CKM risk score,.a novelCVS risk predictor

cardiovascular kidney metabolic syndrome is a new term coined by AHA presidential committee to highlight the coexistence & common patho-physiology of these diseases esp as now we have new therapies in form of SGLT2i which affect all these systems

1. New AHA CKM PREVENT risk score : indian Implications Dr . Deepak Kapila Director Interventional Cardiology. Fortis Escorts Hospital Amritsar

2. Nov 2023 Cardiovascular-kidney-metabolic (CKM) syndrome is defined as a health disorder attributable to connections among obesity, diabetes, chronic kidney disease (CKD), and cardiovascular disease (CVD), including heart failure, atrial fibrillation, coronary heart disease, stroke, and peripheral artery disease. CKM syndrome includes those at risk for CVD and those with existing CVD.

3. Circulation Research. 2023;132:902–914 The Cardio-Kidney Patient Patients with CKD exhibit a pronounced risk for cardiovascular events with 50% of all patients with CKD stage 4/5 experiencing CVD.

4. Integrative and Functional Medical Nutrition Therapy. Humana, Cham. https://doi.org/10.1007/978-3-030-30730-1_46 Cardiometabolic syndrome and insulin resistance

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6. CKM SYNDROME: New Terminology Instead of describing Cardio-Renal Syndrome and Cardio-Metabolic disease as separate entities it became clear that we need to consider their overlap and bring them under broader construct of CKM Syndrome

7. Definition of CKM Syndrome Simplified Cardiovascular-kidney-metabolic (CKM) syndrome is a health disorder due to connections among heart disease, kidney disease, diabetes, and obesity leading to poor health outcomes. Abbreviations: CKM indicates Cardiovascular-Kidney-Metabolic. 8

8. Cardiovascular-Kidney-Metabolic Syndrome (CKM) A systemic disorder characterized by pathophysiologic interactions among metabolic risk factors, chronic kidney disease, and the cardiovascular system , leading to multi-organ dysfunction and a high rate of adverse cardiovascular outcomes. CKM syndrome includes both individuals at risk  for cardiovascular disease due to the presence of metabolic risk factors and/or chronic kidney disease, and individuals with existing cardiovascular disease that is potentially related to or complicates metabolic risk factors and/or chronic kidney disease.  The increased likelihood of CKM syndrome and its adverse outcomes is further influenced by unfavorable conditions for lifestyle and self-care resulting from policies, economics, and the environment. Abbreviations: CKM indicates Cardiovascular-Kidney-Metabolic. Ndumele , C.E. et al., A Synopsis of the Evidence for the Science and Clinical Management of Cardiovascular-Kidney-Metabolic Syndrome: A Scientific Statement From the American Heart Association. 2023. Circulation . 9

9. Conceptual Diagram of the CKM Syndrome​ Abbreviations: CKM indicates Cardiovascular-Kidney-Metabolic; and MASLD, metabolic dysfunction-associated steatotic liver disease. 10

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11. Nearly every major organ system is a f fected as a consequence of CKM Syndrome: Kidney Failure Premature cognitive decline Metabolic dysfunction – associated steatotic liver disease (MDSLD) Obstructive sleep apnoea Increased risk of cancer Disproportionate burden of Cardiovascular diseases Heart failure/Atrial fibrillation/CAD/ PAD/ Stroke /SCD 12 Circulation. 2023;148:1636–1664

12. CKM Syndrome is a public health urgency. High burden of poor CKM health worldwide Obesity Grade III (BMI 40-<45) linked to median survival reduction of 8 – 10 years. Men and women with Diabetes Mellitus have 13 – 14 years shorter life span than their counterparts without DM. CKD : Compared with middle age individuals with eGFR ≥60, those with stage 4 CKD have > 20 years shorter life expectancy. 10 year mortality: DM : 7.7% CKD : 11.5% DM + CKD : 31.1 % Circulation. 2023;148:1636–1664

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15. Circulation. 2023;148:1606–1635

16. STAGING OF CKM SYNDROME Circulation. 2023;148:1606–1635

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25. Screening Approaches for CKM Syndrome Early Life Screening Screening for Metabolic Risk Factors and CKD in Adults Subclinical CVD Diagnosis SDOH Screening Abbreviations: CKD indicates chronic kidney disease; CKM, Cardiovascular-Kidney-Metabolic; CVD, cardiovascular disease; SDOH, social determinants of health. 26

26. Circulation. 2023;148:1982–2004

27. NEW TOOL FOR RISK ASSESSMENT FOR CARDIOVASCULAR DISEASE PREVENT (Predicting Risk of CV Events) 28

28. Risk Calculator ASCVD risk <5% = LOW RISK ASCVD risk 5- < 7.5% = BORDERLINE RISK ASCVD risk 7.5 -<20% = INTERMEDIATE RISK ASCVD >/=20% = HIGH RISK http://clincalc.com/Cardiology/ASCVD/PooledCohort.aspx

29. Circulation. 2023;148:1982–2004

30. PREVENT base and additional equations. Circulation. 2023;148:1982–2004 The base PREVENT model includes traditional CVD risk factors and kidney function ( eGFR ) as predictors with additional models tailored for high-risk subsets of the population with impaired CKM health with urine albumin-to-creatinine ratio or hemoglobin A1c when clinically indicated or available ( ie , individuals free of CVD but with CKD or diabetes at baseline) and to incorporate SDOH with social deprivation index when available.

31. CV Risk Prediction Tools Pooled cohort equation 2013 For ASCVD risk prediction Only includes white and black adults Lack of inclusion of younger patients From age 40 onwards and gives 10 years risk prediction Absence of SDOH & Kidney health markers (eGFR & albuminuria) as predictors. PREVENT risk calculator For ASCVD as well as HF Does not include race because it is a social factor & not a biological variable Evaluates younger people and looks into long term risk From age 30 to 76 and gives 10 yrs and 30 yrs risk prediction Incorporates also blood sugar, kidney function, tobacco use, medications, age and sex Includes SDOH Circulation. 2023;148:1982–2004

32. https://professional.heart.org/en/guidelines-and-statements/prevent-calculator

33. India is witnessing a CVD epidemic. It is well established that South Asians have increased risk of CV disease as compared to other populations. Indians tend to develop CVD at a younger age (approximately 10 years) compared to others. The PREVENT equations enable estimates of short term, and long-term risk, as well, for CVD with accuracy and precision among adults 30 to 79 years of age. The risk factors included in the PREVENT CKM score are relevant to the Indian population, which has a high prevalence of diabetes and its associated complications . Prediction of total CVD also addresses the possibility of underaddressing absolute risk by only focusing on ASCVD, specifically in populations with poor CKM health (severe obesity, diabetes, and CKD) where risk for HF is relatively greater than risk for ASCVD Although, not validated in Indians, PREVENT Score is a valuable option in risk stratification and guide us on future therapy Is the PREVENT score useful in Indian clinical settings ?

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35. T HANK YOU