2022 AHA/ACC/HFSA Guideline for the Management of Heart ...

New Syndrome Identified That Links Heart Disease, Metabolic Disorders, And Kidney Disease

The American Heart Association has released a new advisory regarding a new type of condition related to heart, kidney and metabolic disorders.

Health experts are referring to this as cardiovascular-kidney-metabolic (CKM) syndrome.

The advisory includes updated approaches to screening, stages and treatment.

Heart disease has long been linked to other chronic conditions including diabetes and kidney disease. It is the top cause of death for both men and women in the U.S. And 1 in 3 adults have three or more risk factors that contribute to heart disease, metabolic disorders and kidney disease, according to the American Heart Association.

Now, officials from the American Heart Association (AHA) say in some cases, these connected conditions can be defined as a new syndrome called cardiovascular-kidney-metabolic syndrome or CKM.

Health experts have long noted connections between cardiovascular disease among obesity, type 2 diabetes, and chronic kidney disease.

AHA officials published the advisory in the journal Circulation to help redefine cardiovascular disease risk, prevention and management.

"The advisory addresses the connections among these conditions with a particular focus on identifying people at early stages of CKM syndrome," said Dr. Chiadi E. Ndumele, M.D., Ph.D., M.H.S., FAHA, co-author and an associate professor of medicine and director of obesity and cardiometabolic research in the division of cardiology at Johns Hopkins University in Baltimore said in a statement. "Screening for kidney and metabolic disease will help us start protective therapies earlier to most effectively prevent heart disease and best manage existing heart disease."

The AHA has released a presidential advisory in the hopes that healthcare providers can help people more effectively treat CKM.

The advisory includes information about the stages of the disease and potential causes.

The advisory includes:

The 4 stages of CKM syndrome starting from Stage 0 (no risk factors) to Stage 4 (multiple risk factors).

Screening for and addressing societal factors that could put people at increased risk.

Encouraging physicians across different specialties to work in tandem to help a patient with CKM.

Additionally, the AHA recommends physicians review the risk calculator for heart attack and stroke that can help predict who is most at risk for these cardiac events. They propose the new algorithm offer heart attack and stroke estimates at the 10 year and 30 year mark.

One reason the AHA is releasing this advisory is in the hopes that more people can get access to better treatment.

"This advisory is very timely and includes important changes to incorporate a new model where we think more about the risk factors," Dr. Dennis Bruemmer, doctor of cardiovascular medicine at the Cleveland Clinic, told Healthline. "The guidelines have shifted to a more preventative care approach which I think is important. It's steering away from being a reactive model system to a more proactive system where we look at individual risk factors and how to treat risk factors earlier which ultimately will prevent complex diseases."

Bruemmer was not part of the advisory committee.

When screening for and addressing social factors that impact health and CKM risk, physicians can consider issues such as economic stability, access to health care, and education level.

"These are very important for us to consider when we treat patients," said Bruemmer. "For example, when we encounter a patient who has diabetes, we have to put this into the overall context in the life of the patient – economics, insurance, environmental factors and so on. All of these social determinants affect the care that we provide."

Dr. Rohan Khera, Director of the Cardiovascular Data Science (CarDS) Lab at Yale School of Medicine explained that this advisory reflects the reality of clinical practice.

"Physicians have been aware that things don't live in isolation, and a lot of our cardiovascular risk factors can be concurrent with metabolic risk factors and kidney risk factors," said Khera. "So people who have cardiovascular disease frequently have metabolic challenges and chronic kidney disease."

Khera continued: "From our perspective, we've always recognized that those things tracked together, and therefore we needed to think about these patients in a more holistic fashion. But it's never been reflected in our clinical guidelines."

Khera agreed social factors play a major role.

"We've recognized over the past several decades that poverty, lack of access to education, health literacy – these social determinants of health that pervade diet and lifestyle decisions – can cause people to be at high risk compared to others of the same age and sex," Khera stated. "And we know that underrepresented racial and ethnic groups bear an excessive burden from these social determinants of health, which contributes to worse heart- and kidney-related outcomes."

Another main focus of the advisory is ensuring that physicians are in contact across specialties so a cardiologist will talk to nephrologist or a physician who specializes in kidney care. To help person with CKM multiple physicians may be needed including a primary care physician, cardiologist and endocrinologist, all bringing their expertise to the table.

