A Familiar Diagnosis Gets a New Name
Cardiovascular-kidney-metabolic (CKM) syndrome describes the overlapping biology of obesity, dysglycemia, hypertension, chronic kidney disease, and atherosclerotic disease.
The American Heart Association first framed the syndrome in a 2023 presidential advisory.
A full joint AHA/ACC/ADA/ASN guideline followed this June, formalizing a five-stage classification from stage 0 (no risk factors) through stage 4 (clinical cardiovascular disease).
New data drawn from the National Health and Nutrition Examination Survey (NHANES) now put a number on how well the country is actually managing this population.
The short answer is: not well, and least well in the patients who stand to lose the most.
What the Numbers Show
Investigators analyzed 6,384 adults with stage 2 or higher CKM syndrome enrolled in NHANES between 2015 and 2023.
Most had hypertension or hyperlipidemia, and roughly one in five had diabetes.
Treatment rates, adjusted for age and sex, were highest for diabetes and lowest for hyperlipidemia.
Among those actually receiving treatment, fewer than half of patients with hypertension or diabetes reached guideline-concordant control.
| Risk Factor | Treatment Rate | Control Rate (Among Treated) | 8-Year Trend |
|---|---|---|---|
| Hypertension | 51.3% | 44.7% (BP <130/80 mm Hg) | Declining |
| Hyperlipidemia | 48.8% | 68.2% (total cholesterol <200 mg/dL) | Treatment declining; control improving (64.7%→76.5%) |
| Diabetes | 83.4% | 47.3% (A1c <7%) | Treatment rising; control flat |
The Paradox: Higher Risk, Worse Control
Patients were also stratified by the AHA PREVENT equations into low-to-borderline, intermediate, and high 10-year cardiovascular risk tiers, plus a group with established disease.
Higher-risk patients were more likely to be started on treatment for hypertension and hyperlipidemia.
Yet blood pressure control became less likely, not more likely, as predicted risk climbed.
Glycemic control was worst among patients who already had established cardiovascular disease.
Cholesterol control was the one metric that improved in step with rising risk.
Demographic gaps compounded the problem: young adults, women, and Hispanic adults had the lowest treatment initiation rates across the board.
Black patients had poorer blood pressure control than white patients despite similar treatment rates.
| PREVENT Risk Tier | Treatment Pattern | Control Pattern |
|---|---|---|
| Low-to-borderline (<7.5%) | Lower initiation for HTN and lipids | Relatively preserved BP control |
| Intermediate (7.5–<20%) | Increasing initiation | Progressive decline in BP control |
| High (≥20%) / established CVD | Highest initiation for HTN and lipids | Worst BP and glycemic control |
From "Who Gets Treated" to "Who Gets to Goal"
An accompanying editorial from investigators at a large academic health system framed this as an "intensification gap" rather than a simple access problem.
The editorialists argue that the more actionable signal is not undertreatment of low-risk patients, but insufficient escalation of therapy in the highest-risk group.
Therapeutic inertia is the likely culprit: clinicians start a medication, but asymptomatic risk factors rarely trigger the same follow-through as symptomatic disease.
Closing the gap, the editorial suggests, will require more consistent blood pressure and A1c monitoring, structured uptitration protocols, and system-level support rather than reliance on a single office visit.
The Expanding Drug Toolbox
Two drug classes anchor modern CKM-directed therapy: GLP-1 receptor agonists and SGLT2 inhibitors.
Both classes now carry cardiovascular and renal outcome benefits that extend well beyond glycemic control.
