บทถอดความฉบับเต็มของ Managing Cardiovascular-Kidney-Metabolic (CKM) Syndrome in Patient Care

medicine to try to take a more comprehensive approach. 00:01:55.280 --> 00:02:01.280 Since I noticed a lot of people with diabetes also have heart failure, and we really can't just say we're managing one or the other. 00:02:01.280 --> 00:02:09.280 We need to take the patient as a whole, basically, when we're managing their disease state, so happy now that it's all integrated into one guideline. 00:02:09.599 --> 00:02:10.400 Yeah, absolutely. 00:02:10.400 --> 00:02:12.400 This sounds like very much your bread and butter then. 00:02:12.400 --> 00:02:23.439 And uh already I was uh thinking earlier, you and I had been on a podcast a little while ago about GLP1 agonists, and you had actually mentioned this term CKM during that podcast, and that was actually new to me at that time. 00:02:23.439 --> 00:02:32.719 So I just think it's really timely and interesting that this guideline came out, and now we have sort of this framework to be working around, thinking about CKM syndrome as a whole. 00:02:32.719 --> 00:02:53.439 And so for those of us who aren't familiar with this concept, you sort of alluded to it in your description, but maybe you can just give us I don't know if it's a definition or sort of what CKM syndrome is, how you would describe it, and why it's now sort of has this terminology and is coming to the forefront. 00:02:53.759 --> 00:02:54.879 Yeah, absolutely. 00:02:54.879 --> 00:02:58.159 So I mean the definition is provided in the guidelines. 00:02:58.159 --> 00:03:05.520 So it's really a systemic systemic disorder that's characterized by pathophysiologic interactions among metabolic risk factors. 00:03:05.520 --> 00:03:16.960 So what it's really saying is it's taking cardiovascular disease, chronic kidney disease, individual things like diabetes, hypertension, hyperlipidemia, and it's really looking at all of them together. 00:03:16.960 --> 00:03:28.719 So it's looking at more than just cardiovascular disease, it's looking at all the risk factors, the coexisting chronic kidney disease, and it's looking how they're related to other complications, metabolic risk factors. 00:03:28.719 --> 00:03:36.479 And so in general, it's really just this health disorder that pulls everything together heart disease, kidney disease, diabetes, obesity. 00:03:36.479 --> 00:03:46.560 And it says we need to look at all this as a whole, as a complete picture, to really prevent the progression of cardiovascular disease or anything really leading to poor health outcomes. 00:03:47.439 --> 00:04:05.599 And so, when thinking about sort of this constellation of potential issues and sort of putting them all together into this CKM syndrome, what do you think is the benefit of having a new guideline targeted directly towards that versus individual guidelines individual guidelines? 00:04:05.599 --> 00:04:09.919 Is it is it meant to, like you said before, sort of taking that holistic approach to the patient, I guess? 00:04:10.240 --> 00:04:13.840 Yeah, I think it just really does encourage us to take a more holistic approach. 00:04:13.840 --> 00:04:34.720 Um, historically, I think we send someone comes into internal medicine, they have maybe risk factors for heart disease, they get sent to cardiology, maybe their kidney function starts to decline below 60, they get sent to nephrology, or they have a diagnosis of diabetes, they get sent to endocrine, and then they have fragmented care as they jump through each specialty. 00:04:34.720 --> 00:04:43.759 And really, what this is encouraging is starting to take a better look at the big picture because people with chronic kidney disease have worse cardiovascular outcomes. 00:04:43.759 --> 00:04:44.959 So, how can we work together? 00:04:44.959 --> 00:04:52.160 And so many, I think one of the big things that's influenced this is we talked about GLP ones on our last podcast that I did at least. 00:04:52.160 --> 00:04:58.399 And now GLP ones, if you think about Ozempic, it had benefit reducing the progression of chronic kidney disease. 00:04:58.399 --> 00:05:03.519 It helps with weight loss for weight management, it obviously treats diabetes, which we know it for. 00:05:03.519 --> 00:05:13.360 It has um it lowered the risk of cardiovascular disease and some for some of the GLP ones like subcutaneous semagliotide, terzeptide, delegalotide, oral cymagliotide. 00:05:13.360 --> 00:05:15.920 So we have cardiovascular disease outcomes with those. 00:05:15.920 --> 00:05:19.040 So now we're looking at agents that cross disease states. 00:05:19.040 --> 00:05:24.240 So we've got GLP1s, SGLT2s, we have the non-steroidal MRA phenerinone. 00:05:24.240 --> 00:05:29.120 We've always had our ACEs and RBs as our backbone for heart failure as well as chronic kidney disease. 00:05:29.120 --> 00:05:34.000 So now it's really just optimizing all these different medications, optimizing care. 00:05:34.000 --> 00:05:43.439 There's a bigger focus on social determinants to health and really just thinking about pulling it all together and making sure we're providing the best holistic care possible. 00:05:44.160 --> 00:06:07.439 I think it's really interesting that you called out the, because as you were sort of describing this, I was thinking about SGLT2 inhibitors, GLP1s, you know, and how we've even with diabetes alone moved away from that focus on glycemic management over to this more cardiometabolic focus, and how we're seeing all these drugs having these sort of multitude of effects, and we're using them in that way. 00:06:07.439 --> 00:06:16.399 And so it really does line up with this as well, just this idea that all of these are interconnected, the therapeutic interventions we're considering can all be interconnected too. 00:06:16.399 --> 00:06:26.000 And so you really can't necessarily as effectively look at diabetes as a singular sort of condition or heart failure alone, they are so interconnected. 00:06:27.279 --> 00:06:29.120 Yeah, I mean, and you think about it. 00:06:29.120 -->