"Collaborative care means that we recognize the importance of working within a system of specialists," Bruemmer stated. "Now, we have evidence from clinical studies that have studied collaborative care approaches and have seen that it is effective when doctors work together to manage these risk factors."

Looking at these diseases from a holistic perspective is crucial.

"It's predominantly about making sure there is collaboration across community health, primary care and specialty care providers," said Khera. "The theme I'm seeing emerge is that we need to think of these diseases, and their risk drivers, in a more holistic way. Redefining the way we think about disease management by taking social factors into account."

Understanding risk is important to develop an effective treatment plan for people with these conditions.

"When we sit with a patient in the office and talk about the future of their health, we don't have a crystal ball but we like to assess the risk," said Breummer. "If a person has a higher risk we can implement more aggressive preventive care strategies that will lower the future risk for heart attack, stroke, and diabetes. It is important to convey this to the patient because if they know their risk if higher they are likely going to be more motivated to change."

Khera explained patients should be asking whether they have features or markers that actually put them at a higher risk in the future.

"We've done a lot of assessments of risk factors over the years and over the last 5 to 8 years, we've seen a move toward more quantitative ways of describing risk," Khera stated. "Not just a particular risk factor, or saying you're high-risk or low-risk, but combining risk factors to compute someone's actual risk for developing a disease over the next five years. That information can help develop personalized lifestyle and treatment plans to manage that risk."

If you're concerned you have signs of heart, kidney or metabolic disease, you can talk to your physician about risk factors.

According to Breumer, top four indicators of health can include:

Their weight and body mass index (BMI)

Blood pressure level

Lipids (cholesterol)

Hemoglobin A1C (blood sugar levels)

Officials from the American Heart Association say that multiple chronic conditions can be defined as a new syndrome called cardiovascular-kidney-metabolic syndrome or CKM.

The advisory noted a connection between cardiovascular disease, obesity, Type 2 diabetes and chronic kidney disease, known as cardiovascular-kidney-metabolic (CKM) syndrome.

Revised recommendations for screening, stages and treatment are included.

Health experts confirm a collaborative model ensures optimal patient care.

Can Heart Failure Cause Swollen Feet?

Heart failure can cause swelling in the feet and other parts of the body, such as the abdomen. This may come and go, but often lasts for long periods.

Heart failure causes fluid retention in the body, and this can lead to several conditions, including edema. Edema refers to swelling as a result of excess fluid, and it can affect various parts of the body, including the ankles and feet.

As many conditions or circumstances, including pregnancy, can cause swelling in the feet, it is important to see a doctor rather than try to self-diagnose.

In this article, we describe the signs and symptoms of heart failure that a person might experience alongside swollen feet. We also provide information on treatment, when a person should contact a doctor, and the other possible causes of swollen feet.

Heart failure is when the heart has more difficulty pumping blood through the body, leading to fluid accumulation elsewhere in the body, especially in the feet and legs.

A person may experience the following issues:

feet suddenly looking larger or puffy

shoes are not fitting as well as usual

pain in their feet or legs

more difficulty walking

swelling elsewhere in their body, such as the abdomen

unexplained weight gain

Swelling in the feet and ankles may be less severe when a person first wakes and worsen as their day goes on.

Some other symptoms of heart failure that a person might notice include:

getting easily winded

finding exercise difficult

unexplained fatigue or weakness, even if a person is well-rested

pain in the right upper stomach, under the ribs

heart palpitations

difficulty breathing while lying flat

Heart failure is a life threatening medical condition that a person cannot treat with home remedies or lifestyle changes alone. Most people require the ongoing support of a cardiologist and some may need to take heart medication for the rest of their lives.

Lifestyle adjustments

For people living with heart failure, behavioral changes can make a significant difference in their quality of life. A person can adopt the following measures:

Reducing the amount of salt in the diet: High-sodium foods include prepackaged, fried, and processed foods, such as prepared meals and potato chips. The body needs some sodium to function, so it is important to not eliminate it from the diet. Instead, people should limit their sodium intake to less than 2,300 milligrams per day.

