American Heart Association Advisory Emphasizes Multidisciplinary Care for Cardiovascular-Kidney-Metabolic Syndrome

Early identification

Recognizing that progression toward CKM often begins early in life, the staging model starts with recommending interventions to promote healthy diets and activity in individuals with no metabolic or heart risk factors (stage 0), including children. The model outlines four more stages and suggests prevention approaches at each. The working group designed the model to allow “de-staging” individuals who reduce risk factors.

“We hope that through this staging construct, we can start to have people be aware of risk earlier and address risk earlier, primarily through healthy lifestyle,” Ndumele explained. “We hope that this supports people getting the right therapies when needed and that we have a life-course approach to thinking about prevention from youth onward.”

People with excess weight, larger waist circumferences, impaired glucose tolerance, or prediabetes fall into stage 1. Stage 2 includes individuals with hyperglycemia, hyperlipidemia, metabolic syndrome, diabetes, or moderate- to high-risk kidney diseases. The staging tool categorizes individuals with subclinical cardiovascular disease who have excess weight, metabolic risk factors, or CKD as stage 3. Stage 4 comprises individuals with heart disease, metabolic risk factors, and kidney diseases with or without kidney failure.

Ndumele said 90% of individuals in the United States will classify as stage 1 or higher and that primary care physicians will be the first point of contact for most. By applying the staging construct to identify risk and reduce it, Ndumele and his coauthors hope that primary care practitioners can reduce the number of individuals who progress to later stages of CKM. “We want to reduce the number of individuals who get to the point [in which] they need to see subspecialists because we are addressing risk earlier,” he noted.

Advisory coauthor Janani Rangaswami, MD, section chief of nephrology at the Washington, DC, Veterans Affairs Medical Center and professor of medicine at George Washington University School of Medicine and Health Sciences, said that the document solidifies the role of the nephrologist in helping to identify cardiovascular risk as they follow patients across their disease progression.

“We now practice in an era [in which] we have multiple tools in our toolbox that not only improve kidney health and reduce the progression of CKD to kidney failure and prevent bad kidney outcomes, but we also can make a significant dent in the cardiovascular disease risk,” said Rangaswami, who is also chair of the AHA's Council on the Kidney in Cardiovascular Disease and co-chair of AHA's CKM health initiative.

For example, Rangaswami noted that identifying patients who fall into stage 3 and do not yet have cardiovascular disease but are at high risk of it creates “a window of opportunity” for nephrologists to intervene with preventive approaches. “Ultimately, we want our patients with kidney diseases to live longer and better,” she said. “Importantly, the biggest competing risk of death in our patients is largely cardiovascular disease at every stage of their lifespan.”

Rangaswami noted that stage 4 highlights the unique considerations for patients with and without kidney failure, which are well known to nephrologists but may be less familiar to other specialties. “We want the whole CKM care community to be familiar with this,” she added.

Shared “playbook”

The advisory also outlines ways to streamline and standardize care for patients with CKM, including suggesting multidisciplinary care models and shared algorithms for using proven CKM interventions. “One of the biggest challenges that patients face in this circumstance is care fragmentation as a consequence of having to see multiple [practitioners] again, who may not always be using the same playbook and maybe giving slightly differing recommendations,” Ndumele offered.

“There is so much crosstalk between these organ systems; that's how the disease process evolves.... The way we approach it has to mirror the disease.”

Rangaswami noted that primary care clinicians identify many patients with CKM syndrome and refer them to specialists who may be working in silos and not communicating effectively. She explained that a nephrologist may de-escalate therapies started by a cardiologist. But, as the scientific statement shows, the conditions are interrelated, she said. “There is so much crosstalk between these organ systems; that's how the disease process evolves,” she explained. “The way we approach it has to mirror the disease.”

Adam Whaley-Connell, DO, associate chief of staff for research at the Harry S. Truman Memorial Veterans’ Hospital in Columbia, MO, and professor of medicine at the University of Missouri School of Medicine, said that it was gratifying to see research on the underlying connections translated into action after decades of research on these interrelated conditions. Whaley-Connell was not involved in drafting the advisory or review. “I was extremely excited to see that AHA put this working group together and [is] giving this priority,” noted Whaley-Connell, who helped develop the Journal of the CardioMetabolic Syndrome (3) and the journal Cardiorenal Medicine (4). “We have evolved in our understanding that adipose tissue is a distinct endocrine organ that influences vascular and kidney health.”