00:06:38.959 So, for example, with chronic kidney disease, if someone has an EGFR of 25, let's say I want to start empegalosin, and but I'm also I'm just there to manage diabetes. 00:06:38.959 --> 00:06:41.600 That's what my collaborative practice agreement says. 00:06:41.600 --> 00:07:00.160 I mean, I have a more broad one that covers different disease states, but if I'm solely focused on diabetes management, well, starting an SGLT2 on an EGFR 25, I know I'm not going to get that glycemic benefit that I need for diabetes management, but that absolutely doesn't mean I don't put it on because this person also needs it for cardiovascular and kidney disease benefit. 00:07:00.160 --> 00:07:10.879 Um, so now it's kind of forcing us to focus on all these different disease states together, because really when we're managing someone's glucose, if they have diabetes, I mean, what are we really doing, right? 00:07:10.879 --> 00:07:14.720 We're lowering it because we're trying to protect their kidneys, we're trying to protect their heart. 00:07:14.720 --> 00:07:18.399 So it really makes sense to think about these holistically. 00:07:19.519 --> 00:07:32.879 And when thinking about the impact of this guideline on the population of the US as a whole and thinking about how common CKM syndrome is and how often we might be seeing it in our practices, maybe you can speak to that a little bit. 00:07:32.879 --> 00:07:41.040 And I think part of it too is also just increasing awareness and um increasing awareness about risk factors and trying to intervene early for some of these patients. 00:07:41.040 --> 00:07:45.199 So maybe you can speak to that a little bit in terms of the impact this might have on our patient interactions. 00:07:45.759 --> 00:07:46.639 Yeah, absolutely. 00:07:46.639 --> 00:07:48.879 I think probably to back up and get us started. 00:07:48.879 --> 00:07:58.560 So we talked about CKM syndrome, what it is, but I think it's also important to understand the staging and definitions as well as the diagnostic criteria that they've created for CKM syndrome. 00:07:58.560 --> 00:08:01.040 So they've even created stage zero now. 00:08:01.040 --> 00:08:03.680 So this is someone with no CKM risk factors. 00:08:03.680 --> 00:08:09.680 It's just individuals with normal BMI, waist circumference, normal glycemia, normal tension. 00:08:09.680 --> 00:08:13.920 So healthy individuals with no evidence of chronic kidney disease or cardiovascular disease. 00:08:13.920 --> 00:08:15.120 So that's stage zero. 00:08:15.120 --> 00:08:32.480 So they're even just starting, you know, with the general population and talking about life's essential eight and basically making sure we have good sleep habits, we're not smoking, we're eating healthy, all that good stuff to even prevent progression to stage one CKM, which is excess or dysfunctional adiposity. 00:08:32.480 --> 00:08:46.240 So CKM in general, even though it we're talking about stage four is overt cardiovascular disease,

stage one is really just being overweight or obese, having this excess or dysfunctional adiposity or adipose tissue. 00:08:46.240 --> 00:08:51.600 And it's really anyone with a BMI over 25 or 23 of evasion ancestry. 00:08:51.600 --> 00:08:59.440 So it's starting early with this stage one and making sure we're managing those people early to prevent progression of further disease. 00:08:59.440 --> 00:09:05.440 So they do start with like healthy people, stage zero, stage one, those with excess or dysfunctional adiposity. 00:09:05.440 --> 00:09:08.480 And in stage two is where the metabolic risk factors come in. 00:09:08.480 --> 00:09:14.240 So most of the people that we see in our clinic, diabetes, hypertension, hyperlipidemia, have stage two CKM. 00:09:14.240 --> 00:09:26.960 So these are people without overt cardiovascular disease that just have either high blood pressure, hypertriglyceridine, diabetes, metabolic syndrome, or moderate to high risk of chronic kidney disease progression per the Cadigo heat map or guidelines. 00:09:26.960 --> 00:09:29.200 So those are your stage two. 00:09:29.200 --> 00:09:34.320 Then stage three, it starts to classify those with subclinical cardiovascular disease. 00:09:34.320 --> 00:09:44.480 So these are people that don't have overt cardiovascular disease yet, but maybe they have subclinical coronary atherosclerosis, maybe they have pre-heart failure, which is stage B heart failure. 00:09:44.480 --> 00:09:57.600 So these are people screening high, having an elevated NT pro BMP, having an elevated coronary artery calcium score, or those with a very high predicted tenure risk on the prevent calculator, which would be over 20%. 00:09:57.600 --> 00:10:01.200 So those are people that are subclinical cardiovascular disease. 00:10:01.200 --> 00:10:27.440 And in stage four CAM, which is what we're trying to prevent people from going into, is really the clinical cardiovascular disease aspect, where now it's not only just ASCBD, which we think of as like stroke, heart attack, peripheral arterial disease, now they also include atrial fibrillation and heart failure in this clinical cardiovascular as well, which is why in the prevent equation you see the 10-year and 30-year risk of cardiovascular disease, heart failure as well as ASCBD. 00:10:27.440 --> 00:10:32.159 So stage four is really this overt clinical cardiovascular disease. 00:10:32.159 --> 00:10:49.919 And what they're doing with this guideline is they're progressing through each of the stages and trying to help us understand that we need to prevent people that are overweight or obese from really developing metabolic risk factors or chronic kidney disease, and in further developing cardiovascular disease from not controlling those risk factors well. 00:10:49.919 --> 00:10:54.960 So that's really how CKM is staged in the definitions of each stage. 00:10:55.360 --> 00:10:55.679 Okay. 00:10:55.679 --> 00:10:56.240 Okay. 00:10:56.240 --> 00:11:02.320 So, and I I really appreciate they called out stage zero because that means the guideline applies to the entire population. 00:11:02.320 --> 00:11:02.879 Right. 00:11:02.879 --> 00:11:05.039 So stage zero. 00:11:05.039 --> 00:11:07.600 And then stage one is the overweight obesity. 00:11:07.600 --> 00:11:14.080 Stage two is where you have the at least one co comorbidity, is sort of what you described, right? 00:11:14.080 --> 00:11:18.320 And then stage three is where you're sort of stacking on from there. 00:11:18.320 --> 00:11:20.320 Would that be a fair sort of assessment? 00:11:20.559 --> 00:11:20.720 Yeah. 00:11:20.720 --> 00:11:22.000 Stage three is you have this. 00:11:22.000 --> 00:11:25.200 I have a stage, stage three is more like a subclinical cardiovascular disease. 00:11:25.200 --> 00:11:37.120 So these are people that maybe have like an incidental coronary artery calcium score that shows up over 100 on a screen, or maybe their if their prevent score is over 20%, then that puts them in stage three. 00:11:37.120 --> 00:11:42.159 Also, too, what we're seeing now is if they have a when you calculate the prevent score for a patient. 00:11:42.159 --> 00:11:47.039 So I guess to back up, another thing that came out with this guideline is the prevent score. 00:11:47.039 --> 00:12:03.519 So historically, we've known the pooled cohort equation, which though that was the equation where we calculated someone's 10-year ASCVD risk based on different profile factors such as their race, their age, their sex, their cholesterol profile, blood pressure, whether or not they have diabetes. 