Increasing, or maintaining, physical activity levels, where possible: A doctor should be able to provide advice on how to create and stick to a healthy exercise routine. Exercise can help the heart function more efficiently, and it may also address other risk factors, such as excess body weight and high blood pressure.

Managing stress, where possible: People can practice stress management techniques, such as meditation, therapy, or journaling. People with heart failure may find that their symptoms get worse during emotional crises.

Alcohol and tobacco: People should avoid or quit smoking and limit or avoid their intake of alcohol.

Learn how to follow a heart-healthy diet here.

It is also important for a person to monitor their symptoms. A doctor may recommend at-home blood pressure monitoring or regular heart health checkups.

People can check their own blood pressure at home. Learn how to do this here.

Medical treatment

There is no cure for heart failure, but treatment can greatly prolong a person's life and reduce their symptoms. A doctor may recommend the following treatments:

Medication: A combination of medications can help, including beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and sodium-glucose cotransporter-2 (SGLT-2) Inhibitors, among others. The right drugs for a person will depend on their type of heart failure, lifestyle, and other medical conditions.

Implantable devices: Various devices can help the heart work better. A left ventricular assist device, for example, can help the left ventricle work better and reduce the overall effort of the heart. It can be a good option for a person who is waiting for a heart transplant.

Implantable cardioverter defibrillators (ICDs): A doctor may recommend an ICD in certain people with heart failure to reduce their risk of sudden cardiac death. It will not help the heart work better, however.

Heart transplant: Some people with heart failure, especially those with severe heart failure, who have a good chance of survival with treatment, may need a heart transplant.

Cardiac interventions and surgery: In some cases of heart failure, surgery may help. A cardiologist may perform various procedures, such as cardiac catheterization or coronary artery bypass surgery.

Fluid restrictions: In people with heart failure who retain fluid, a doctor may recommend restricting their fluid and salt intake. Sometimes doctors prescribe diuretics, or "water pills," to help a person get rid of excess fluid and help keep their fluids balanced.

People who notice unusual swelling in their feet should always call a doctor. A person should also speak with a doctor if they:

know they have heart failure and notice new or worsening swelling

have a high fever or feel shivery

have swelling on just one side of the body

have swelling in one or both feet or ankles for no obvious reason

experience painful, severe, and sudden swelling

have symptoms that are not responding to home treatment

have swelling along with other symptoms, such as difficulty breathing

develop painful or unpleasant side effects after they start taking a medication

suddenly gain weight for no apparent reason

have diabetes and their legs or ankles have swollen

have a swollen area that is red and feels hot to the touch

Numerous other conditions can cause swelling in the feet, including:

Pregnancy: Swollen feet during pregnancy are very common due to increased blood volume.

Blood clots: A blood clot in the veins of the leg may cause swelling in one foot.

Organ failure: Problems with other organs, such as the liver or kidneys, may cause swelling. Organ failure may also eventually affect the heart.

Long periods of standing or sitting: Long periods of physical activity or standing may cause swelling that goes down when a person rests. Likewise, sitting for long periods, such as when flying, can also cause swelling that improves with movement. Sometimes, this swelling is worse in the heat. Instead of standing, sitting with the feet raised or walking around can help.

Injuries: Injuries to the feet or legs can cause inflammation and swelling. In most cases, the swelling will be in just one foot.

Venous insufficiency: In this condition, the veins in the legs do not function properly, potentially leading to a buildup of blood in the feet.

Lymphedema: Lymphedema occurs when damage to the lymph system leads to the accumulation of fluids.

Infection: Cellulitis, a skin and soft tissue infection, can affect the feet and cause swelling.

Learn whether certain causes of swelling are serious here.

The following images show how swollen feet can look due to heart failure and other causes.

Here are some questions people often ask about swollen feet and heart failure.

How do you get rid of swollen feet from heart failure?

It is essential to follow the treatment plan for heart failure to help manage symptoms. A doctor may also recommend diuretics to help eliminate some fluid from the body. Other tips include raising the feet when sitting, minimizing salt intake, avoiding tight footwear, getting some gentle exercise, and speaking with a doctor about how much water to drink.

At what stage of heart failure does edema happen?

Swollen feet can happen at any stage of heart failure, but worsening edema may mean that heart failure is becoming more severe.

Do swollen feet mean heart failure?

