New Delhi: The American Heart Association (AHA), a US-based nonprofit, has for the first time defined a medical condition that underscores the strong links between cardiovascular disease (CVD), kidney disease, Type 2 diabetes and obesity. This could, in turn, lead to earlier diagnosis and treatment for those at risk of CVD-related complications.
In a ‘presidential advisory’ issued Monday, the AHA termed cardiovascular-kidney-metabolic (CKM) syndrome a ‘health disorder’. Based on this definition, the AHA — known for publishing guidelines on cardiovascular diseases and prevention and standards of care — advocated for CVD risk prevention and management.
“People who have or are at risk for cardiovascular disease may have CKM syndrome,” said a press statement issued by the AHA. It added that while CKM affects nearly every major organ in the body, including the heart, brain, kidney and liver, it impacts the cardiovascular system the most, affecting blood vessels and heart muscle function in addition to the rate of fatty buildup in arteries and electrical impulses in the heart.
The development holds immense significance for clinicians in India, which is seeing a high burden of cardiovascular, kidney and metabolic diseases such as diabetes and obesity.
According to a peer-reviewed study by the Indian Council of Medical Research (ICMR) and Madras Diabetes Research Foundation, published in The Lancet this June, 10.1 crore Indians have diabetes, 31.5 crore have hypertension and 25.5 crore Indian adults are obese.
Another study published last year in the Clinical Kidney Journal said India witnessed a 38 percent increase in the proportion of deaths attributable to kidney failure between 2001–03 and 2010–13.
“The new risk calculator proposed by AHA is sophisticated, can lead to an earlier risk identification, better stratifying kidney and heart diseases’ risk at young age,” Dr C. Raghu, clinical director and senior interventional cardiologist with Yashoda Hospitals, Hyderabad, told ThePrint.
Dr Charit Bhograj, founder & CEO of Tricog Health — which specialises in preventive diagnosis and cardiac care — said recognition of CKM by “global apex bodies like the AHA highlights the need for comprehensive preventive care in India”.
The press statement issued by the AHA quoted Chiadi E. Ndumele, writing committee chair and an associate professor of medicine at Johns Hopkins University, as saying that the “advisory addresses the connections among these conditions (heart and kidney disease, diabetes and obesity) with a particular focus on identifying people at early stages of CKM syndrome”.
“Screening for kidney and metabolic disease will help us start protective therapies earlier to most effectively prevent heart disease and best manage existing heart disease,” added Ndumele, who is also the director of obesity and cardiometabolic research at Johns Hopkins University’s division of cardiology. He also said that the advisory provides guidance for healthcare professionals on how and when to use those therapies, and for the medical community and the general public on the best ways to prevent and manage CKM syndrome.
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CKM screening, stages & treatment
CKM-related screening is intended to detect cardiovascular, metabolic and kidney health changes early, identify social and structural barriers to care, and prevent progression to the next stage of CKM syndrome, said the AHA.
The advisory addresses care for adults, but as studies suggest the syndrome is progressive and begins early in life, it also aligns with the American Academy of Pediatrics’ recommendations for children and young people to undergo annual assessments of weight, blood pressure, and mental and behavioural health, starting at the age of three.
The AHA has classified CKM syndrome into four stages, with therapeutic and screening strategies suggested for each stage.
For adults categorised in ‘stage 0’, recommendations include maintaining healthy eating and sleeping habits, carrying out physical activity, avoiding nicotine and maintaining optimal weight, blood pressure, blood sugar and cholesterol levels. The advisory suggested screening adults in this stage every three to five years to assess blood pressure, triglycerides (a type of fat circulating in the blood), HDL (good) cholesterol and blood sugar.
For adults in ‘stage 1’ with excess body fat, an unhealthy distribution of body fat, such as abdominal obesity, impaired glucose tolerance or prediabetes, recommendations included support for healthy lifestyle changes: healthy eating, regular physical activity, and a goal of at least 5 percent weight loss with treatment for glucose intolerance if needed.
The advisory also advised screening every two to three years for adults in this stage to assess blood pressure, triglycerides, cholesterol and blood sugar.
In comparison, ‘stage 2’ includes people with Type 2 diabetes, high blood pressure, high triglycerides or kidney disease, and indicates a higher risk for worsening kidney disease and heart disease. The goal of care at this stage, said the advisory, is to address risk factors to prevent progression to cardiovascular disease and kidney failure.
Treatment may include medications to control blood pressure, blood sugar and cholesterol and kidney conditions. Screening suggestions for these adults include yearly assessment of blood pressure, triglycerides, cholesterol, blood sugar and kidney function.
In the case of ‘stage 3’, this includes those with cardiovascular disease without symptoms or those with metabolic risk factors or kidney disease or those at high predicted risk for cardiovascular disease.
“The goal of care in stage 3 is to intensify efforts to prevent people who are at high risk of progressing to symptomatic cardiovascular disease and kidney failure,” the AHA said, adding that this “may involve increasing or changing medications, and additional focus on lifestyle changes”.
The advisory also described CKM syndrome regression, in which people making healthy lifestyle changes and achieving weight loss may regress to lower CKM syndrome stages and a better state of health.
On the other hand, the AHA divided ‘stage 4’ into two subcategories: (4a) for those without kidney failure and (4b) for those with it.
In this stage, people may have already suffered a heart attack or stroke or may be suffering from heart failure. They may also have additional cardiovascular conditions including peripheral artery disease or atrial fibrillation.
The goal of care in this stage, said that AHA, is individualised treatment for cardiovascular disease with consideration for CKM syndrome conditions.
Further, the advisory called upon the public to educate themselves about this new syndrome and invest in future research to better understand the disease pathways leading to novel therapeutic strategies.
‘Important to understand interconnectivity’
Raghu added that countries around the world are witnessing an epidemic of obesity, diabetes, cardiovascular disease and kidney disease, with significant overlap between diseases. The risk factors for the development of these diseases, he said, are the same and it is not uncommon for a person with one disease to develop another.
“But the healthcare delivery systems have not recognised this as an interconnected entity. To address this gap, the AHA has come up with the new advisory and is exhorting physicians working across various specialties to work as a unified team for the patient with CKM syndrome,” he said. Raghu added that this allows “earlier preventive strategies to mitigate progression to advanced stages of CKM syndrome”.
“In the long-term this helps reduce treatment gaps and improve patient outcomes,” he said.
Bhograj stressed that the advisory reinforces the idea that good health does not occur in isolation; it is interconnected and interdependent.
The surge in cardiovascular deaths, especially younger adults in India, is of grave concern, he added. “With the alarming rise of obesity and hypertension, one in four adults, we will face a future tsunami of heart disease, including heart failure,” he told ThePrint.
(Edited by Amrtansh Arora)
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