Cited by 1,405Diabetes, Cardiovascular Risks, and LipoproteinsChronic Kidney Disease and DiabetesCardiovascular Function and Risk Factors

A synopsis of the evidence for the science and clinical management of cardiovascular-kidney-metabolic (CKM) syndrome: a scientific statement from the American Heart Association

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Ndumele, Chiadi E., Neeland, Ian J., Tuttle, Katherine R., Chow, Sheryl L., Mathew, Roy O., Khan, Sadiya S., Coresh, Josef, Baker-Smith, Carissa M. +22 more·2023·Circulation

Abstract

A growing appreciation of the pathophysiological interrelatedness of metabolic risk factors such as obesity and diabetes, chronic kidney disease, and cardiovascular disease has led to the conceptualization of cardiovascular-kidney-metabolic syndrome. The confluence of metabolic risk factors and chronic kidney disease within cardiovascular-kidney-metabolic syndrome is strongly linked to risk for adverse cardiovascular and kidney outcomes. In addition, there are unique management considerations for individuals with established cardiovascular disease and coexisting metabolic risk factors, chronic kidney disease, or both. An extensive body of literature supports our scientific understanding of, and approach to, prevention and management for individuals with cardiovascular-kidney-metabolic syndrome. However, there are critical gaps in knowledge related to cardiovascular-kidney-metabolic syndrome in terms of mechanisms of disease development, heterogeneity within clinical phenotypes, interplay between social determinants of health and biological risk factors, and accurate assessments of disease incidence in the context of competing risks. There are also key limitations in the data supporting the clinical care for cardiovascular-kidney-metabolic syndrome, particularly in terms of early-life prevention, screening for risk factors, interdisciplinary care models, optimal strategies for supporting lifestyle modification and weight loss, targeting of emerging cardioprotective and kidney-protective therapies, management of patients with both cardiovascular disease and chronic kidney disease, and the impact of systematically assessing and addressing social determinants of health. This scientific statement uses a crosswalk of major guidelines, in addition to a review of the scientific literature, to summarize the evidence and fundamental gaps related to the science, screening, prevention, and management of cardiovascular-kidney-metabolic syndrome.

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Crossref · 10.1161/cir.0000000000001186

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  • Assessments for prediabetes or diabetes with fasting blood glucose, HbA1c, or oral glucose tolerance tests are critical because of the strong association of hyperglycemia with cardiovascular and kidney disease.

    “Assessments for prediabetes or diabetes with fasting blood glucose, HbA1c, or oral glucose tolerance tests are critical because of the strong association of hyperglycemia with cardiovascular and kidney disease.39,40”

    From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [40]

    The ‘Gaps in Screening for Metabolic Risk Factors and CKD in Adulthood’ section recommends assessments for prediabetes and diabetes, and the CKM staging table lists fasting blood glucose and HbA1c. ‘The Current Scientific Understanding of CKM Syndrome’ links hyperglycemia to kidney and vascular damage. The copy does not specify oral glucose tolerance tests as a screening option, so it does not support the full list of tests. (LLM, conf=0.86)

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  • Frequent feedback and support positively impact program adherence.

    “Successful interventions included frequent feedback and support, which have been shown to positively impact program adherence.24”

    From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [24]

    The Interdisciplinary Care section says coordinated care models show promise for supporting adherence to recommended therapies. It does not establish that frequent feedback improves adherence to an intervention program; the Strategies to Support Lifestyle Changes and Weight Loss section discusses support but does not make that link. Page numbers were unavailable in our copy. (LLM, conf=0.76)

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  • GLP-1-based therapy has a more substantial impact than SGLT2i on incident ASCVD events.

    “Both classes of agents reduce major adverse cardiovascular events (MACE) and CVD mortality across multiple clinical trials,39,40 with SGLT2i having a particular impact on HF hospitalizations and GLP-1–based therapy having a more substantial impact than SGLT2i on incident ASCVD events.”