00:12:03.519 --> 00:12:10.159 So historically, I think as pharmacists, we've been just kind of conditioned to plug in that person's information and get their risk score. 00:12:10.159 --> 00:12:14.559 And then that was how we decided on, you know, do they need moderate high-intensity statin? 00:12:14.559 --> 00:12:17.440 What should we be doing to lower their cardiovascular risk? 00:12:17.440 --> 00:12:20.559 Well, that's been updated recently with the PREVENT equation. 00:12:20.559 --> 00:12:25.600 So now what the PREVENT equations do is it basically starts at age 30. 00:12:25.600 --> 00:12:28.720 So you're seeing it start at a lower age in the population. 00:12:28.720 --> 00:12:33.039 So they're recognizing that cardiovascular risk develops earlier than life than age 40. 00:12:33.039 --> 00:12:35.120 So it goes down to age 30, which is nice. 00:12:35.120 --> 00:12:38.080 So we can start to calculate it in a younger population as well. 00:12:38.080 --> 00:12:44.320 And then what it does is it gives you their 10 and 30 year ASCBD cardiovascular disease and heart failure risk. 00:12:44.320 --> 00:12:54.480 So for stage three, if you do the prevent score and it's greater than 20% using the prevent cardiovascular disease calculator, definitely they fall into stage three. 00:12:54.480 --> 00:13:03.120 And we need to start doing more aggressive, basically, modifications to make sure they don't

prevent or make sure they don't progress to avert cardiovascular disease. 00:13:03.120 --> 00:13:21.200 Another thing that the new guideline recommends is if their prevent calculator comes back with their heart failure score is greater than 5%, they recommend screening cardiac biomarkers such as NT ProBMP or high sensitivity troponin, just to make sure that they actually don't have subclinical heart failure. 00:13:21.200 --> 00:13:34.960 So these are just different things that the guideline recommends because if someone comes in and their prevent score for heart failure, let's say, is greater than 5%, they screen positive on their NT prob with a number greater than 125. 00:13:34.960 --> 00:13:42.480 Um then we could consider maybe putting on an SGLT2 inhibitor just to prevent the progression of heart failure. 00:13:42.480 --> 00:13:46.480 So there's different things that we can do to basically help educate people. 00:13:46.480 --> 00:13:48.480 Like your risk for heart failure is high. 00:13:48.480 --> 00:13:56.960 We could start this medication, you could make these lifestyle interventions, just different things that we can talk to them about to make sure that they don't progress to overt heart failure. 00:13:57.600 --> 00:14:05.600 Okay, so you you called out a really important point, which is that um the prevent calculator is is still new, I think, for many of us. 00:14:05.600 --> 00:14:24.159 And so being aware of that first and foremost, but then also leveraging that not only in the assessment of cardiovascular risk broadly, but in this context to help identify potential patients who may have this subclinical ASCVD, subclinical, yeah, subclinical ASCVD, right, is how you would call it. 00:14:24.159 --> 00:14:28.159 And then before they get to stage four, which is ASCVD established. 00:14:28.159 --> 00:14:32.960 So I think what I want to call it there is just this prevent calculator. 00:14:32.960 --> 00:14:40.080 It is like you referred to the the pool cohort equation, and that was you know something we're very used to, plugging in the information and getting the results. 00:14:40.080 --> 00:14:43.919 But this is also an online tool that people can very easily plug in. 00:14:43.919 --> 00:14:54.399 And pharmacists, I think, are well in in a great position to be able to have that data to be able to get these scores and communicate that with the patient and help us as next steps. 00:14:54.399 --> 00:14:59.200 Maybe you can just walk through that a little bit again for people who might not be as familiar with that prevent calculator. 00:14:59.200 --> 00:15:04.159 It is online, it's free, it's you know, just asking for some information the same way, right? 00:15:04.159 --> 00:15:10.320 Like it would be something that could be integrated into practice for community pharmacists or earning care pharmacists. 00:15:10.720 --> 00:15:11.440 Yeah, yep. 00:15:11.440 --> 00:15:12.000 Sorry, go ahead. 00:15:12.000 --> 00:15:14.159 Yeah, so I mean, oh no, absolutely. 00:15:14.159 --> 00:15:15.200 So it's very similar. 00:15:15.200 --> 00:15:19.600 So for our older pharmacists, like I know when I was in school, you actually did the framing ham equation. 00:15:19.600 --> 00:15:20.639 So we did that. 00:15:20.639 --> 00:15:23.120 That was we're dating ourselves now. 00:15:23.120 --> 00:15:26.399 So we did the pool cohort equation around 2013, right? 00:15:26.399 --> 00:15:28.639 We converted over to the pool cohort equation. 00:15:28.639 --> 00:15:34.080 And really now this is just the update to the Framingham pool to cohort equation, and now we have the Prevent Equation. 00:15:34.080 --> 00:15:37.279 So those are on it's through the American Heart Association. 00:15:37.279 --> 00:15:48.080 And you can honestly, if you just did a search engine and put in Prevent Equations, American Heart Association, you would get the link to the website, or maybe we can even include it on this podcast link. 00:15:48.080 --> 00:15:57.600 But what you do is you enter in all the same inform, not the same information, but inner information as you would when you did the pool cohort equations, you would enter it very in very similar. 00:15:57.600 --> 00:16:02.000 It did remove race and it added a few extra things that have been kind of interesting. 00:16:02.000 --> 00:16:05.039 So it has kind of like the bread and butter components. 00:16:05.039 --> 00:16:14.159 You add in different lipid values, you enter in blood pressure, does the person have diabetes, smoking, status, and age, and all that good stuff that we're normally used to adding in? 00:16:14.159 --> 00:16:19.600 But there's actually three optional ones that you can put in to further stratify their risk a little bit better. 00:16:19.600 --> 00:16:25.600 And to capture social determinants of health, it actually has you put in the patient's zip code, which is helpful. 00:16:25.600 --> 00:16:32.399 So it is kind of interesting to play with if you are listening to this and you've searched the pool code or the prevent equation and you're playing with it. 00:16:32.399 --> 00:16:38.799 You could put in different zip codes and just see how it actually impacts the person's score based on where they live. 00:16:38.799 --> 00:16:48.559 So, for example, like right now I'm at Northwestern, but previously my last job, I was at advocate on excuse me, on the south side of the city where there was less resources. 00:16:48.559 --> 00:16:58.320 So I would put in advocate southeast zip code versus northwestern zip code, and you would see a difference in their cardiovascular risk score just based on their zip code. 00:16:58.320 --> 00:17:07.440 So to capture social determinants of health, they've added zip code in there to further stratify people based on what's available in those areas. 00:17:07.440 --> 00:17:11.519 And then they also have A1C and then urinal bumin creatinine ratio. 00:17:11.519 --> 00:17:23.839 So another thing that we're starting to see is a push towards really, I

