Risk factors for cardiovascular disease have been formally identified for over six decades. Providing education and targeting therapeutic approaches against these risk factors have been responsible for the steady decline in the morbidity and mortality of heart and vascular diseases.
It has been a distinct privilege to have played a small part in the validation of these interventions and the education of clinicians and the public on their impact. Indeed, many of my articles over the last 25 years have been about new developments in cholesterol management, treatment of high blood pressure, novel therapies for diabetes, and more recently the medical approaches to obesity. And, of course, many of my articles have focused the the barriers to patients getting the treatments they need because of the financial and political environments that are obstacles rather than facilitators of patients getting affordable and necessary healthcare.
But there have been other hurdles that have proved irksome, and that includes the siloing of responsibilities for providing the evidence validated therapies to the affected patients. For example, I and my cardiology colleagues focused on blood fat abnormalities and elevated blood pressures. If the patient had complex diabetes, they would see their endocrinology specialists. As their kidneys started to fail, they would be referred to their nephrology doctors. And if they were significantly overweight, they may have been sent to our bariatric colleagues. And if the patients were lucky, they may have a superb primary care clinician like an internist or a family practice doctor or an advanced practice nurse who could act like an air traffic controller to get the patient to the right specialist as needed.
This system has worked pretty well, if one had the right insurance coverage, but the complexities of multi-organ diseases in one patient often meant that communication and cross purposes often meant that care was fragmented and not coordinated as tightly as it should be. Often different specialists were operating with different guidelines, and just like parts of an orchestra playing from different sheet music at the same time, the result may be a disharmonious cacophony rather than a mellifluous symphony.
Efforts to harmonize guidelines have been increasing, especially since we all have come to realize that all of these risk factors may have common causes and be present in a single patient. The goals of therapies converge as we learn more about disease states and our new treatments get better at targeting those root causes. Lifestyle changes play a fundamental role in mitigating risks, but it is naïve to think that diet and exercise can reverse genetically determined pathology which are often exacerbated by environmental factors.
This is an introduction to new multi-specialty guidelines focused on a constellation of disorders that run together because of common mechanisms of diseases. The elegance of this approach is that it gives both doctors and patients an uniform strategy to look at multi-organ disease states and recognize that these may occur simultaneously in one patient. This holistic approach to deal with interrelated conditions and complications may be potentially better than dealing with each condition separately.
You may start hearing about CKM Syndrome, the shorthand of cardiovascular-kidney-metabolic syndrome, which turns out to be a predominant underlying mechanism of cardiovascular risk in our population. The CKM guideline is the collaborative work product of the American Heart Association, American College of Cardiology, American Diabetes Association, Obesity Association, and American Society of Nephrology. Our colleagues in Europe, specifically the European Society of Cardiology, are looking to develop their own set of CKM guidelines and I expect there to be general consensus. These efforts will facilitate how doctors and patients focus on the care of these conditions.
One highlight is that obesity is not just a cardiovascular risk factor, but is now appreciated as a central driver of the CKM Syndrome. This may be more of a first-world problem. Obesity per se may be less of an independent issue in Asia and the Global South, but it will be interesting to see how the CKM workshops worldwide structure their recommendations
The guideline reintroduces a progressively more serious staging nomenclature.
Stage 1 describes overweight patients without cardiovascular, kidney, or metabolic risk factors.
Stage 2 describes overweight patients with at least one metabolic risk factor such as high blood pressure, elevated triglycerides (a blood fat), type 2 diabetes, metabolic syndrome, moderate to high risk chronic kidney disease, but no overt cardiovascular disease.
Stage 3 describes patients with cardiovascular disease without clear symptoms but with higher risk based on validated cardiovascular or kidney disease risk calculator algorithms.
Stage 4 describes patients with diagnosed cardiovascular disease with overweight, other metabolic risk factors, or kidney disease.
The report estimates that over 90% of U.S. adults can be placed into one of these stages. The point is to shift attention to earlier opportunities for intervention rather than the traditional focus on the latter stages. The hope is that earlier awareness and treatment, especially with weight management, will positively alter the trajectory of the disease and produce better clinical outcomes.
Based on the documented cardiovascular benefits of the GLP-1 therapies, these medications can now be recommended for some patients with obesity, type 2 diabetes, and other risk factors. Formal guidelines often presage broader insurance coverage, but cost will undoubtedly be a limiting factor.
This also reminds us that care coordination is paramount to minimize the fragmentation that characterizes modern complex medical management. Our healthcare systems will need to create the infrastructure and financial incentives to implement integrated CKM care. Thoughtful applications of AI enabled chart review can help identify at risk patients. Once again, our public health leaders need to emphasize that prevention is the key to better clinical outcomes.
Irving Kent Loh, M.D., is a preventive cardiologist and the director of the Ventura Heart Institute in Thousand Oaks. Email him at drloh@venturaheart.com.
This article originally appeared on Ventura County Star: Identifying a major cardiovascular risk factor | Dr. Loh
Reporting by Dr. Irving Kent Loh, Second Opinion / Ventura County Star
USA TODAY Network via Reuters Connect
By Dr. Irving Kent Loh, Second Opinion | USA TODAY Network
