDR. The associations between eGDR and incident CVD were evaluated using multivariate logistic regression analyses and restricted cubic spline. Seven machine learning models were utilized to assess the predictive value of the eGDR index for CVD events. To assess the model's performance, we applied receiver operating characteristic (ROC) and precision-recall (PR) curves, calibration curves, and decision curve analysis.

RESULTS

A total of 4,950 participants (mean age: 73.46 ± 9.93 years), including 50.4% females, were enrolled in the study. During follow-up between 2011 and 2018, 697 (14.1%) participants developed CVD, including 486 (9.8%) with heart disease and 263 (5.3%) with stroke. The eGDR index outperformed six other IR indices in predicting CVD events, demonstrating a significant and linear relationship with all outcomes. Each 1-unit increase in eGDR was associated with a 14%, 14%, and 19% lower risk of CVD, heart disease, and stroke, respectively, in the fully adjusted model. The incorporation of the eGDR index into predictive models significantly improved prediction performance for CVD events, with the area under the ROC and PR curves equal to or exceeding 0.90 in both the training and testing sets.

CONCLUSIONS

The eGDR index outperforms six other IR indices in predicting CVD, heart disease, and stroke in individuals with CKM syndrome stages 0-3. Its incorporation into predictive models enhances risk stratification and may aid in the early identification of high-risk individuals in this population. Further studies are needed to validate these findings in external cohorts.

Risk-Based Primary Prevention of Heart Failure: A Scientific Statement From the American Heart Association

The growing morbidity, mortality, and health care costs related to heart failure (HF) underscore the urgent need to prioritize its primary prevention. Whereas a risk-based approach for HF prevention remains in its infancy, several key opportunities exist to actualize this paradigm in clinical practice. First, the 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America HF guidelines provided recommendations, for the first time, on the clinical utility of multivariable risk equations to estimate risk of incident HF. Second, the American Heart Association recently developed the PREVENT (Predicting Risk of Cardiovascular Disease Events) equations, which not only enable prediction of incident HF separately, but also include HF in the prediction of total cardiovascular disease. Third, the predominant phenotype of HF risk has emerged as the cardiovascular-kidney-metabolic syndrome. Fourth, the emergence of novel therapies that prevent incident HF (eg, sodium-glucose cotransporter-2 inhibitors) and target multiple cardiovascular-kidney-metabolic axes demonstrate growing potential for risk-based interventions. Whereas the concept of risk-based prevention has been established for decades, it has only been operationalized for atherosclerotic cardiovascular disease prevention to date. Translating these opportunities into a conceptual framework of risk-based primary prevention of HF requires implementation of PREVENT-HF (Predicting Risk of Cardiovascular Disease Events-Heart Failure) equations, targeted use of cardiac biomarkers (eg, natriuretic peptides) and echocardiography for risk reclassification and earlier detection of pre-HF, and definition of therapy-specific risk thresholds that incorporate net benefit and cost-effectiveness. This scientific statement reviews the current evidence for accurate risk prediction, defines strategies for equitable prevention, and proposes potential strategies for the successful implementation of risk-based primary prevention of HF.

AI-enabled opportunistic measurement of liver steatosis in coronary artery calcium scans predicts cardiovascular events and all-cause mortality: an AI-CVD study within the Multi-Ethnic Study of Atherosclerosis (MESA)

INTRODUCTION

About one-third of adults in the USA have some grade of hepatic steatosis. Coronary artery calcium (CAC) scans contain more information than currently reported. We previously reported new artificial intelligence (AI) algorithms applied to CAC scans for opportunistic measurement of bone mineral density, cardiac chamber volumes, left ventricular mass, and other imaging biomarkers collectively referred to as AI-cardiovascular disease (CVD). In this study, we investigate a new AI-CVD algorithm for opportunistic measurement of liver steatosis.

METHODS

We applied AI-CVD to CAC scans from 5702 asymptomatic individuals (52% female, age 62±10 years) in the Multi-Ethnic Study of Atherosclerosis. Liver attenuation index (LAI) was measured using the percentage of voxels below 40 Hounsfield units. We used Cox proportional hazards regression to examine the association of LAI with incident CVD and mortality over 15 years, adjusted for CVD risk factors and the Agatston CAC score.

RESULTS

A total of 751 CVD and 1343 deaths accrued over 15 years. Mean±SD LAI in females and males was 38±15% and 43±13%, respectively. Participants in the highest versus lowest quartile of LAI had greater incidence of CVD over 15 years: 19% (95% CI 17% to 22%) vs 12% (10% to 14%), respectively, p<0.0001. Individuals in the highest quartile of LAI (Q4) had a higher risk of CVD (HR 1.43, 95% CI 1.08 to 1.89), stroke (HR 1.77, 95% CI 1.09 to 2.88), and all-cause mortality (HR 1.36, 95% CI 1.10 to 1.67) compared with those in the lowest quartile (Q1), independent of CVD risk factors.

CONCLUSION

AI-enabled liver steatosis measurement in CAC scans provides opportunistic and actionable information for early detection of individuals at elevated risk of CVD events and mortality, without additional radiation.

Clinic- and home-based renal rehabilitation improves spKt/V and uremic syndrome in hemodialysis patients: a case report

There was an increasing uptake of hemodialysis and patient life expectancy due to improved treatment efficiency. However, the quality of life (QOL) of chronic kidney disease (CKD) patients is not parallelly improved, leading to a shift in focus towards promoting the QOL. Among the common complications of CKD such as anaemia and mineral bone disorder, uremic syndrome has been found as the main contributor to poor QOL. We present the case of an 80-year-old man with hemodialysis, who presented with poor appetite and weakness following recovering from COVID-19. Biochemical, echocardiographic, body composition, psychological, nutritional, and QOL assessments suggested multi-organ dysfunction attributable to uremic syndrome. Renal rehabilitation involving the combination of clinic- and home-based exercise and nutritional interventions effectively improved his symptoms while elevating spKt/V. Our case report not only demonstrated exercise and nutritional rehabilitation as an effective approach to managing uremic syndrome in hemodialysis patients, but also provided insight into the effects of improved nutritional status on spKt/V.

Using guideline-directed medical therapies to improve kidney and cardiovascular outcomes in patients with chronic kidney disease

PURPOSE

An estimated 37 million people currently live with chronic kidney disease in the US, which places them at increased risk for kidney disease progression, cardiovascular disease, and mortality. This review discusses current standard-of-care management of patients with chronic kidney disease, identifies key gaps in care, and briefly highlights how pharmacists can address gaps in care as members of the multidisciplinary care team.

SUMMARY

Recent advances in guideline-directed medical therapies for patients with chronic kidney disease, including agents from the sodium-glucose cotransporter, glucagon-like peptide-1 receptor agonist, and nonsteroidal mineralocorticoid receptor antagonist classes, can dramatically improve cardiovascular-kidney-metabolic care and outcomes. Unfortunately, gaps in screening, diagnosis, and implementation of recommended therapies persist. Team-based models of care-inclusive of the person with chronic kidney disease-have the potential to significantly improve care and outcomes for people with chronic kidney disease by addressing current gaps in care.