Uptake, however, remains far below the eligible population, and pricing is a major barrier for cash-paying patients.
| Agent (Generic / Brand) | Class | Manufacturer | Analyst Consensus | GoodRx Cash Price |
|---|---|---|---|---|
| Semaglutide (Ozempic) | GLP-1 RA | Novo NordiskNVO | Buy (PT $47.91) | From $149/mo with coupon |
| Semaglutide (Wegovy) | GLP-1 RA | Novo NordiskNVO | Buy (PT $47.91) | From $149/mo with coupon |
| Tirzepatide (Mounjaro) | GIP/GLP-1 RA | Eli LillyLLY | Buy (PT $1,240.46) | From ~$1,087/mo with coupon |
| Empagliflozin (Jardiance) | SGLT2 inhibitor | Boehringer Ingelheimno ticker (private) / Eli LillyLLY | Buy (PT $1,240.46, LLY) | From $249/mo with coupon |
| Dapagliflozin (Farxiga) | SGLT2 inhibitor | AstraZenecaAZN | Strong Buy (PT ~$221–224) | From $288/mo with coupon |
Prices shown are cash, discount-card rates for the most common dose and reflect a single point in time; actual out-of-pocket cost depends on insurance, pharmacy, and manufacturer savings-card eligibility.
A Policy Lever: CMS's ACCESS Model
Payment reform is arriving alongside the pharmacology.
The Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model is a 10-year, voluntary Medicare payment model that launched its first cohort in mid-2026.
ACCESS pays participating organizations recurring, outcome-aligned payments for managing chronic conditions rather than paying for visit volume.
One of its four initial clinical tracks, "Early CKM," specifically targets hypertension, dyslipidemia, obesity, and prediabetes — the exact risk factors highlighted as undertreated in the NHANES analysis.
For employed physicians on wRVU-based compensation, participation questions will hinge on how outcome-based payments interact with existing productivity metrics and whether they flow through to individual clinicians or only to the parent organization.
A 58-year-old patient with type 2 diabetes, stage 3 chronic kidney disease, and a calculated 10-year PREVENT risk of 24% is seen for a routine follow-up.
Blood pressure in clinic is 142/86 mm Hg on a single antihypertensive agent, and the most recent A1c is 7.9% on metformin alone.
Under a traditional visit-based model, a stable-appearing, asymptomatic patient like this is easy to leave unchanged for another interval.
Applying the intensification-gap framework, this is precisely the highest-risk profile in which therapy should be escalated rather than maintained.
A reasonable next step is uptitration of the antihypertensive regimen toward a target below 130/80 mm Hg and initiation of an SGLT2 inhibitor, which addresses glycemic, renal, and cardiovascular risk simultaneously.
Roughly half of US adults with CKM syndrome who need treatment for hypertension or hyperlipidemia are not receiving it, and fewer than half of those who are treated reach target.
The gap is worst, not best, in patients at the highest predicted cardiovascular risk — a reversal of what risk-based care should look like.
Closing it will depend less on starting new prescriptions and more on systematic uptitration, monitoring infrastructure, and payment models like ACCESS that reward outcomes over visit volume.
For physician-investors, the sustained underuse of GLP-1 and SGLT2 therapy relative to guideline eligibility remains a multi-year demand runway for Novo Nordisk, Eli Lilly, and AstraZeneca, tempered by pricing pressure and increasing competition among agents.
References
- NHANES Data Point to Subpar Treatment of Risk Factors in CKM Syndrome. TCTMD.
- AHA/ACC Release First Comprehensive Guideline on CKM Syndrome. TCTMD.
- CV Risk Factor Treatment, Control Rates Low Among Adults With CKM. American College of Cardiology.
- ACCESS (Advancing Chronic Care with Effective, Scalable Solutions) Model. Centers for Medicare & Medicaid Services.
- Jardiance Prices, Coupons & Savings Tips. GoodRx.
- Farxiga Prices, Coupons & Savings Tips. GoodRx.
- Novo Nordisk A/S (NVO) Stock Price & Overview. StockAnalysis.com.
- Eli Lilly and Company (LLY) Stock Price & Overview. StockAnalysis.com.
- AstraZeneca (AZN) Stock Price & Overview. StockAnalysis.com.
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