think when we think of chronic kidney disease, we've always thought of EGFR, but now really we should also be monitoring urinal bumin creatinine ratio as well. 00:17:23.839 --> 00:17:30.799 And when you look at the Cadigo heat map, that's how you stage and determine the progression of chronic kidney disease is based on both those values. 00:17:30.799 --> 00:17:37.759 So they also encourage you to make sure you're monitoring UACRs and entering them into the prevent equations as well. 00:17:38.240 --> 00:17:38.559 Okay. 00:17:38.559 --> 00:17:39.200 Okay. 00:17:39.200 --> 00:17:43.519 So yeah, lots of new information. 00:17:44.480 --> 00:17:44.799 Yeah. 00:17:44.799 --> 00:17:46.720 If you're still with us, thank you. 00:17:47.680 --> 00:17:50.880 But all good, all to the benefit of patients. 00:17:50.880 --> 00:18:02.880 And um the reason I went back to the prevent equation, just to talk through that a little bit further, is because I do think it's a very powerful tool in terms of patients empowering themselves to, you know, go in and enter their data as well. 00:18:02.880 --> 00:18:18.720 And also for pharmacists to be able to be early identifying these patients who may be at risk and could benefit from additional potential screening for the heart failure risk or the CAC or some of these other factors and and just at least starting those conversations. 00:18:18.720 --> 00:18:22.720 Because again, I think a lot of this is to be identifying patients early. 00:18:22.720 --> 00:18:34.640 So maybe we go back to that question in terms of how many patients you're thinking this will impact in terms of looking at these risks and having those conversations. 00:18:34.640 --> 00:18:38.160 Is this something we should be thinking about with all of our patients? 00:18:38.160 --> 00:18:41.759 And how do you how do we how do we integrate this into practice? 00:18:41.759 --> 00:18:43.200 I guess is what I'm asking. 00:18:43.599 --> 00:18:52.240 I mean, I think even as pharmacists, like patients coming into our community pharmacy, for example, someone comes in and you notice their fill history is not great with their statin therapy. 00:18:52.240 --> 00:19:04.880 I mean, even just kind of sitting down, having them look at their prevent risk, if someone told me that there was a 60% chance that I was going to have cardiovascular disease in the next 10 years, I might be more apt to pick up and take that statin. 00:19:04.880 --> 00:19:18.079 So I do think it's a nice tool where you can show them, you can sit down with them, pull up the prevent calculator, and show them if we modify these risk factors, like if your cholesterol changes by this much, then your risk decreases this much. 00:19:18.079 --> 00:19:22.160 Or if we lower your blood pressure this much, this is how much more your risk would decrease. 00:19:22.160 --> 00:19:33.119 So I think it is a helpful tool to show people if you took your medication and we were able to lower your blood pressure or maybe even manage your diabetes better, then this is, you know, how much your risk would reduce. 00:19:33.119 --> 00:19:36.240 So it also helps too with one, what's their baseline risk? 00:19:36.240 --> 00:19:41.599 And then if we modify some of these risk factors and better manage them, what will your risk be? 00:19:41.599 --> 00:19:45.279 So I actually think it's a useful tool to get people more motivated for self-care. 00:19:45.279 --> 00:19:49.680 Because I think there's only so much we can do as providers and clinicians and pharmacists. 00:19:49.680 --> 00:19:56.240 But really, at the end of the day, like we need to motivate people to want to take care of themselves at home and understand how to do it too. 00:19:56.240 --> 00:20:07.200 So I think it gets them started with okay, this is your risk, and this is what we're worried about, and this is what you run the risk of progressing to, whether it be heart failure, cardiovascular disease, ASCBD. 00:20:07.200 --> 00:20:13.119 Um, and then these are how these modifiable risk factors and treatment of them can influence your risk. 00:20:13.119 --> 00:20:18.799 So I think that's just some basic counseling that we can do for all patients, really, if we have time. 00:20:19.279 --> 00:20:27.440 And when thinking about this new guideline, so we we've had uh recent hypertension guidelines be updated, dyslipidemia guidelines be updated. 00:20:27.440 --> 00:20:29.759 They've talked about the prevent calculator as well. 00:20:29.759 --> 00:20:37.039 And so when thinking about this and how this is going to impact our discussions with patients, would you be telling a patient? 00:20:37.039 --> 00:20:40.079 I I think we're very used to siloing these conditions. 00:20:40.079 --> 00:20:48.799 So, how would you frame your education to a patient about CKM syndrome versus perhaps the individual conditions on their own? 00:20:48.799 --> 00:20:50.799 How how how do you navigate that? 00:20:51.359 --> 00:20:57.920 Yeah, I mean, I think most people that I see that have type two diabetes also have hypertension. 00:20:57.920 --> 00:21:08.240 So I think in general, it's hard to just manage diabetes and not think about blood pressure or not think about starting a statin to lower their cardiovascular disease risk. 00:21:08.240 --> 00:21:14.000 So in general, I think we need to just start thinking about all of these together. 00:21:14.000 --> 00:21:18.960 And the nice thing is, is it's incorporated the blood pressure guidelines, it's incorporated the lipid guidelines. 00:21:18.960 --> 00:21:20.720 So I'm just gonna ask, yeah. 00:21:20.720 --> 00:21:24.480 Yeah, so everything is all here for you, like within one guideline now. 00:21:24.480 --> 00:21:33.359 So if you're like, oh, she's sitting here telling me I need to know and be the master of all of these and know everything for blood pressure, everything for lipids. 00:21:33.359 --> 00:21:37.839 This guideline is nice because it takes all the information, because it's all ACC, H A.