CONCLUSION

As members of the multidisciplinary care team, pharmacists can play a critical role in addressing current gaps in care, including optimized use of guideline-directed medical therapies, in patients with chronic kidney disease.

On the Frontlines of Cardiovascular-Kidney-Metabolic Syndrome: A Review of GLP-1 and Dual GLP-1/GIP Receptor Agonists in Cardiovascular and Kidney Health

PURPOSE

The purpose of this review is to highlight the role of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and dual GLP-1/glucose-dependent insulinotropic polypeptide (GIP) receptor agonists (GLP-1/GIP RAs) in managing cardiovascular-kidney-metabolic (CKM) syndrome, focusing on their cardiovascular (CV) and kidney-protective effects beyond glycemic control.

SUMMARY

In multiple randomized controlled trials, GLP-1 RAs were demonstrated to confer significant benefits in reducing CV events and preserving kidney function in patients with preexisting atherosclerotic cardiovascular disease (ASCVD) and those at high CV risk. Current guidelines, including those from the Kidney Disease: Improving Global Outcomes (KDIGO) initiative and the American Diabetes Association (ADA), underscore the therapeutic potential of these agents for managing chronic kidney disease (CKD), type 2 diabetes mellitus (T2DM), and metabolic syndrome. Additionally, emerging data suggests their utility beyond T2DM. This review summarizes the evidence supporting these guidelines, along with newer findings not yet fully integrated into clinical practice. It also examines the role of pharmacists and multidisciplinary teams, safety considerations, and practical strategies for managing common adverse effects.

CONCLUSION

The integration of GLP-1 RAs and dual GLP-1/GIP RAs into clinical practice offers substantial benefits for patients, both with and without diabetes. Pharmacists play a pivotal role in recommending evidence-based treatments for those at high CV and kidney risk, educating patients, addressing social determinants of health, and bridging gaps across multidisciplinary care teams.

A holistic approach to managing cardio-kidney metabolic syndrome: insights and recommendations from the Italian perspective

Cardio-kidney metabolic (CKM) syndrome represents a complex and circular interplay of cardiovascular, renal, and metabolic dysfunctions, significantly contributing to global morbidity and mortality. This expert opinion synthesizes insights from a panel of Italian specialists in cardiology, nephrology, and diabetology, advocating for a holistic and integrated framework for CKM management. The recommendations underline the critical need for early identification and stratification of CKM stages, fostering an interdisciplinary approach that bridges specialties and ensures comprehensive care. Emphasizing innovative pathways for collaboration, including dynamic referral protocols, telemedicine, and shared decision-making, the proposed strategies aim to overcome structural and organizational barriers in healthcare. By promoting a unified approach, the framework seeks to streamline CKM care, enhance communication among specialists, and improve the coordination of services. This holistic strategy represents a pivotal step toward mitigating disease progression, improving clinical outcomes, and enhancing the quality of life for patients with CKM syndrome.

Principles for the Future of Biomedical Research in the United States and Optimizing the National Institutes of Health: A Presidential Advisory From the American Heart Association

Groundbreaking achievements in science and medicine have contributed to reductions in cardiovascular disease and stroke mortality over the past 7 decades. Many of these advances were supported through investments by the National Institutes of Health, the global leader in funding biomedical research. This public investment has produced important economic returns, including supporting >400 000 jobs and roughly $93 billion in economic activity in the United States. Unfortunately, public funding has not kept pace with the burden of disease or rates of inflation. As the nation's oldest and largest volunteer organization dedicated to fighting heart disease and stroke, research is critical to the American Heart Association's mission. Given the American Heart Association's unique position in representation of patients, clinicians, and scientists and as a research funder, we offer the following principles to optimize the future of the US biomedical research enterprise in general and the National Institutes of Health in particular. Specifically, the United States should continue to prioritize innovative and impactful research; to improve efficiency and transparency in its peer review process; to lead in translating evidence into practice; to support the current and future biomedical workforce; and to ensure robust and reliable public investment for the future. The American Heart Association reiterates our strong support for the National Institutes of Health and federal agencies that fund and implement biomedical and population-based research initiatives, which yield important economic returns. These agencies are vital to support today's current and future health challenges, to drive foundational science, to improve patient health, to reduce the global disease burden, to address upstream and preventive strategies, and to improve the value of our public health and health care investments.

From Liver to Kidney: The Overlooked Burden of Nonalcoholic Fatty Liver Disease in Chronic Kidney Disease

Nonalcoholic fatty liver disease (NAFLD) is increasingly recognized as a contributor to chronic kidney disease (CKD), yet its impact remains underappreciated in clinical practice. Recent studies reveal a strong association between NAFLD and CKD progression, with evidence linking hepatic dysfunction to renal impairment through metabolic and inflammatory pathways. NAFLD not only increases the risk of CKD but also accelerates its progression, leading to worse cardiovascular outcomes and higher mortality, particularly in patients with advanced fibrosis. Despite this growing evidence, NAFLD often goes undiagnosed in CKD patients and routine hepatic evaluation is rarely integrated into nephrology care. Emerging diagnostic tools, including noninvasive biomarkers and imaging techniques, offer potential for earlier detection, yet their clinical implementation remains inconsistent. Although lifestyle modifications remain the foundation of treatment, pharmacotherapeutic strategies, including SGLT2 inhibitors and GLP-1 receptor agonists, have demonstrated potential in mitigating both hepatic and renal impairment. Recognizing the interplay between NAFLD and CKD is essential for improving patient outcomes. A multidisciplinary approach, integrating hepatology and nephrology expertise, is crucial to refining screening strategies, optimizing treatment, and reducing the long-term burden of these coexisting conditions.

Increasing incidence of hypertensive disorders of pregnancy and association with decreased GFR and albuminuria: The need for post-partum follow-up

BACKGROUND

Hypertensive disorders of pregnancy (HDP) are associated with increased postpartum risk of cardiovascular disease or kidney failure. However, there is scarce information on the association with actionable kidney outcomes that should be treated to prevent progression to kidney failure.

OBJECTIVES

To evaluate the incidence of HDP over time and its association with kidney function, hypertension, and albuminuria during follow-up after discharge.

METHODS

Single center retrospective cohort study of women without previous history of CKD among 20484 deliveries over 10 years.