The advisory suggests that patients with two or more overlapping CKM conditions receive care from an interdisciplinary care team, including primary care, cardiology, nephrology, endocrinology, pharmacy, nursing, social workers, and community health workers. A CKM care coordinator, who organizes patient care and facilitates communication among care team members, would play a central role in the model. “We want to all be reading from a similar playbook, which makes things easier for patients,” Ndumele said. When subspecialists are needed, the CKM care coordinator can help patients navigate across practitioners and ensure that they are receiving holistic care, he said.

The multidisciplinary model outlined in the advisory reinforces and expands on the multidisciplinary diabetic kidney disease care models recommended by Kidney Disease: Improving Global Outcomes (KDIGO) (5), the American Diabetes Association (6), and ASN (7), Tuttle said. She noted that this involves multiple specialties, including cardiology, endocrinology, and nephrology, as well as nurses, pharmacists, advanced practitioners, and social workers. “[CKM syndrome] is such an enormous problem,” Tuttle explained. “There are so many people affected. If we can align on the guiding principles and overall care approaches, together we will have a much larger impact.”

The advisory also provides broad guidance on how and when to use newer drugs that may benefit the patient's heart, kidneys, and metabolic health along with mainstay medications, noted Rangaswami. She expects this guidance to be updated regularly as new data emerge. In November at the organization's Scientific Sessions 2023, AHA unveiled a new cardiovascular risk calculator that considers CKM risk to help further guide patient assessment (8). “We are just really at a place where there is this embarrassment of riches with so many high-quality trials showing overwhelming benefit [for new classes of drugs],” she said. “It's up to us now to close this loop [and] implement these therapies, not just in a meaningful way, but in an equitable way.”

Social determinants of health

The advisory also emphasizes the role that social determinants of health play in contributing to CKM and the need to identify and address them to care for patients successfully. “At every level, social determinants of health play a role in both the development and the impact of CKM syndrome,” Ndumele noted.

Rangaswami explained that, for example, an individual with metabolic syndrome may be experiencing homelessness, food insecurity, racism, or other social determinants that can impact their outcomes. “If we don't screen and acknowledge that social determinants of health matter, then we won't have the ability to intervene and make that better,” she said. “The advisory puts that up front.”

It recommends systematically screening patients for social determinants of health and incorporating them into risk assessment. It suggests building social determinants of health into electronic health records, clinical workflows, and the make-up of patient care teams. For example, it recommends having team members who can address patients’ social determinants of health and help them overcome barriers to care by leveraging community programs and resources. Rangaswami also emphasized the need to ensure equitable use of new therapies.

“Nephrologists are very familiar with the fact that patients who come from [populations that are disenfranchised] or are racial or ethnic minorities have a disproportionate burden of CKM syndrome, but they are also less likely to receive appropriate therapies,” she said. Creating more systematic ways of identifying and treating CKM syndrome and addressing related social determinants will help reduce these disparities and allow patients to access preventive therapies earlier. “We hope patients will have optimal risk factor control and that a lot of them will be on RAAS [renin–angiotensin–aldosterone system] inhibitors or SGLT2s [sodium-glucose cotransporter-2s] before they even get to the nephrologist, who can then manage the additional risks patients have,” Rangaswami continued.

Ndumele acknowledged that some practice models may only work in some settings. One of the next steps for him and his colleagues will be to develop implementation plans that help address the needs of specific practice settings. For example, rural settings with limited access to local specialists may leverage telehealth to connect patients with specialist care.

“Our intent is to make this as flexible as possible so that no matter where a person is in the world, that the guiding principles could help provide a framework [to] deliver care,” Tuttle said. She noted that health systems can tailor how they implement the advisory to their contexts and hopefully share successful strategies. She also said that there is a need for implementation and cost-effectiveness studies.

Whaley-Connell agreed that more work is needed to develop multidisciplinary systems for caring for these complex patient populations and address some root causes, for example, crafting policies and guidance to address refined sugar, salt, and fat content and improving access in areas of food deserts. “The workgroup has provided an important conversation for the nephrology community to think about how we stage and address cardiometabolic health for patients with kidney diseases,” Whaley-Connell said. “We can use the advisory with existing tools for diagnosis and management of kidney diseases.”

Tuttle added that there will also be a role for professional organizations in advocating for policies that support the multidisciplinary care models that the advisory recommends. Having multiple professional organizations working across specialties and disciplines on advocacy will also likely have a greater impact on helping to enact the needed policy changes. “Health policy changes are critical,” she said.

Tuttle also expressed gratitude for the AHA issuing the advisory and review and the scientific statement and bringing its expertise and experience targeting the early origins of disease to tackling CKM syndrome. “It's the right thing to do, and [AHA has] the influence to make substantial change,” she said.