00:21:37.839 --> 00:21:40.960 This is actually endorsed by the American Diabetes Association as well. 00:21:40.960 --> 00:21:46.000 It takes all of these guidelines, incorporates them together, and has them in one place for you. 00:21:46.000 --> 00:21:49.039 So you don't have to go searching for each individual guideline. 00:21:49.039 --> 00:21:58.720 If you want to provide comprehensive care and think about the patient holistically, it's all right here for you what their goals are, treatment options, different ways to approach it. 00:21:58.720 --> 00:21:59.200 Yeah. 00:21:59.200 --> 00:22:02.240 So I I don't think you need to comb through all the guidelines. 00:22:02.240 --> 00:22:05.279 It's all right here for you in the new CKM guideline. 00:22:06.160 --> 00:22:09.440 That's really interesting because that I think that's sort of the first time. 00:22:09.440 --> 00:22:11.359 I know it's been challenging for me. 00:22:11.359 --> 00:22:16.720 You're thinking about okay, if you have a patient with diabetes, you also have to be thinking about hypertension and dyslipidemia. 00:22:16.720 --> 00:22:38.559 And so you're trying to string these guidelines together historically, whereas now you're saying this can really be the guideline if you know a patient has multiple or falls into stage two, three, four of the CKM syndrome, you can use this guideline to help shape your recommendations rather than sort of picking and choosing from the various guidelines. 00:22:38.559 --> 00:22:39.279 Is that fair? 00:22:39.279 --> 00:22:43.759 You really could rely on this guideline to care for a patient with multiple comorbidities like that. 00:22:44.319 --> 00:22:45.200 Yeah, I think so. 00:22:45.200 --> 00:22:52.240 I mean, if you really needed to take a dip, a deeper dive into like advanced lipid management, sure, like absolutely you should go to the lipid guidelines. 00:22:52.240 --> 00:23:00.720 But for general information, I mean, here you've got, you know, you start the statin first once they're a maximally tolerated statin, you do PCSK9 inhibitor or you do a Z. 00:23:00.720 --> 00:23:04.480 And it's got kind of the basic recommendations to get you treated through. 00:23:04.480 --> 00:23:07.839 And it aligns really well with the ACCHA lipid guideline. 00:23:07.839 --> 00:23:13.839 Now, in terms of like more advanced screening, advanced management, familial diseases, sure, sure. 00:23:13.839 --> 00:23:16.240 I would definitely go to the lipid guideline first. 00:23:16.240 --> 00:23:23.920 But I think just for general overall tips and tricks and a high-level overview of managing lipid disorders, it's all in here for you. 00:23:23.920 --> 00:23:26.559 Same for blood pressure, same for diabetes. 00:23:26.559 --> 00:23:38.319 And it really, because it does take that holistic approach, definitely encouraging GLP1s, SGLT2s first for people with diabetes, those with you know proven benefit to reduce cardiovascular disease risk. 00:23:38.799 --> 00:23:39.920 That's super interesting. 00:23:39.920 --> 00:23:48.880 It really, to me, it's like flipping how I've been thinking about managing these conditions on its head because it really it's just it makes so much sense. 00:23:48.880 --> 00:23:54.079 These are interconnected conditions, they are really meant to be managed together. 00:23:54.079 --> 00:23:57.920 And I I'm hopeful this will help simplify patient care. 00:23:58.160 --> 00:23:58.640 Do you think? 00:23:58.640 --> 00:23:59.039 Yeah. 00:23:59.039 --> 00:24:03.759 I think I mean once you get the hang of it, I think when you first pull up the guideline, you're like, okay, this is overwhelming. 00:24:03.759 --> 00:24:08.960 I I'm looking at it over here, it's 119 pages, but no different than any other guideline, of course. 00:24:08.960 --> 00:24:17.200 They've got your take-home messages up at the top, but really I think what it is is it's just starting to think about okay, all of these conditions together. 00:24:17.200 --> 00:24:20.880 And I like that the focus is just we're preventing cardiovascular disease. 00:24:20.880 --> 00:24:22.480 Like that's really the end game. 00:24:22.480 --> 00:24:29.680 It's not, it is about managing all these individual conditions, but also it's about preventing the progression to cardiovascular disease. 00:24:29.680 --> 00:24:32.400 And I really like that the focus is now on prevention. 00:24:32.400 --> 00:24:38.559 I think historically it's always like, okay, you have diabetes, now we're going to focus on treating you and sending you to endo. 00:24:38.559 --> 00:24:43.839 Okay, you have heart disease or you have these conditions, now we're going to send you to cardiology. 00:24:43.839 --> 00:24:49.039 This is really shifting our focus to okay, you have overweight or obesity. 00:24:49.039 --> 00:25:02.559 Let's get ahead of the game, slow this down, and make sure you don't progress to, you know, another metabolic disease such as hypertension, hyperlipidemia, diabetes, metabolic syndrome, and then slow the progression of chronic kidney disease. 00:25:02.559 --> 00:25:10.400 So I like that it really starts to tackle everything up front and it's more about prevention than it is even about overt treatment. 00:25:10.400 --> 00:25:19.759 It definitely has both in the guidelines, but I just love the prevention component because that's really, I mean, for years, it's like, what are we doing when we manage glucose? 00:25:19.759 --> 00:25:22.400 We're preventing kidney disease and we're preventing heart disease. 00:25:22.400 --> 00:25:24.720 That's the reason we're managing diabetes, right? 00:25:24.720 --> 00:25:28.559 It's not, there's nothing really about glucose specifically. 00:25:28.559 --> 00:25:32.480 It's the what happens if you leave your glucose too high too long. 00:25:32.480 --> 00:25:39.680 So I love now that the focus has really shifted to prevention of cardiovascular disease, chronic kidney disease. 00:25:39.920 --> 00:25:41.119 Yeah, yeah, I agree. 00:25:41.119