RESULTS

From 2008 to 2017, HDP was diagnosed in 846 (4.13 %) pregnant women. The incidence increased over time and was higher in women from Africa and America than in European women. The Nephrology department evaluated 210 (27 %) women with HDP during hospitalization and 170 (21 %) during follow-up. At follow-up, 5.3 % of the 150 women with available follow-up eGFR data had decreased eGFR (<90 ml/min/1.73 m2), 16.1 % albuminuria ≥30 mg/g and 8.6 % persistent hypertension. In multivariate analysis, gestational diabetes mellitus [OR 8.03 (95 % CI: 1.49-43.13; p 0.01)] and higher number of pregnancies [OR: 1.27 (95 % CI: 1.00-1.62; p 0.04)] were associated with persistent hypertension; diabetes mellitus [OR 14.07 (1.59-123.89); p = 0.02] with decreased glomerular filtration rate; and obesity [OR: 5.79 (1.70-19.13); p = 0.004] and diabetes mellitus [OR 5.86 (1.18-29.09); p = 0.03] with persistent albuminuria. Kaplan Meier analysis was consistent with a higher risk of decreased eGFR within 12 months for patients with albuminuria ≥30 mg/g (p = 0.02, logRank Test).

CONCLUSION

The incidence of HDP is increasing but most patients with HDP lack outpatient follow-up. In those with nephrological follow-up, decreased eGFR, evidence of CKD or residual hypertension are common. Metabolic conditions (obesity, diabetes mellitus) may identify those at higher risk of actionable short-term adverse kidney outcomes.

AKHOMM initiative curriculum and learning and action collaborative

PURPOSE

The Advancing Kidney Health through Optimal Medication Management (AKHOMM) initiative was developed with the vision that every person with kidney disease receives optimal medication management through team-based care including a pharmacist to improve kidney health. Due to the need for education and clinical practice implementation strategies, the AKHOMM initiative designed 2 educational programs to help achieve our vision: a continuing education curriculum and a learning and action collaborative (LAC).

SUMMARY

The curriculum is online, interactive, and case based, with interprofessional accreditation, to provide baseline competency in comprehensive medication management (CMM) across chronic kidney disease and address health disparities in this population. The development process involved an interprofessional approach with input from persons with kidney disease and care partners. Modules have been well received based on postactivity surveys, with over 90% of respondents (970/1,044) indicating that the activity will improve their ability to treat and manage their patients. Ongoing quality assurance of existing modules, coupled with development of new modules in prioritized areas (cardiovascular-kidney-metabolic [CKM] syndrome, glomerular diseases) will continue to provide education to the pharmacy and broader healthcare communities. The LAC was designed using implementation science principles to facilitate pharmacist inclusion in patient care teams to provide CMM to patients with CKM. Site teams will include a pharmacist, provider champion, and others coupled with an implementation coach and field expert. Through a continuous quality improvement framework, the teams will work towards achieving their bold aim over a 12-month implementation period.

CONCLUSION

The curriculum and LAC address the current void of pharmacist-based care in CKM.

Associations of cardiovascular-kidney-metabolic syndrome stages with premature mortality and the role of social determinants of health

OBJECTIVES

The American Heart Association defined cardiovascular-kidney-metabolic (CKM) syndrome as a novel multi-stage disorder. We examined the associations of CKM stages with premature mortality and the role of social determinants of health (SDOHs).

DESIGN

A prospective cohort study.

SETTING AND PARTICIPANTS

A nationally representative sample of US adults from NHANES 1999-2018.

MEASUREMENTS

CKM included 5 stages (stages 0-4), reflecting progressive pathophysiology. Premature mortality (deaths before 75 years) were ascertained via linkage to the National Death Index with follow-up until 2019. Cox proportional-hazards models adjusted for age, sex, race/ethnicity, medical history, and other confounding factors were used to calculate the hazard ratios (HR) and 95% CIs for CKM-mortality associations.

RESULTS

Among 27,909 participants (mean age 49.7 years, 49.0% females), 1762 premature deaths occurred over a median follow-up of 8.3 years. Compared with stage 0, the adjusted HRs for all-cause premature mortality at CKM stages 1-4 were 0.88 (95% CI 0.66-1.17), 1.31 (0.99-1.73), 1.94 (1.31-2.87), and 2.19 (1.61-2.98), respectively. For CVD premature mortality, the adjusted HRs for CKM stages 1-4 were 1.12 (0.46-2.72), 1.74 (0.71-4.28), 3.93 (1.53-10.12), and 6.48 (2.95-14.20), respectively. Among adults at CKM stages 3-4, unfavorable SDOHs, particularly not living with a partner, low family income, lack of private health insurance, unemployment, or ≥2 cumulative SDOHs (4.16, 95% CI 3.35-5.18) were associated with increased all-cause premature mortality. Among those at CKM stages 0-2, unfavorable SDOHs were also related to increased premature mortality.

CONCLUSION

CKM stages 3-4, but not stages 1-2, were associated with increased risks of premature mortality compared with stage 0. The risks were increased by unfavorable SDOHs across CKM stages.

Efficacy of myo-inositol and zinc on insulin resistance in a paediatric population with obesity

AIM

To assess the efficacy of the combined administration of myo-inositol and zinc, a mineral involved in the insulin pathway, in paediatric obesity with insulin resistance on HOMA-IR, glucose-insulin metabolism, and lipid profile.

MATERIALS AND METHODS

Double-blind, randomized, placebo-controlled study conducted in North Italy. Fifty-six patients (10-18 years, Tanner stage ≥3) with obesity and insulin resistance were randomized to myo-inositol (2000 mg), zinc gluconate (5 mg), and galactooligosaccharides (GOS) from plant-based origin (1000 mg) (TRT) or placebo (PLC) containing only GOS from plant-based origin (1000 mg). All patients received an isocaloric diet following the Mediterranean diet style. Data were collected at baseline (V0) and after 3 months (V1). The primary outcome was the insulin resistance index (HOMA-IR).

RESULTS

Fifty out of 56 recruited subjects completed the study. TRT improved HDL cholesterol level compared to PLC (p = 0.05) but not insulin resistance. A stratified post hoc analysis was performed by sex, BMI, and subgroups of adherence to the Mediterranean diet. Subjects were divided for obesity grade, fasting insulin (p = 0.0137) and HOMA-IR (p = 0.0273) were lower in TRT than in PLC patients, with a greater effect on severe obesity. No adverse events were detected.

CONCLUSION

Three months of supplementation with myo-inositol and zinc were beneficial on lipid profile and in managing obesity complications at least in subjects with severe phenotype. Thus, myo-inositol and zinc could be used as non-pharmacological agents. This work suggests a long-term study with a larger sample size to enrich the findings.

What Is 'Food Is Medicine,' Really? Policy Considerations On The Road To Health Care Coverage

Food Is Medicine interventions are increasingly gaining attention from policy makers, payers, and health care professionals as a promising approach to addressing diet-related chronic health conditions in the health care setting, given the increasing burden and cost of these conditions. The American Heart Association defines Food Is Medicine as the provision of healthy food such as medically tailored meals, medically tailored groceries, and produce prescriptions to treat or manage specific clinical conditions in a way that is integrated with and paid for by the health care sector. Importantly, Food Is Medicine is distinct from, yet complementary to, food and nutrition assistance programs and population-level healthy food policies and programs. In this article, we discuss the importance of this distinction and the prerequisites for successfully integrating Food Is Medicine interventions within the health care system: a standard definition of Food Is Medicine focused on medically tailored meals, medically tailored groceries, and produce prescriptions; a research base showing clinical effectiveness and cost-effectiveness; and implementation that ensures fidelity and quality.

