Carlos Vergara, MD and his take on the new CKM guidelines

Last November, at AHA 2025, I had a few conversations with some leading cardiologists about the concept of a “cardio-metabolic-kidney syndrome” and some were convinced, while others saw it as too broad of a definition.

Whatever your opinion, the ACC/AHA have made it an official driver of CVD complete with its own guidelines.

Thanks for reading,

Vik

Cardiology Guidelines

The CKM Guidelines Have Officially Arrived

The AHA/ACC, in alliance with the ADA and ASN have officially recognized and released the first guidelines addressing cardiovascular-kidney-metabolic (CKM) syndrome as a real and important driver of cardiovascular disease.

• The concept of CKM syndrome was first defined in a 2023 AHA presidential advisory.
• It includes a variety of interconnected diseases, including ASCVD, HF, hypertension, T2D, obesity, CKD, and kidney failure.
• The new guidelines also serve as a replacement for a 2013 guideline on managing obesity in adults.

To start, the guidelines provide a staging system, similar to other CV risk factors like hypertension. They are as follows:

• Stage 0 – No components of CKM syndrome, so focus should be on CVD prevention.
• Stage 1 – Excess or dysfunctional fat tissue.
• Stage 2 – Metabolic risk factors are present (high BP, hypertriglyceridemia, metabolic syndrome, and T2D), CKD, or both.
• Stage 3 – Subclinical CVD or a predicted 10-year CVD risk of 20% or higher based on the PREVENT-CVD equation.
• Stage 4 – Patients have clinical CVD.

With staging and classification standardized, the guidelines also define best practices for managing patients with obesity, T2D, and CKD to reduce CVD risk.

• Treating obesity relies on GLP-1s and bariatric surgery.
• Meanwhile GLP-1s, MRAs, and SGLT2s feature heavily for CKD and T2D.
• The document also gives a class 1 recommendation to interdisciplinary, team-based care for stages 2-4 of CKM.

But what does this official statement mean for cardiology? We often think of the heart and what happens to it in isolation.

• This reclassification of CKM as a multistage risk factor pushes cardiology into a broader realm of patient management.
• Patients living with CKM will need more than one type of physician to reach the best outcomes.

There are, of course, caveats.

• For reference, under these guidelines 90-95% of U.S. adults are in CKM stage 1-4.
• That underscores the problem, but it also highlights the challenges of scaling an integrated care model to all patients.

The Takeaway

The new CKM guidelines represent a shift in the way we understand CVD risk factors. What once was thought to be an isolated pathology now firmly belongs to a web of bodily systems, all of which impact the heart.

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Source: Fearon WF, Jeremias A, Witberg G, et al. Angiography-Derived Fractional Flow Reserve to Guide PCI. NEJM 2026. doi: 10.1056/NEJMoa2600949

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