--> 00:25:43.359 And outcomes that really matter to patients. 00:25:43.359 --> 00:25:49.839 And therefore, we can hopefully work with them and engage them in these interventions that are going to possibly impact them. 00:25:49.839 --> 00:25:56.880 Are are you thinking you would you use the term cardiovascular kidney metabolic syndrome with patients? 00:25:56.880 --> 00:26:02.400 Is this something you're starting to actually use that term and get patients familiar with this as well? 00:26:02.720 --> 00:26:03.920 I actually haven't yet. 00:26:03.920 --> 00:26:06.240 So I do stage every patient in our note. 00:26:06.240 --> 00:26:10.720 So in our clinical note, I'll start with like this is their CKM stage, and then I'll break it down. 00:26:10.720 --> 00:26:12.960 And I still break down the disease states independently. 00:26:12.960 --> 00:26:15.519 Like I'll assess diabetes, chronic kidney disease progression. 00:26:15.519 --> 00:26:22.079 We do MACL D screening, even primary and secondary prevention screening and assessment, heart failure assessment. 00:26:22.079 --> 00:26:26.000 So we do break them down individually in our note and stage the person. 00:26:26.000 --> 00:26:30.640 I haven't started using the terminology yet, just because I don't think patients really understand. 00:26:30.640 --> 00:26:37.839 Okay, like your CPM stage three, like they they might not even understand what four is, or like that four is the top or the max. 00:26:37.839 --> 00:26:39.359 Um, so we'll see if this takes. 00:26:39.359 --> 00:26:51.599 I think it's going to take probably some influencers and information and the uh just basically in social media and the press for us to really start to use it more in clinic. 00:26:51.599 --> 00:26:57.839 But in general, I I use more of the terms, like I just talk to them about preventing disease. 00:26:57.839 --> 00:27:00.079 It helps me focus a bit more on prevention. 00:27:00.079 --> 00:27:04.720 We do the prevent calculator and I'll tell them, like, I calculated your risk, this is what it is. 00:27:04.720 --> 00:27:09.519 So I'm using it more still in general terms, as opposed to CKM. 00:27:10.000 --> 00:27:10.799 Okay, yeah. 00:27:10.799 --> 00:27:12.160 But I think we might see a shift. 00:27:12.160 --> 00:27:12.559 You're right. 00:27:12.559 --> 00:27:17.359 Uh it may just take some some social media influence to aggressively that way. 00:27:17.680 --> 00:27:18.960 I think about GLP1s. 00:27:18.960 --> 00:27:23.680 I mean, back in 2019, it was like, can you please take your subcutaneous amagalite? 00:27:23.680 --> 00:27:29.519 And it was like motivating people to get on just like, please, please, please, like this is good for your diabetes, it's good for your heart. 00:27:29.519 --> 00:27:31.680 And people would be like, No, I don't think so. 00:27:31.680 --> 00:27:34.880 You know, they wanted to stay on metformin and they wanted to stay on glypazide. 00:27:34.880 --> 00:27:42.160 Then all of a sudden, you know, people are on these on social media, and now you can't even get them for people with diabetes are on shortage because everyone wants them. 00:27:42.160 --> 00:27:45.359 And then people with diabetes are coming in, like, I want this now. 00:27:45.359 --> 00:27:52.319 So, unfortunately, unfortunately, I think social media just plays a huge role in some of this taking off. 00:27:52.319 --> 00:27:54.160 I hate to say it, but I think it's true. 00:27:54.160 --> 00:28:02.319 I saw it in diabetes, like it was motivating people to get on a GLP one was definitely a lot easier once they became more popular through social media. 00:28:02.319 --> 00:28:04.160 So even Absolutely. 00:28:04.160 --> 00:28:05.680 Yeah, absolutely. 00:28:05.920 --> 00:28:13.920 Well, and I I like how you called out the prevention focus of this, and again, the stage zero concept that this this these discussions can happen with all of our patients. 00:28:13.920 --> 00:28:31.519 And prevention is often something that's not that exciting to be thinking about, or you know, people always hear lifestyle changes and yeah, but I mean, what are some of the key takeaways you would share you share with patients in terms of helping to get that buy and helping to take those steps with say they are in stage one or stage two? 00:28:31.519 --> 00:28:35.759 Where do you find the most impactful recommendations are? 00:28:36.720 --> 00:28:42.960 Yeah, I think the most impactful recommendations are really just when I'm trying to get the right medications on board. 00:28:42.960 --> 00:28:44.640 So I'll calculate their risk. 00:28:44.640 --> 00:28:48.480 And I think a lot of it too is okay, GLP ones, everyone wants one. 00:28:48.480 --> 00:28:49.680 Like, no argument. 00:28:49.680 --> 00:28:52.000 That's pretty easy to implement in clinical practice. 00:28:52.000 --> 00:28:56.160 And we know those are going to prevent progression of kidney disease, heart disease, help with diabetes. 00:28:56.160 --> 00:29:04.079 I think where you start to need a little bit more help with this is looking at the Cadigo heat map, looking at their chronic kidney disease progression risk. 00:29:04.079 --> 00:29:17.200 And then once we have on the GLP1, maximally tolerated Acer and ARB, SGLT2 inhibitor, getting on that non-steroidal MRA for Narinone as well, like showing people, okay, this is what your kidney disease progression risk is on the Cadigo heat map. 00:29:17.200 --> 00:29:24.160 This is why you need the four pillars really of CKD to help prevent that risk, or even the same with heart failure. 00:29:24.160 --> 00:29:34.160 I mean, once you have overt heart failure, you obviously don't calculate the prevent scores for the primary prevention, but just using that risk score to say, okay, this is your risk of heart failure. 00:29:34.160 --> 00:29:41.359 You know, this is why we should be using SGLT2s and GLP1s to help better manage your diabetes is so we don't get to this point. 00:29:41.359 --> 00:29:53.599 So, in terms of