Prognosis of non-albuminuric patients with the cardiovascular-kidney-metabolic syndrome

Background

Cardiovascular-kidney-metabolic (CKM) syndrome affects a significant portion of the general population. Urinary albumin-to-creatinine ratio (UACR) is an important indicator of kidney injury. While some studies have indicated associations between UACR within the normal range and mortality outcomes, it remains uncertain whether traditionally normal UACR could help to distinguish the prognosis of CKM patients.

Methods

This cohort study included patients with CKM syndrome at stages 2 and 3 and traditionally normal UACR from the China Renal Data System (CRDS) and UK Biobank (UKB) databases. UACR was treated as a continuous variable and categorized into low-normal and high-normal. The associations were initially assessed in the CRDS database and subsequently validated in the UKB database. Multivariable Cox proportional hazards regression was employed to estimate the associations with UACR. Additionally, subgroup analyses and sensitivity analyses were conducted to enhance the robustness of the results.

Results

The study encompassed a total of 14 602 patients from the CRDS database and 82 694 patients from the UKB database. Near-linear associations were identified between continuous UACR levels and progression to CKM stage 4, as well as all-cause mortality. When compared with the low-normal UACR group, individuals with high-normal UACR exhibited an elevated risk of progression to CKM stage 4 (HR 1.133, 95% CI 1.026-1.250) and increased all-cause mortality (HR 2.321, 95% CI 1.679-3.208) within the CRDS database. These associations were further corroborated in the UKB database. Consistent findings were also observed through subgroup analyses and sensitivity analyses.

Conclusions

The findings indicate that elevated UACR levels within the normal range are significantly associated with poor prognosis among CKM patients at stages 2 and 3. These results underscore the critical role of UACR in identifying high-risk populations, particularly among individuals with metabolic disorders. This information may prove valuable for monitoring and implementing risk intervention strategies for CKM patients.

Liver-Kidney-Metabolic Health, Sex, and Menopause Impact Total Scores and Monovessel vs. Multivessel Coronary Artery Calcification

INTRODUCTION

Liver-kidney-metabolic health (LKMH) depends on complex interactions between metabolic dysfunction-associated steatotic liver disease (MASLD), chronic kidney disease (CKD), sex, and reproductive status. This study evaluates in a holistic manner how LKMH, sex, and menopause influence coronary artery calcification (CAC) burden.

METHODS

Patients without previous cardiovascular disease were prospectively recruited. Liver fat was assessed via ultrasonography and categorized as mild or moderate-to-severe. CKD was classified using estimated glomerular filtration rate (eGFR). CAC burden was quantified as 0, 1-299, ≥ 300, single-vessel, or multivessel with coronary computed tomography. Stepwise backward multinomial logistic regression was applied for analysis.

RESULTS

A total of 446 patients (59.2% female, average age 52.9 years) were included. Moderate-to-severe MASLD was independently associated with an increased risk of CAC 1-299 [OR 2.30 (1.21-4.36)], CAC ≥ 300 [OR 4.93 (1.46-16.59)], and single-vessel CAC [OR 2.03 (1.03-4.00)]. Mild MASLD [OR 2.47 (1.20-4.21)], moderate-to-severe MASLD [OR 3.74 (1.76-7.93)], and CKD stage 2 [OR 2.27 (1.26-4.08)] were independently associated with increased multivessel CAC risk. Liver fat content showed a dose-response association with CAC burden. Subgroup analysis revealed that MASLD and CKD increased CAC risk in male but not female patients, with menopause significantly modifying LKMH's effect.

CONCLUSION

LKMH's impact on CAC burden is significantly influenced by liver fat content, eGFR, sex, and menopause, suggesting that MASLD, CKD, sex, and reproductive status should be integrated into CAC risk prediction models.

Life's Essential 8, Cardiovascular Health, and CKD Progression among Hispanic/Latino Adults: The Hispanic Community Health Study/Study of Latinos Study

Key Points

In US Hispanic/Latino adults with CKD, better cardiovascular health is associated with slower eGFR declines and improvements in albumin-to-creatinine ratio over 6 years. These findings support the implementation of a heart healthy lifestyle to delay CKD progression among US Hispanic/Latino adults.

Background

The primary cause of death in CKD is cardiovascular disease. Life's essential 8 (LE8) is an established measure of cardiovascular health (CVH). Our objective was to examine the relationship between CVH (LE8 score) and CKD progression among Hispanic/Latino adults, an understudied but growing population.

Methods

The Hispanic Community Health Study/Study of Latinos is a longitudinal cohort of Hispanic/Latino adults aged 18–74 years from four cities in the United States, examined at visit 1 (V1, 2008–2011) and visit 2 (2014–2017). At V1, participants underwent a comprehensive assessment of health behaviors (diet, physical activity, nicotine exposure, and sleep health) and clinical measurements (body mass index, blood lipids, blood glucose, and BP) used to estimate an LE8 score (range: 0–100). We included 1284 participants with CKD at V1, defined as eGFR <60 ml/min per 1.73 m2 and/or urine albumin-to-creatinine ratio (ACR) ≥30 mg/g. Change in eGFR and log(ACR) was defined as the difference in each measure between V1 and visit 2. To estimate the association between LE8 score with change in eGFR and log(ACR), we used linear regression models adjusted for follow-up time and demographic, socioeconomic, and clinical factors. All analyses accounted for Hispanic Community Health Study/Study of Latinos complex survey design.

Results

Among 1284 Hispanic/Latino participants with CKD at V1, the mean age was 48.6 years (SEM: 0.8), 57.2% were women, and the mean LE8 score was 61.1 (SEM: 0.7). Over an average of 6 years of follow-up, eGFR declined by 5.8 ml/min per 1.73 m2 and log(ACR) declined by 0.60. From multivariable adjusted models, for each 10-unit higher LE8 score, eGFR was lower by 0.97 ml/min per 1.73 m2 less (95% confidence interval, −1.93 to −0.02) and log(ACR) was lower by an additional 0.15 (95% confidence interval, 0.05 to 0.25).

Conclusions

Among diverse US Hispanic/Latino adults with CKD, higher LE8 score (better CVH) was associated with a slower decline in eGFR and lower albuminuria over 6 years.

Comparative effectiveness of insulin glargine, glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors in veterans with type 2 diabetes

AIMS

To compare the risk of all-cause death and cardiovascular events in new users of insulin glargine, glucagon-like peptide-1 receptor agonists (GLP-1RA) and sodium-glucose cotransporter-2 inhibitors (SGLT2i), particularly in subgroups defined by baseline haemoglobin A1C (HbA1C), body mass index (BMI) and estimated glomerular filtration rate (eGFR).

