Cardiometabolic-Based Chronic Disease, Addressing Knowledge and Clinical Practice Gaps: JACC State-of-the-Art Review

Abstract

In the second part of this JACC State-of-the-Art Review, an early and sustainable preventive care plan is described for cardiometabolic-based chronic disease. This plan can improve cardiometabolic health by targeting early mechanistic events to decrease the risk for certain cardiovascular diseases (e.g., coronary heart disease, heart failure, and atrial fibrillation). Included are various prevention modalities, intensive lifestyle interventions, pharmacotherapy and cardiovascular outcome trial evidence, and bariatric/metabolic procedures. A tactical approach of implementing published clinical practice guidelines/algorithms for early behavioral, adiposity, and dysglycemia targeting is emphasized, as well as relevant educational and research implications.

Keywords: adipokines; adiposity; atherosclerosis; atrial fibrillation; cardiometabolic; cardiomyopathy; cardiovascular; chronic disease; dysglycemia; health; insulin; obesity; resistance; type 2 diabetes.

FIGURE 1. The Adiposity-, Dysglycemia-, and Cardiometabolic-Based Chronic Disease Models

Four distinct chronic disease stages are based on a logical clustering of pathophysiological events for ABCD, DBCD, and CMBCD models. Shaded areas and arrows indicate main causal relationships: abnormal adiposity to insulin resistance to dysglycemia to cardiovascular disease. Asterisks indicate exertions of other metabolic syndrome traits. ABCD = adiposity-based chronic disease; AF = atrial fibrillation; CHD = coronary heart disease; CMBCD = cardiometabolic-based chronic disease; DBCD = dysglycemia-based chronic disease; HF = heart failure; LA = left atrial; LV = left ventricular.

CENTRAL ILLUSTRATION. Cardiometabolic Prevention Care Plan

The 4 stages of cardiometabolic-based chronic disease (CMBCD) are depicted at the top. In CMBCD stage I (first column), adiposity, dysglycemia, and other metabolic drivers act concurrently and independently to produce cardiovascular disease. For cardiovascular pre-disease (bottom row, second column), subclinical coronary heart disease is suspected by interrogating 3 vascular beds: increased coronary calcium score, 3-dimensional carotid ultrasound, and ankle-brachial index; left ventricular dysfunction by echocardiography; and left atrial abnormality by electrocardiogram and echocardiogram. Stages are currently defined by artificial boundaries, determined by thresholds of detectability, and positioned along a continuum. Blue arrows indicate complex causal relationships among drivers and stages. Insulin resistance (red) occupies a critical integrating pathophysiological role. Preventive care modalities are depicted in the bottom purple panel and represented by the most current evidence-based clinical practice guidelines and clinical practice algorithm applicable for the specific CMBCD stage and targets. Dotted lines are demarcations between stages in column headings. AF = atrial fibrillation; CHD = coronary heart disease; CI = confidence interval; CMBCD = cardiometabolic-based chronic disease; CPA = clinical practice algorithm; CPG = clinical practice guidelines; HF = heart failure; LA = left atrial; LV = left ventricular; wc = waist circumference.