just using it clinically, I think I use it because there's so many meds now that treat different GLP1s, like we talked about SGLT2s, they are doing so many different things. 00:29:53.599 --> 00:29:59.440 I think it helps people understand the importance of actually taking them because we also know adherence is a big issue. 00:29:59.440 --> 00:30:06.559 So it's like, okay, you need a statin, you need an Acer and Arb, you need an SGLT2, you need a GLP one, potentially phenerinone. 00:30:06.559 --> 00:30:09.519 Like it's exhausting for patients to take that many different medications. 00:30:09.519 --> 00:30:17.119 So I think this does is it helps basically them understand how it's helping slow their risk down. 00:30:17.119 --> 00:30:21.759 So um, like why the why behind everything. 00:30:22.079 --> 00:30:22.799 Yeah, yeah. 00:30:22.799 --> 00:30:30.559 And and again, thinking about the outcome we're trying to prevent cardiovascular disease, and again, tying that home to an outcome that matters for patients. 00:30:30.559 --> 00:30:41.039 So helping again, I I think all of this is is in going in the right direction in terms of patient education and supporting them and in empowering them in adherence and and staying on therapy. 00:30:41.039 --> 00:30:44.799 We don't need to get into all of the specific details. 00:30:44.799 --> 00:30:50.240 I don't think it's terms of management outside of that, but is there anything else that we should be aware of when it comes to this guideline? 00:30:50.240 --> 00:30:57.920 Anything else that you wanted to highlight from either those top 10 tips or general things you're thinking about in practice when you're managing these patients? 00:30:59.519 --> 00:31:01.680 I think I feel like we've covered so much today. 00:31:01.680 --> 00:31:02.160 I know. 00:31:02.160 --> 00:31:10.160 I just I think in general, really the big thing is is just understanding that the prevent calculator is new, the prevent equations. 00:31:10.160 --> 00:31:15.519 It should be calculated for each patient to help them stratify and understand their different risk scores. 00:31:15.519 --> 00:31:24.960 And then also now that it expands to heart failure and cardiovascular disease, which includes ASCBD as well as AFib and heart failure, and really just starting early. 00:31:24.960 --> 00:31:47.599 So people coming in, maybe not taking their meds, like, oh, well, I don't really have diabetes yet, or you know, those people that are maybe borderline, like our pre-diabetes population, making sure they understand, you know, we really want to try to help you prevent progression of disease so that we can prevent progression to diabetes, progression to overt cardiovascular disease, because we know it's a spectrum and it keeps adding on. 00:31:47.599 --> 00:32:05.039 So I think the big takeaway is really using this as a preventative medicine tool and really just helping people understand the risk of continuing to let these basically the unfortunately the consequences of not managing these different factors well, these metabolic risk factors well. 00:32:05.440 --> 00:32:20.319 And and further driving home the emphasis on uh lifestyle modifications and the you know, the impact there, because um one I saw one statistic that nearly 90% of US adults have at least one CKM syndrome risk factor. 00:32:20.319 --> 00:32:28.160 So if you're thinking about the patients you're interacting with on a daily basis, regardless of your practice setting, that is so many patients that we can have a positive impact on. 00:32:28.480 --> 00:32:29.519 Yeah, absolutely. 00:32:29.519 --> 00:32:45.680 I mean, so it starts the foundation of this, and I know we've kind of been more talking about the advanced conditions of this, but don't forget it starts at stages zero with just making sure everyone understands they call it life's essential eight, but managing blood pressure, managing cholesterol, making sure people aren't smoking, getting enough sleep, that's a big one. 00:32:45.680 --> 00:32:50.480 I know I'm trying to do a better job at that, making sure people exercise. 00:32:50.480 --> 00:32:54.640 So just different things um to make sure we're just living healthy lifestyles. 00:32:54.640 --> 00:32:57.920 So there's a lot of barriers out there to that, unfortunately. 00:32:57.920 --> 00:33:04.960 So it really does focus emphasis on that too, just lifestyle mods and then making sure everyone's living healthy lifestyles. 00:33:05.200 --> 00:33:06.000 Yeah, yeah. 00:33:06.000 --> 00:33:12.240 Well, I I think it's uh I really appreciate you sharing your expertise on this because it's so important to know about this. 00:33:12.240 --> 00:33:18.400 And again, even just remembering the the acronym CKM, you know, that's something I needed to say a few times. 00:33:18.400 --> 00:33:23.119 Uh, the nice part is that it is alphabetical, cardiovascular, kidney metabolic. 00:33:23.119 --> 00:33:27.359 And you do think of those three sort of spheres when you're thinking about these patients. 00:33:27.359 --> 00:33:30.240 So it's just a very positive move, I think. 00:33:30.240 --> 00:33:40.480 And and I love the fact that the guidelines are sort of consolidated now and we can use this sort of in primary care to be managing a big swath of patients that maybe we would have had to go digging into different guidelines before. 00:33:40.480 --> 00:33:41.920 So I think that's a big benefit. 00:33:41.920 --> 00:33:44.319 So, Christy, thank you so much for your time. 00:33:44.319 --> 00:33:46.160 It is our game changers podcast. 00:33:46.160 --> 00:33:54.400 So, in terms of sort of the bottom line takeaway that we want our listeners to remember after walking away from this podcast, what would you say is the game changer? 00:33:54.880 --> 00:34:03.920 Um, I think the game changer is we can't we can no longer just think about people as having heart disease, having kidney disease, having diabetes, for example. 00:34:03.920 --> 00:34:06.559 We