MATERIALS AND METHODS

We conducted an active comparator, new user design study in a national cohort of 161 405 veterans with type 2 diabetes (T2D) on metformin and initiated insulin glargine (n = 54 375), GLP-1RA (n = 22 145) or SGLT2i (n = 84 885) between 1 January 2018 and 31 December 2021. Patients were followed until 31 March 2023. Inverse probability weighted Cox regression models were used for treatment comparisons on all-cause deaths and cardiovascular events in the entire cohort and above subgroups.

RESULTS

There were 20 788 cardiovascular events/414 414 person-years and 15 268 all-cause deaths/446 458 person-years. Insulin glargine had a higher hazard of all-cause death compared to GLP-1RA (hazard ratio [HR] 1.57, 95% confidence interval [CI] 1.48-1.67) or SGLT2i (HR 1.55, 95% CI 1.48-1.61) in the entire cohort and across subgroups, especially in those with HbA1C levels <9.0%. Results were similar for secondary outcomes. Compared to GLP-1RA, SGLT2i had similar risk of all-cause death (HR 1.03, 95% CI 0.97-1.10) but higher hazard of cardiovascular events (HR 1.13, 95% CI 1.08-1.19). Across subgroups, GLP-1RA and SGLT2i had generally similar effects, with SGLT2i showing a slightly higher risk in some cases.

CONCLUSIONS

Insulin glargine might be deleterious particularly in those with HbA1C <9.0%. There was no clear evidence for prioritization of SGLT2i versus GLP-1RA across subgroups.

Overall Sleep Quality Is Associated With Advanced Stages in Patients With Cardiovascular-Kidney-Metabolic Syndrome

BACKGROUND

In 2023, the American Heart Association defined the concept of cardiovascular-kidney-metabolic (CKM) syndrome as a health disorder ascribed to connections among obesity, diabetes, chronic kidney disease, and cardiovascular disease. We aim to examine the association between overall sleep quality and advanced CKM syndrome.

METHODS

This cross-sectional study used data on US adults from the National Health and Nutrition Examination Survey 2015 to 2020. Overall sleep quality was evaluated by summarizing 5 sleep behaviors: sleep duration, trouble sleeping, daytime sleepiness, snoring, and nocturia. CKM syndrome was classified into 5 stages: stage 0, no risk factors; stage 1, excess adiposity; stage 2, metabolic risk factors and kidney disease; stage 3, subclinical cardiovascular disease; and stage 4, clinical cardiovascular disease. CKM syndrome stages 3 and 4 are considered advanced. The association between overall sleep quality and advanced CKM syndrome was assessed using a multivariable weighted logistic regression model.

RESULTS

Of the 12 245 adults included in our study, 10 607 participants met the criteria for CKM syndrome (stage ≥1), and 8930 were categorized into nonadvanced CKM syndrome, while 1677 were categorized into advanced CKM syndrome. Compared with patients with CKM syndrome in the low-sleep-quality group, the adjusted odds ratios for advanced CKM syndrome were 0.68 (95% CI, 0.54-0.87) for those in the moderate sleep quality group and 0.55 (95% CI, 0.40-0.75) for those in the high-sleep-quality group, respectively.

CONCLUSIONS

Patients with CKM syndrome with higher overall sleep quality had a lower likelihood of being in advanced stages.

Unifying Efforts to Empower Equitable Obesity Care: Synopsis of an American College of Physicians and Council of Subspecialty Societies Summit

Obesity is a leading cause of morbidity and mortality with health consequences that crosscut most medical specialties. Despite the emergence of effective and promising new therapies, many impediments to comprehensive obesity care remain. As part of their commitment to improving obesity care, the American College of Physicians (ACP) and its Council of Subspecialty Societies (CSS) held a summit on 24 October 2023 to identify barriers to and opportunities for collaborative action in the domains of physician education, health care policy and care delivery, and addressing weight bias. This report summarizes the summit proceedings and provides a postsummit synthesis from ACP and CSS. Key themes were centered on knowledge, advocacy, action, and compassion, including the need for culture change, paradigm shifts, and stakeholder engagement and collaboration; a focus on empowerment of both clinicians and patients; the importance of knowing patients as people to help address social determinants of health; the need to address learned helplessness; and the importance of embracing artificial intelligence and technology as disruptive innovations. Recommendations for next steps for collaborative action include leveraging and improving already available educational and clinical resources, developing obesity education and care standards that incorporate patients' perspectives and address social determinants of health, developing community and public-private partnerships to improve access and public awareness, and coordinating messaging and policy advocacy efforts that align with mitigating the longstanding obesity epidemic.

Sex-Divergent Blood Pressure Associations With Multiorgan System Metabolic Stress-Brief Report

BACKGROUND

Women experience excess cardiovascular risk compared with men in the setting of similar metabolic disease burden. We aimed to examine sex differences in the vascular response to various forms of metabolic stress.

METHODS

We conducted an observational study of 4299 adult participants (52% women, aged 59±13 years) of the National Health and Nutrition Examination Survey 2017 to 2018 cohort and 110 225 adult outpatients (55% women, aged 64±16 years) from the Cedars-Sinai Medical Center in 2019. We used natural splines to examine the association of systemic and organ-specific measures of metabolic stress including body mass index, hemoglobin A1c, hepatic FIB-4 (Fibrosis-4) score, and CKD-EPI estimated glomerular filtration rate with systolic blood pressure (SBP). Piecewise linear models were generated using normal value thresholds (body mass index <25 kg/m2, hemoglobin A1c <5.7%, FIB-4 <1.3, and estimated glomerular filtration rate ≥90 mL/min), which approximated observed spline break points. The primary outcome was an increase in SBP in association with increase in each metabolic measure.

RESULTS

Women compared with men demonstrated larger magnitudes and an earlier onset of increase in SBP per increment increase across all metabolic stress measures. The slope of SBP increase per increment of each metabolic measure was greater for women than men particularly for metabolic measures within the normal range, with slope differences of 1.86 mm Hg per kg/m2 of body mass index, 12.48 mm Hg per %hemoglobin A1c, 6.87 mm Hg per FIB-4 unit, and 0.44 mm Hg per mL/min decrement of estimated glomerular filtration rate in the National Health and Nutrition Examination Survey cohort (P difference <0.05 for all). Overall results were consistent in the Cedars-Sinai Medical Center cohort.

CONCLUSIONS

Women exhibited greater SBP alteration in the setting of multiple types of metabolic stress, particularly in periods representing the transition from metabolic health to disease. These findings suggest potential benefit of early metabolic health interventions as part of efforts to mitigate vascular risks in both women and men.

Impact of DNA-Methylation Age Acceleration on Long-Term Mortality Among US Adults With Cardiovascular-Kidney-Metabolic Syndrome

BACKGROUND

The association between DNA methylation age acceleration (DNAmAA) and cardiovascular-kidney-metabolic (CKM) syndrome stages and long-term mortality in the population with CKM syndrome remains unclear.

