Chapters Transcript Video Management of the Cardiometabolic Patient Back to Symposium Haney, she's one of our general cardiology physician assistant. It's always a pleasure to work with Kristen, and she's gonna give us a nice talk on the management of the cardio metabolic patient, uh, from a cardiology perspective. All right. So, yes, I'm Kristen McElhaney. I'm the general cardiology APP team coordinator for Center of Cardiology. Um, and today we'll talk a little bit about management of the cardio metabolic patient. We'll probably tie together a little bit of what we've heard already, might expand upon that, and I have, uh, no conflict of interest disclosures for y'all today. So the objectives for today, we'll quickly review the prevalence and definition of cardometabolic disease and CKM syndrome. You may be hearing more often now, um, including global and US specific data. We'll go over a little bit of pharmacotherapy and identifying strategy strategies for treating. Um, each risk factor and the downstream consequences, um, and focus at the end a little bit more on how to pull together our practices and, um, focus on a multidisciplinary approach to management of cardio metabolic disease. So cardio metabolic disease is, uh, it is estimated that more than half of the world population over the age of 5 is projected to be overweight or obese by 2035. So in the next nine years. In the US alone, it's projected that 58% of adults will be classified as obese with a BMI greater than 30 as of 2035. For the CDC, heart disease remains the leading cause of death in the United States, and about 1 in 20 adults, uh, over the age of 20 are diagnosed with CID, so about 5%. So while that sinks in a bit, um, we'll kind of focus more on what is cardio metabolic disease or cardiovascular kidney metabolic syndrome, CKM. Um, it's not a single condition. CKM is a group of interrelated risk factors that together dramatically amplify your patient's risk of or or likelihood of severe, serious cardiovascular events. Those risk factors can include hypertension, uh, insulin resistance, CKD, hyperlipidemia, and obesity. And when you combine those risk factors, you have a substantially greater risk than if each of those risk factors exist in isolation. Um, the associated outcomes of these risks tend to lead to more heart attack and stroke, diabetes, CKD progression, and so forth. Despite this grand interconnected pathophysiology, these conditions, um, current clinical practice often addresses each disease in isolation, treating the downstream consequence rather than the root causes driving the syndrome. What if we change that up a bit? So the, uh, biggest takeaways today are going to be focusing on addressing obesity through multiple modalities, using cardoprotective glucose lowering therapies, targeting blood pressure control, using kidney protective agents, uh, to prevent kidney and CBD events, and lipid lowering therapies, uh, according to CBD risk. Um, risk factor modification, uh, as Doctor Ver noted, um, The goals, um, specific goals should be specific to each of your patients. You want to individualize your treatments for your specific patient types. Um, for hypertension, we should all be aiming, uh, ideally less than. 130 or 120, um, systolic, um, individualizing based on comorbidities, frailty and tolerability. That individualization may include patients that have had orthostatic issues in the past who might not be as aggressive, um, their age and so forth. In patients with diabetes, we'll prioritize ACE and ARB. Um, for additive renal protection. Um, and in lipid management, we'll consider potentially even lower goals than historic, um, than we did historically. Um, often you'll see many of our notes, I'm guilty of this still saying aim for an LDL less than 70, um, with a patient with a history of CAD. More times than not, um, we should be probably pushing our patients even lower to a goal of less than 55, especially if they have a history of bypass or multiple stents. Um, so for those patients, I would recommend optimizing or maximizing their maximum tolerated statin therapy, and then considering addition of other agents such as Zetia, PSK9 inhibitors, etc. Um, I'll focus more on this talk and it's, sorry, it's blocked off a little bit by the image at the bottom, but there are 3 classes of medications that, um, can also help with kidney and heart protection. So SGLT2 inhibitors, MRAs, and GLP-1RAs. Um, I've put up a, a slew of studies here to support this background, um, but some of them have become more commonplace, um, Than others. So SGLT2 inhibitors, I think have been very well accepted, at least amongst our group. Um, many of our patients, uh, it's almost a knee-jerk reaction. You don't even have to think about it. Let's add, uh, Farxiga or Jardiance, uh, basically whichever one their insurance covers best. Um, MRAs, I think, um, Um, it's still emerging a bit in terms of, um, it's stressed importance, but it does help, these studies show that, uh, planone, spironolactone, and phenarinone, um, can also help reduce your risk