really have to think of them more holistically. 00:34:06.559 --> 00:34:09.440 So if someone has diabetes, what's their cardiovascular risk? 00:34:09.440 --> 00:34:15.599 Or if they have overt cardiovascular disease, what are we doing to make sure they don't have another event or have an event to begin with? 00:34:15.599 --> 00:34:21.280 So I think the biggest takeaway from this is we need to stop being so siloed in our patient care. 00:34:21.280 --> 00:34:35.199 And we really need to be more comprehensive in our management of people because so many of these conditions are interconnected, and we need to stop basically just thinking, okay, I only manage diabetes or I only manage hypertension. 00:34:35.199 --> 00:34:47.199 And we really need to do start looking at the patient holistically and start thinking about all of it and how if we don't manage one, how it's going to impact the other one, so that we can really slow down the risk of progression. 00:34:47.599 --> 00:34:48.480 Absolutely. 00:34:48.480 --> 00:35:03.440 And you know, that also makes me think of pharmacists' role in the healthcare team and not being siloed either, and sort of that interconnectivity between the healthcare team more broadly, and even as you mentioned, like endo and neprology working more holistically in healthcare too. 00:35:03.440 --> 00:35:05.119 I think it's right too. 00:35:05.440 --> 00:35:06.320 Yeah, that's a great point. 00:35:06.320 --> 00:35:22.960 I mean, pharmacists in general were kind of unique because for my position, actually, like, yes, I'm funded through the pharmacy team, but I actually never interact with the pharmacy team because I'm in a clinic with you know almost 50 providers, 50 physicians, medical residents, nurse practitioners, physicians assistants. 00:35:22.960 --> 00:35:28.719 Um, and I actually spend more time communicating actually with my team in the internal medicine clinic. 00:35:28.719 --> 00:35:40.639 So it's kind of unique because we're so used to just being like, okay, we're pharmacy, but now we really, if we want to be members of the healthcare team, we need to be more patient-centric, more provider-centric and working together with everyone. 00:35:40.639 --> 00:35:42.800 And how can we use all of our resources? 00:35:42.800 --> 00:35:52.800 So, you know, learning and meeting different people within your system, like who's the nutritionist who are helping me with all these different things because there's so many different resources we can use. 00:35:52.800 --> 00:35:56.480 So getting a pharmacy mindset too, yeah. 00:35:56.719 --> 00:35:57.519 Yeah, absolutely. 00:35:57.519 --> 00:36:00.800 Leveraging the expertise of everyone on that team and that team-based care approach. 00:36:00.800 --> 00:36:01.360 Absolutely. 00:36:01.360 --> 00:36:04.719 Patient case, patient-based approach and team-based approach. 00:36:04.719 --> 00:36:05.280 I love it. 00:36:05.280 --> 00:36:06.880 They go hand in hand, I think. 00:36:07.119 --> 00:36:08.320 You need it, you need it, yeah. 00:36:08.320 --> 00:36:12.480 And so, I mean, yeah, I always tell our students never forget the patient comes first. 00:36:12.480 --> 00:36:14.719 It's really all about them. 00:36:14.719 --> 00:36:15.119 Yeah. 00:36:15.360 --> 00:36:15.920 I love that. 00:36:15.920 --> 00:36:17.679 Actually, that's a great game changer too. 00:36:17.679 --> 00:36:22.320 The patient comes first, and this is putting the patient at the heart of what we're trying to support them with. 00:36:22.719 --> 00:36:22.960 Yeah. 00:36:22.960 --> 00:36:28.320 So even just I our students will come in and they'll be like, okay, well, we're gonna, you know, adjust this medication today. 00:36:28.320 --> 00:36:30.880 And it's like, well, did they even do what we recommended last time? 00:36:30.880 --> 00:36:34.559 Like, let's go in there and see what they're doing and what they want to do today and like where they're at. 00:36:34.559 --> 00:36:36.000 Like, let's meet them where they're at. 00:36:36.000 --> 00:36:39.360 So figure out how we can work with them to make it happen. 00:36:39.360 --> 00:36:40.480 So yeah. 00:36:40.880 --> 00:36:41.360 Awesome. 00:36:41.360 --> 00:36:42.480 Thank you so much, Christy. 00:36:42.480 --> 00:36:43.280 This is a great discussion. 00:36:43.280 --> 00:36:45.119 Really appreciate your time and your expertise. 00:36:45.119 --> 00:36:48.400 Um, this was very enlightening, I know for me, and I'm sure our listeners agree. 00:36:48.400 --> 00:36:49.360 So thank you. 00:36:49.360 --> 00:36:50.880 Thank you for having me. 00:36:50.960 --> 00:36:52.559 It was great to be here today. 00:36:52.559 --> 00:36:54.719 And that's it for this week. 00:36:54.719 --> 00:36:59.039 Be sure to log in to Healthmart University to claim your CE credit for this episode. 00:36:59.039 --> 00:37:01.440 As always, have a great week and keep learning. 00:37:01.440 --> 00:37:02.559 We'll talk to you next week.