METHODS AND RESULTS

This cohort study included 1889 participants from the National Health and Nutrition Examination Survey (1999-2002) with CKM stages and DNA methylation age data. DNAmAA was calculated as residuals from the regression of DNA methylation age on chronological age. The primary outcome was all-cause mortality, with cardiovascular and noncardiovascular mortality as secondary outcomes. Proportional odds models assessed the associations between DNAmAAs and CKM stages, and Cox proportional hazards regression models estimated the associations between DNAmAAs and mortality. Significant associations were found between DNAmAAs and advanced CKM stages, particularly for GrimAge2Mort acceleration (GrimAA) (odds ratio [OR], 1.547 [95% CI, 1.316-1.819]). Over an average follow-up of 14 years, 1015 deaths occurred. Each 5-unit increase in GrimAA was associated with a 50% increase in all-cause mortality (95% CI, 1.39-1.63), a 77% increase in cardiovascular mortality (95% CI, 1.46-2.15), and a 42% increase in noncardiovascular mortality (95% CI, 1.27-1.59). With the lowest GrimAA tertile as a reference, the highest GrimAA tertile showed hazard ratios of 1.95 (95% CI, 1.56-2.45) for all-cause mortality, 3.06 (95% CI, 2.13-4.40) for cardiovascular mortality, and 1.65 (95% CI, 1.20-2.29) for noncardiovascular mortality. Mediation analysis indicated that GrimAA mediates the association between various exposures (including physical activity, Healthy Eating Index-2015 score, hemoglobin A1c, etc.) and mortality.

CONCLUSIONS

GrimAA may serve as a valuable biomarker for assessing CKM stages and mortality risk in individuals with CKM syndrome, thereby informing personalized management strategies.

Beyond glycated haemoglobin: Modelling contemporary management of type 2 diabetes with the updated Cardiff model

AIMS

Recommendations on the use of newer type 2 diabetes (T2D) treatments (e.g., SGLT2 inhibitors and GLP-1 receptor agonists [RA]) in contemporary clinical guidelines necessitate a change in how T2D models approach therapy selection and escalation. Dynamic, person-centric clinical decision-making considers factors beyond a patient's HbA1c and glycaemic targets, including cardiovascular (CV) risk, comorbidities and bodyweight. This study aimed to update the existing Cardiff T2D health economic model to reflect modern T2D management and to remain fit-for-purpose in supporting decision-making.

MATERIALS AND METHODS

The Cardiff T2D model's therapy selection/escalation module was updated from a conventional, glucose-centric to a holistic approach. Risk factor progression equations were updated based on UKPDS90; the cardio-kidney-metabolic benefits of SGLT2i and GLP-1 RA were captured via novel risk equations derived from relevant outcomes trial data. The significance of the updates was illustrated by comparing predicted outcomes and costs for a newly diagnosed T2D population between conventional and holistic approaches to disease management, where the latter represents recent treatment guidelines.

RESULTS

A holistic approach to therapy selection/escalation enables early introduction of SGLT2i and GLP-1 RA in modelled pathways in a manner aligned to guidelines and primarily due to elevated CV risk. Compared with a conventional approach, only considering HbA1c, patients experience fewer clinical events and gain additional health benefits.

CONCLUSIONS

Predictions based on a glucose-centric approach to therapy are likely to deviate from real-world observations. A holistic approach is more able to capture the nuances of contemporary clinical practice. T2D modelling must evolve to remain robust and relevant.

A Portuguese expert panel position paper on the management of heart failure with preserved ejection fraction - Part I: Pathophysiology, diagnosis and treatment

Heart failure (HF) with preserved ejection fraction (HFpEF) affects more than 50% of HF patients worldwide, and more than 70% of HF patients aged over 65. This is a complex syndrome with a clinically heterogeneous presentation and a multifactorial pathophysiology, both of which make its diagnosis and treatment challenging. A Portuguese HF expert panel convened to address HFpEF pathophysiology and therapy, as well as appropriate management within the Portuguese context. This initiative resulted in two position papers that examine the most recently published literature in the field. The present Part I includes a review of the HFpEF literature covering pathophysiology, clinical presentation, diagnosis and treatment, including pharmacological and non-pharmacological strategies. Part II, the second paper, addresses the development of a holistic and integrated HFPEF clinical care system within the Portuguese context that is capable of reducing morbidity and mortality and improving patients' functional capacity and quality of life.

Association of cardiovascular-kidney-metabolic health and apolipoprotein E4 genotype with risk of dementia and mortality

BackgroundPoor cardiovascular-kidney-metabolic (CKM) health is becoming prevalent; however, sparse data exist regarding the association of CKM health with incident dementia and all-cause mortality.ObjectiveThis study aimed to examine whether poor CKM health is associated with a higher risk of dementia and all-cause mortality, regardless of APOE4 carrier status.MethodsIn this prospective cohort study, 352,364 participants from the UK Biobank were included. CKM syndrome was identified as a medical condition with the presence of metabolic risk factors, cardiovascular disease, and chronic kidney disease, and was classified into five stages (stage 0 to 4). Cox proportional hazards models were applied to explore the association of CKM health with incident dementia and all-cause mortality.ResultsParticipants in stage 2-3 and stage 4 had 1.12-fold (95% CI: 1.02-1.23, p = 0.023) and 2.18-fold (95% CI: 1.96-2.43, p < 0.001) increased risk of incident all-cause dementia compared with those in stage 0. Similarly, participants in stage 4 also had an increased risk of Alzheimer's disease (HR = 1.51, 95% CI: 1.28-1.78, p < 0.001) and vascular dementia (HR = 4.62, 95% CI: 3.54-6.03, p < 0.001). Participants in later stages were at higher risk of all-cause mortality. We found an interaction between CKM health and APOE4 carrier status (p for interaction <0.001), and the relationship between CKM health and dementia was more pronounced in non-APOE4 carriers. Moreover, there were significant additive interactions between APOE4 carrier status and CKM health on the risk of dementia.ConclusionsPoor CKM health is independently associated with an increased risk of dementia, regardless of APOE4 carrier status, and all-cause mortality. These findings imply that promoting CKM health may help to reduce the risk of subsequent dementia and mortality.

Allocation of Semaglutide According to Coronary Artery Calcium and BMI: Applying the SELECT Trial to MESA

BACKGROUND

Implementation of semaglutide weight loss therapy has been challenging due to drug supply and cost, underscoring a need to identify those who derive the greatest absolute benefit.

OBJECTIVES

Allocation of semaglutide was modeled according to coronary artery calcium (CAC) among individuals without diabetes or established atherosclerotic cardiovascular disease (CVD).

METHODS

In this analysis, 3,129 participants in the MESA (Multi-Ethnic Study of Atherosclerosis) without diabetes or clinical CVD met body mass index criteria for semaglutide and underwent CAC scoring on noncontrast cardiac computed tomography. Cox proportional hazards regression assessed the association of CAC with major adverse cardiovascular events (MACE), heart failure (HF), chronic kidney disease (CKD), and all-cause mortality. Risk reduction estimates from the SELECT (Semaglutide Effects on Heart Disease and Stroke in Patients with Overweight or Obesity) trial (median follow-up: 3.3 years) were applied to observed incidence rates for semaglutide 5-year number-needed-to-treat calculations.