    From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [40]

    The Diabetes section (page unavailable) says GLP-1RAs may be particularly useful for people at high ASCVD risk. But the Cardioprotective Antihyperglycemic Therapies in Those With CVD section says the two classes have not been directly compared in clinical trials and prioritization is unclear. Our copy therefore does not establish that GLP-1-based therapy has a more substantial effect than SGLT2 inhibitors on incident ASCVD events. (LLM, conf=0.84)

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  • Both SGLT2i and GLP-1-based therapy reduce major adverse cardiovascular events (MACE) and CVD mortality across multiple clinical trials.

    “Both classes of agents reduce major adverse cardiovascular events (MACE) and CVD mortality across multiple clinical trials,39,40 with SGLT2i having a particular impact on HF hospitalizations and GLP-1–based therapy having a more substantial impact than SGLT2i on incident ASCVD events.”

    From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [40]

    The Diabetes and CVD section (page unavailable) says multiple trials show that both classes reduce major adverse cardiovascular outcomes in patients with type 2 diabetes and ASCVD. The Diabetes section (page unavailable) also reports reduced CVD events and mortality with these therapies, but does not specify cardiovascular mortality for both classes; the explicit cardiovascular-mortality finding concerns SGLT2 inhibitors in heart-failure trials. (LLM, conf=0.84)

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  • Incidentally identified moderate-to-severe coronary calcifications on a nongated chest computed tomography scan typically correlates with CAC ≥100, carries similar prognostic value, and can also identify patients with CKM syndrome most likely to benefit from preventive therapies.

    “Incidentally identified moderate-to-severe coronary calcifications on a nongated chest computed tomography scan typically correlates with CAC ≥100, carries similar prognostic value, and can also identify patients with CKM syndrome most likely to benefit from preventive therapies.21–24”

    From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [24]

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Research works printed but not linked: 1

  1. [71]71. Kidney Disease: Improving Global Outcomes (KDIGO) Lipid Work Group. Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline for lipid management in chronic kidney disease. Kidney Int Suppl. 2013;3:259-305.

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Authors
Ndumele, C. E., Neeland, I. J., Tuttle, K. R., Chow, S. L., Mathew, R. O., Khan, S. S., Coresh, J., Baker-Smith, C. M., Carnethon, M. R., Després, J.-P., Ho, J. E., Joseph, J. J., Kernan, W. N., Khera, A., Kosiborod, M. N., Lekavich, C. L., Lewis, E. F., Lo, K. B., Ozkan, B., Palaniappan, L. P., Patel, S. S., Pencina, M. J., Powell-Wiley, T. M., Sperling, L. S., Virani, S. S., Wright, J. T., Rajgopal Singh, R., Elkind, M. S. V., Rangaswami, J., & on behalf of the American Heart Association
Venue
Circulation
Published
2023-11-14
Volume
148
Issue
20
Pages
1636-1664
ISSN
  • 0009-7322 (ISSN-L)
  • 1524-4539
OpenAlex
W4387435427
Cited by
1,405
References
208
Citations by year
2026: 694 · 2025: 569 · 2024: 134 · 2023: 8
FWCI
50.50
Type
journal article
Language
en
Open access
Locations
  • Circulation (publishedVersion)
  • PubMed (publishedVersion)
  • eCommons - AKU (Aga Khan University) (submittedVersion)
Funders
  • American Heart Association
  • Public Health Agency of Canada
  • National Heart, Lung, and Blood Institute (R01HL140224)
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
  • Health Sciences › Medicine › Nephrology › Chronic Kidney Disease and Diabetes
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Function and Risk Factors
Keywords
cardiovascular-kidney-metabolic syndrome, chronic kidney disease, cardiovascular disease, obesity, diabetes mellitus, metabolic risk factors, cardiovascular risk, renal outcomes, prevention, screening, lifestyle modification, weight loss, cardioprotective therapy, social determinants of health, competing risks, multidisciplinary care
MeSH terms
American Heart Association, Cardiovascular Diseases, Humans, Kidney, Risk Factors, United States, Metabolic Syndrome, Renal Insufficiency, Chronic

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