First-Ever Guideline on Cardio-Kidney-Metabolic Syndrome Calls for Earlier Screening, Coordinated Care

A landmark joint guideline published in both Circulation and the Journal of the American College of Cardiology establishes the first-ever evidence-based framework for the prevention, detection, evaluation, and management of cardiovascular-kidney-metabolic (CKM) syndrome—a complex, interrelated condition defined by the interconnections among metabolic risk factors, including obesity and type 2 diabetes (T2D), chronic kidney disease (CKD), and cardiovascular disease (CVD).¹

The 2026 AHA/ACC/ADA/ASN guideline, developed in collaboration with the American Diabetes Association and the American Society of Nephrology, retires and replaces the 2013 guideline on the management of overweight and obesity in adults, substantially broadening the scope of clinical guidance for clinicians across disciplines.¹

“From a pharmacist’s perspective, this guideline reinforces that obesity, kidney disease, diabetes, and cardiovascular risk should no longer be managed as separate problems,” Dave L. Dixon, PharmD, BCACP, CLS, FACC, FAHA, FCCP, FNLA, the Nancy and Ronald McFarlane Professor of Pharmacy at the Virginia Commonwealth University College of Pharmacy and co-author on the new guidelines, told Pharmacy Times. “The message is to move beyond treating obesity, diabetes, kidney disease, and cardiovascular risk as separate medication decisions and instead build a coordinated treatment plan that lowers risk across the whole CKM spectrum.”

Four-Stage Framework and Risk Assessment

Central to the guideline is a 4-stage CKM syndrome classification system designed to reflect the progressive pathophysiology and escalating cardiovascular risk along the spectrum of the condition. Stage 0 represents patients with no CKM risk factors, whereas stage 4 denotes established CVD in the context of metabolic or kidney disease. Stage 2, for example, describes patients with metabolic risk factors or CKD, including those with type 2 diabetes, hypertension, hypertriglyceridemia, metabolic syndrome, or CKD of metabolic or nonmetabolic etiology. The frequency and intensity of recommended screening increases with each stage, giving clinicians a scalable, practical tool for triage and management.^1,2

For risk prediction, the guideline endorses newly developed PREVENT equations, tools that estimate 10-year and 30-year CVD risk while incorporating kidney and metabolic health factors for a more comprehensive assessment than prior instruments. The writing committee noted that screening for social drivers of health—including food insecurity, housing instability, and financial strain—is also recommended at every stage of care, reflecting growing recognition that adverse social determinants disproportionately burden patients with CKM syndrome.^1,3

“Pharmacists play a central role in facilitating interdisciplinary CKM care, with several unique skills, including comprehensive medical management, being critical to providing optimal care for patients with CKM syndrome,” Chiadi E. Ndumele, MD, PhD, MHS, FAHA, chair of the guideline writing committee and the director of obesity and cardiometabolic research at Johns Hopkins School of Medicine in Baltimore, said in an interview with Pharmacy Times.

Lifestyle, Medications, and Surgical Therapies

The guideline outlines a comprehensive treatment spectrum that begins with lifestyle modification and escalates to pharmacologic and surgical interventions based on CKM stage and individual risk profiles. Reinforcement of healthy behaviors—including physical activity, evidence-based nutrition, weight management, blood pressure control, and optimization of blood glucose and cholesterol levels—forms the foundation of management at all stages. Authors emphasized that early action on these modifiable risk factors can meaningfully alter long-term cardiovascular trajectories.¹

In a significant development for medication management, the guideline formally recommends glucagon-like peptide-1 (GLP-1) receptor agonist-based therapies for select patients with obesity and/or type 2 diabetes who have additional cardiovascular risk factors—marking the first time this drug class has been incorporated into a major CKM-specific guidance document. The guideline also recommends concurrent use of estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR) to characterize CKD and guide the use of kidney-protective agents for both cardiovascular and renal benefits. Additional pharmacologic options for managing blood pressure, lipids, blood glucose, and weight are addressed with stage-specific recommendations, and metabolic and bariatric surgery are acknowledged as therapeutic options in appropriate patients.¹

“Pharmacists can be natural CKM coordination point people because so much of this framework depends on selecting, sequencing, monitoring, and helping patients stay on evidence-based therapies,” Dixon noted, citing numerous responsibilities of pharmacists such as “monitoring kidney function…tolerability, drug interactions, and accessibility and affordability.”

Interdisciplinary Care and Implementation

A defining feature of the new guideline is its call to move beyond subspecialty silos toward coordinated, patient-centered, interdisciplinary care models. To support this, the writing committee recommends designating a CKM coordination point person within care teams to facilitate adherence to guideline recommendations and support continuity across cardiology, nephrology, endocrinology, and primary care settings. Pharmacists—given their expertise in medication management, chronic disease monitoring, and patient counseling—are well positioned to serve in or alongside this coordination role, particularly in outpatient and ambulatory settings.¹

The guideline authors also identified important implementation challenges and knowledge gaps requiring future attention. Unanswered questions persist regarding optimal treatment strategies for patients with heart failure and CKD and those with advanced kidney disease. The authors called for re-examination of educational training, automated technology infrastructure, billing and reimbursement policies, and communication frameworks to ensure guideline recommendations can be operationalized across diverse clinical and geographic settings.¹

“[This is] a tremendous opportunity,” Dixon explained. “Pharmacists are well suited for this role, and I believe [they] can make a real difference in the successful implementation of the guideline.”

REFERENCES

1. Ndumele CE, Rodriguez F, Dixon DL, et al. 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. Published online June 9, 2026. doi:10.1161/CIR.0000000000001453

2. Ndumele CE, Rangaswami J, Chow SL, et al. Cardiovascular-kidney-metabolic health: a presidential advisory from the American Heart Association. Circulation. 2023;148(20):1606–1635. doi:10.1161/CIR.0000000000001184

3. Morris AA, Masoudi FA, Abdullah AR, et al. 2024 ACC/AHA key data elements and definitions for social determinants of health in cardiology. Circ Pop Health Outcomes. 2024;17(10):e000133. doi:10.1161/HCQ.0000000000000133