RESULTS

Mean age was 61.2 years, 54% were female, 62% were non-White, mean body mass index was 31.8 kg/m2, and 49% had CAC. Compared with CAC = 0, CAC ≥300 conferred a 2.2-fold higher risk for MACE (HR: 2.16 [95% CI: 1.57-2.99]; P < 0.001). Higher risks for HF (HR: 2.80 [95% CI: 1.81-4.35]; P < 0.001), CKD (HR: 1.59 [95% CI: 1.15-2.22]; P = 0.006), and all-cause mortality (HR: 1.35 [95% CI: 1.08-1.69]; P = 0.009) comparing CAC ≥300 vs CAC = 0 were also observed. There were large 5-year number-needed-to-treat differences between CAC = 0 and CAC ≥300 for MACE (653 vs 79), HF (1,094 vs 144), CKD (1,044 vs 144), and all-cause mortality (408 vs 98).

CONCLUSIONS

Measurement of CAC may enhance value of care with weight loss dose semaglutide in those without diabetes or clinical CVD, improving allocation of a limited health care resource.

Inter-organ communication: pathways and targets to cardioprotection and neuro-protection. A report from the 12th Hatter Cardiovascular Institute workshop

A long-standing aim in the setting of various pathologies including acute myocardial infarction, chronic kidney disease (CKD), and ischaemic stroke, has been to identify successful approaches to augment cellular and organ protection. Although the continual evolution and refinement of ideas over the past few decades has allowed the field to progress, we are yet to realise successful clinical translation of this concept. The 12th Hatter Cardiovascular Workshop identified a number of important points and key questions for future research relating to cardio- and neuro-protection and interorgan communication. Specific topics that were discussed include the 'cardio-metabolic-renal' axis of organ protection, the parasympathetic signalling hypothesis, the role of the coronary microvasculature in myocardial infarction, the RISK pathway of cardioprotection, extracellular vesicles and the way forward, the future for clinical studies of remote ischaemic conditioning, and new experimental models for cardio-oncology investigations.

Role of oxidative balance score in staging and mortality risk of cardiovascular-kidney-metabolic syndrome: Insights from traditional and machine learning approaches

OBJECTIVES

To evaluate the roles of oxidative balance score (OBS) in staging and mortality risk of cardiovascular-kidney-metabolic syndrome (CKM).

METHODS

Data of this study were from the National Health and Nutrition Examination Survey 1999-2018. We performed cross-sectional analyses using multinomial logistic regression to investigate the relationship between OBS and CKM staging. Cox proportional hazards models were used to assess the impact of OBS on mortality outcomes in CKM patients. Additionally, mediation analyses were performed to explore whether OBS mediated the relationships between specific predictors (Life's Simple 7 score [LS7], systemic immune-inflammation index [SII], frailty score) and mortality outcomes. Then, machine learning models were developed to classify CKM stages 3/4 and predict all-cause mortality, with SHapley Additive exPlanations values used to interpret the contribution of OBS components.

RESULTS

21,609 participants were included (20,319 CKM, median [IQR] age: 52.0 [38.0-65.0] years, 54.3% male, median [IQR] follow-up: 9.4 [5.3-14.1] years). Lower OBS quartiles were associated with advanced CKM staging. Moreover, lower OBS quartiles were related to increased mortality risk, compared to Q4 of OBS (all-cause mortality: Q1: HR 1.31, 95% CI 1.18-1.46, Q2: HR 1.27, 95% CI 1.14-1.42, Q3: HR 1.18, 95% CI 1.06-1.32; cardiovascular mortality: Q1: HR 1.44, 95% CI 1.16-1.79, Q2: HR 1.39, 95% CI 1.11-1.74, Q3: HR 1.26, 95% CI 1.01-1.57; non-cardiovascular mortality, Q1: HR 1.27, 95% CI 1.12-1.44, Q2: HR 1.23, 95% CI 1.08-1.40, Q3: HR 1.16, 95% CI 1.02-1.31), with optimal risk stratification threshold for OBS was 22. Additionally, OBS mediated (ranging 4.25%-32.85 %) effects of SII, LS7, frailty scores on mortality outcomes. Moreover, light gradient boosting machine achieved the highest performance for predicting advanced CKM staging (area under curve: 0.905) and all-cause mortality (area under curve: 0.875). Cotinine increased risk, while magnesium, vitamin B6, physical activity were protective.

CONCLUSIONS

This study highlights OBS as a risk stratification tool for CKM, emphasizing oxidative stress's role in CKM staging and mortality risk management.

How 'miracle' weight-loss semaglutide promises to change medicine but can we afford the expense?

Obesity is a complex and growing global concern, affecting one in eight individuals and compromising health, quality of life and life expectancy. It carries significant metabolic, cardiovascular, oncological, hepatorenal, skeletal and psychiatric risks, imposing substantial costs on health-care systems. Traditional treatments have often been ineffective or have led to relapse after lifestyle changes. Whereas bariatric surgery is effective, it also involves risks such as mortality and hospitalisation. Semaglutide, licensed in 2018, is a synthetic analogue of glucagon-like peptide 1 which regulates glucose metabolism and gastrointestinal (GI) motility. Studies show that semaglutide, administered either weekly and subcutaneously, or daily orally, induces an average weight loss of -11.62 kg compared to placebo and reduces waist circumference by up to -9.4 cm. It also improves blood pressure, fasting glucose levels, C-reactive protein levels and lipid profiles. The most common adverse events are mild-to-moderate GI complaints occurring more frequently with daily administration than weekly doses; hypoglycaemia is more common without lifestyle intervention. Weight regain often follows semaglutide withdrawal. Furthermore, semaglutide offers cardiovascular benefits for patients with established atherosclerotic cardiovascular disease (CVD), lowers the risk of kidney outcomes and cardiovascular-related death, resolves nonalcoholic steatohepatitis in many cases, and positively impacts mental health and quality of life. In conclusion, semaglutide therapy could significantly benefit many adults regarding CVD and mortality if made widely accessible. Ethical and financial considerations must be addressed for personalised obesity treatment approaches.

Associations between Class I, II, or III Obesity and Health Outcomes

BACKGROUND

The burden of obesity-related health conditions remains incompletely explored. Previous studies have been underpowered to study severe obesity, focused on a limited set of health outcomes, and lacked diversity in study populations.