Swollen feet can be a sign of heart failure. When the heart is unable to pump blood around the body effectively, it pools in the lower extremities. However, swelling in the feet can happen for many reasons, such as kidney failure, lymphedema, a blood clot, an injury, or an infection, such as cellulitis.

When should I worry about swollen feet?

People should see a doctor if there is new or persistent swelling, or if their symptoms are severe. They should also seek medical help if they have a fever or other symptoms or if the swollen area feels red or hot to the touch.

Swollen feet do not always mean that a person has a serious medical condition. However, it can be an important early warning sign of heart disease or other health issues, particularly if it persists, recurs, or occurs alongside other symptoms.

Anyone with any concerns about swollen feet or other symptoms of heart failure should speak with a doctor as soon as possible.

Read this article in Spanish.

Living With Arrhythmia: Tips For Managing Your Heart Rhythm Disorder

SOURCES:

National Heart, Lung, and Blood Institute: "Arrhythmia," "Who Needs an Implantable Cardioverter Defibrillator?" "How Does an ICD Work?" "How Will an Implantable Cardioverter Defibrillator Affect My Lifestyle?" "Living with an Arrhythmia."

American Academy of Family Physicians: "Arrhythmia."

Cleveland Clinic: "Arrhythmia," "Dos and Don'ts: Life with an ICD," "Don't Let Heart Disease Derail Your Travel Plans," "Biventricular Pacemaker," "Pulmonary Vein Isolation," "Physical Examination," "Dysrhythmia."

Harvard Health Publishing: "Cardiac Arrhythmias," "What is a normal heart rate?" "Antidepressants and arrhythmias."

American Heart Association: "Arrhythmia," "Holter Monitor," "Electrocardiogram (ECG or EKG)," "FAQs About Atrial Fibrillation," "Prevention and Treatment of Arrhythmia," "FAQs of Atrial Fibrillation (AFib or AF)," "About Arrhythmia," "Warning Signs of a Heart Attack," "Living with Your Implantable Cardioverter Defibrillator," "Electrophysiology Studies (EPS)."

Merck Manual Consumer Version: "Sinus Node Dysfunction."

Johns Hopkins University: "Holter Monitor."

NIH: "Who Needs a Holter or Event Monitor?"

Zimetbaum, P. Circulation, Oct. 19, 2010.

University of Michigan Frankel Cardiovascular Center: "Frequently Asked Questions: Implantable Cardiac Defibrillator (ICD)."

Texas Heart Institute: "Implantable Cardioverter Defibrillator (ICD)."

International Society for Sexual Medicine: "Can a Person with an Implantable Cardioverter Defibrillator (ICD) Have Sex Regularly?" "How Might an Implantable Cardioverter Defibrillator (ICD) Affect a Person's Sex Life?"

Transportation Security Administration: "TSA Travel Tips Tuesday: Traveling With Personal Medical Electronic Devices."

Up-to-Date: "Patient education: Implantable cardioverter-defibrillators (Beyond the Basics)."

European Heart Journal: "Driving and arrhythmia: a review of scientific basis for international guidelines."

Maine Department of Motor Vehicles: "Cardiovascular Disorders."

American College of Cardiology: "When Is It Safe to Resume Driving After ICD Implantation."

National Highway Traffic Safety Administration: "Physician's Guide to Assessing and Counseling Older Drivers."

The BMJ: "Driving and arrhythmias."

Mayo Clinic: "Brugada syndrome," "Heart arrhythmia," "Mitral valve repair and mitral valve replacement," "​​Coronary artery bypass surgery," "​​What's a normal resting heart rate?" 

NHS Choices: "Brugada syndrome."

U.S. National Library of Medicine: "Brugada syndrome."

American Academy of Family Physicians: "High Blood Pressure Medicines."

Edward-Elmhurst Health: "Know the symptoms of arrhythmia and when to worry."

Marshfield Clinic Health System: "HEART ARRHYTHMIA."

Medanta: "Heart Palpitations: 10 Reasons That Causes This Heart Ailment."

Mount Sinai: "Atrial fibrillation or flutter."

NYU Langone Health: "Lifestyle Changes for Atrial Fibrillation & Atrial Flutter."

Penn Medicine: "Surgical Treatment of Arrhythmias."

---