METHODS

We studied 270,657 participants from the All of Us research program with linked electronic health records and body mass index (the weight in kilograms divided by the square of the height in meters) greater than or equal to 18.5. We investigated the prevalence and incidence of 16 a priori-identified outcomes covering cardiovascular-kidney-metabolic syndrome and others: hypertension, type 2 diabetes mellitus, hyperlipidemia/dyslipidemia, heart failure, atrial fibrillation, atherosclerotic cardiovascular disease, chronic kidney disease, pulmonary embolism, deep vein thrombosis, gout, metabolic dysfunction-associated steatotic liver disease, biliary calculus, obstructive sleep apnea, asthma, gastroesophageal reflux disease, and osteoarthritis. Adjusted hazard ratios were calculated for each BMI category and compared with normal weight. The population-attributable fraction was calculated for different obesity classifications.

RESULTS

The included population was 62.0% women and 22.0% Black. Class I, II, and III obesity was observed in 21.2%, 11.3%, and 9.8% of participants, respectively. Obesity was strongly associated with all incident outcomes, with graded associations across higher classes of obesity. Class III obesity was most strongly associated with obstructive sleep apnea, type 2 diabetes mellitus, and metabolic dysfunction-associated steatotic liver disease (hazard ratio [95% confidence interval {CI}], 10.94 [9.97 to 12.00], 7.74 [7.03 to 8.53], and 6.72 [6.01 to 7.50], respectively), with weaker associations for asthma, osteoarthritis, and atherosclerotic cardiovascular disease (hazard ratio [95% CI], 2.14 [1.95 to 2.35], 2.06 [1.94 to 2.19], and 1.96 [1.70 to 2.25], respectively). Associations were consistent across sex and race. The obesity-related population-attributed fraction ranged from 14.0% (osteoarthritis) to 51.5% (obstructive sleep apnea) in this population.

CONCLUSIONS

Obesity, particularly severe obesity, was strongly associated with the incidence of 16 common health outcomes.

Effects of statins on kidney function in older adults

BACKGROUND

The effect of statin therapy on kidney function among older adults is unclear.

OBJECTIVES

To examine the association between statin use and changes in estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR), positive or negative, in an older adult cohort with versus without chronic kidney disease (CKD) at baseline.

METHODS

This analysis included 18,056 participants aged ≥65 years with versus without CKD at baseline in a randomized trial of low-dose aspirin, who had no prior cardiovascular events, major physical disability, or dementia initially. Outcome measures included eGFR and UACR. Linear mixed-effects models were used to estimate the associations of baseline statin use versus no use with eGFR and UACR changes over time. The inverse-probability of treatment-weighting technique was used for all analyses to address confounding by indication due to the lack of randomization in treatment assignment.

RESULTS

Statin use was not associated with change in eGFR, UACR, or incident CKD in participants with or without CKD at baseline (p > 0.05 for all associations). Subgroup analyses found no significant interactions between statin and age, sex, diabetes, country, and frailty status on any of the study outcomes.

CONCLUSIONS

Among adults ≥65 years of age, with and without CKD, statin therapy was not associated with improved or worsened kidney function. This data suggests that the decision to use versus not use statins in this population may be ideally guided by factors other than kidney health.

The association between county-level social determinants of health and cardio-kidney-metabolic disease attributed all-cause mortality in the US: A cross sectional analysis

BACKGROUND

The American Heart Association recently defined cardio-kidney-metabolic (CKM) syndrome as the intersection between metabolic, renal, and cardiovascular disease. Understanding the contemporary estimates of CKM related mortality in the US is essential for developing targeted public interventions.

METHODS

We analyzed state-level and county-level CKM-associated all-cause mortality data (2010-2019) from the CDC Wide-ranging Online Data for Epidemiologic Research (WONDER). Median and interquartile (IQR) age-adjusted mortality rates (aaMR) per 100,000 were reported and linked with a multi-component metric for social deprivation: the Social Deprivation Index (SDI: range 0 - 100) grouped as: I: 0 - 25, II: 26 - 50, III: 51 - 75, and IV: 75 - 100. We fit pairwise comparisons between SDI groups and evaluated aaMR stratified by sex, race, and location.

RESULTS

In 3101 counties, pooled aaMR was 505 (441-579). Oklahoma (643) and Massachusetts (364) had the highest and lowest values. aaMR increased across SDI groups [I: 454(404, 505), IV: 572(IQR: 495.9, 654.7); p < 0.001]. Men had higher rates [602 (526, 687)] than women [427 (368, 491)]. Metropolitan [476 (419, 542)] had lower rates than non-metropolitan counties [521 (454, 596)]. Non-Hispanic Black [637 (545, 731)] had higher rates than non-Hispanic White residents [497 (437, 570]. CKM associated aaMR remained reasonably constant between 2010 and 2019 (Mann Kendall test for trend p-value = 0.99).

CONCLUSIONS

In the US, CKM mortality disproportionately affects more socially deprived counties. Inability to reduce CKM mortality rates over the study period highlights the need for targeted policy interventions to curb the ongoing high burden.

Comparison of the efficacy and safety of GLP-1 receptor agonists on cardiovascular events and risk factors: A review and network meta-analysis

OBJECTIVE

This study aims to systematically evaluate and perform a systematic review and network meta-analysis comparing the comprehensive cardiovascular protective effects of various glucagon-like peptide-1 receptor agonists (GLP-1RAs), focusing on cardiovascular events and risk factors.

METHODS

We searched PubMed, Embase, Cochrane Library and Web of Science from inception to December 15, 2024. Included studies were published randomized controlled trials (RCTs) comparing GLP-1RAs to placebo or other GLP-1RAs. Missing data were standardized, and network meta-analysis was performed using Stata 17.0. Study heterogeneity, publication bias and evidence quality were assessed using the Cochrane Risk of Bias tool and Confidence in Network Meta-Analysis (CINeMA).

RESULTS

As of December 15, 2024, a total of 18 313 articles were retrieved. Based on the inclusion and exclusion criteria, 156 high-quality studies were included, incorporating 144 782 patients and 14 different GLP-1RAs. The network meta-analysis demonstrated low heterogeneity, ensuring the reliability of the results. Comprehensive analysis revealed the following: Efpeglenatide was the most effective in reducing major adverse cardiovascular events. Oral semaglutide shows more significant advantages in reducing all-cause mortality and cardiovascular mortality. Orforglipron excelled in glycaemic control and weight reduction. SC-Semaglutide showed the greatest efficacy in lowering both systolic blood pressure and diastolic blood pressure, Liraglutide showed the greatest efficacy in lowering total cholesterol, Noiiglutide in triglycerides and Taspoglutide in low-density lipoprotein cholesterol, but no GLP-1RAs in high-density lipoprotein cholesterol. GLP-1RAs did not significantly increase the incidence of adverse events, but Orforglipron and Taspoglutide significantly increased the incidence of gastrointestinal adverse events compared with placebo.

CONCLUSION

This study compared the cardiovascular benefits of different GLP-1RAs, including reductions in cardiovascular events and improvements in multiple cardiovascular risk factors. However, due to limitations in the quantity and quality of the included studies, the conclusions should be interpreted with caution. Future large-scale, high-quality clinical trials are needed to validate these findings and further optimize comprehensive cardiovascular management strategies for patients.