of, um, cardiovascular death, heart failure, hospitalization, uh, readmission rates, and so forth. And then GLP-1 RAs, I'll get too much more, but also have some kidney and heart protection as well. Um, so obesity and glycemic management, historically, this has been a massive gap in manage in, in, in care for our patients. Um, obesity is not simply a comorbidity. It plays a central role central role in CKM syndrome and often amplifies your other risk factors like hypertension, hyperlipidemia, insulin resistance, and inflammation. Um, historically, it's so easy to tell your patient, change your diet, change your lifestyle. We see our patients once a year if we're lucky. Um, if we're lucky, maybe twice in primary care, you prob you probably see them a bit more. Um, but access is a big problem and We really can't change people's lifestyle and diet in one single sentence. I threw it out there, I charted it, I said it. That's not enough. Um, so historically, there's really been a lack in following through and caring for our patients in this aspect. Um, there's also historically been a lack of effective, tolerable pharmacotherapy. Um, and a significant stigma around treating obesity and talking about obesity with our patients. Um, but that's changing. I, I truly believe that the emergence of GLP ones, as controversial as they can be sometimes, um, it is, is really changing our, our management of patients, um, and we're seeing a lot more benefits than we ever expected. So how do GLP ones work? GLP-1 RAs exert their effects through appetite suppression, delayed gastric emptying, insulin sensitization and secretion, and glucagon inhibition. Um, there are a slew of GLP ones out there. Um, however, I'm going to focus mostly on those who have, uh, indications for cardiovascular benefit. Uh, Victoza, Ozempic, and Trulicity have shown to have a reduction in MACE in patients with diabetes. MACE. is defined as a reduction in cardiac events, non-fatal MI, and typically tends to be one of the primary endpoints of most studies. Um, WeOV reduces the risk of major cardiovascular events in obese or overweight individuals with preexisting CVD regardless of their diabetes status. And this was part of the select trial. Um, and then you'll also see that there's this slide may be somewhat outdated, but there's ongoing studies surrounding GLP1s in general, um, trying to figure out which other drugs may still have a role in reducing cardio or reducing the risk of long-term cardiovascular disease. Um, and I made a note to the side there, um, trazepetide or Zbound, sorry, also has an approved, uh, indication for the management of moderate to severe sleep apnea. So, the select trial, um, the select trial was very important in showing that patients with overweight or obesity, who are overweight or obese, um, with established CBD but without diabetes, once weekly semaglutide was associated with a 20% decreased risk of MCE, um, a 28% reduction in heart attacks, and a 19% reduction in all-cause mortality. Um, so those are huge, huge, very, uh, changes. And I think my favorite takeaway from this was also that patients did not necessarily have to see dramatic weight loss to have these benefits. So, When I'm talking to patients, um, who may be a little bit frustrated in starting their first doses of GLP ones, I really emphasize to them that while it may take time to reach their weight goals, if that's one of their goals, which it often is, um, they're still receiving a large benefit long term in their health, um, with the use of these medications. Um, so types of GLP-1 medications, I'll go through very quickly. Um, but just like, I'd, I'd love for everyone to leave this talk kind of being more comfortable with the, the million different names, uh, of each drug and kind of the different indications of you. For each. Um, Ozempic, um, branded semaglutide is indicated for type 2 diabetes and is available in weekly injections. Um, and also, uh, previously, or sorry, previously Ribelsis available as an oral tablet. Um, WeOV indicated for chronic weight management and reducing cardiovascular risk, um, in patients with established CBD. Um, is available in weekly injections and is now even available in new high dose dosing for your patients that may not have reached their goals, um, on the standard titration. Um, and it's also now, uh, recently available as well as an oral tablet. So if you have patients that have been hesitant in the past to injections, um, it's now available oral and can the only kind of caveat is that it should be taken with a sip of water, uh, sorry, 30 minutes with a sip prior to any food or drink in the morning with a sip of water. Um, trazepatide comes branded as Manjaro or Z-bound. Manjaro is indicated for diabetes and also available in weekly injections. Zep-bound is indicated for chronic weight management, overweight or, sorry, obese or overweight patients with at least At least one comorbid weight-related condition, hypertension, hyperlipidemia, uh, and so forth. Um, it comes in weekly injections and, uh, an oral variant of it is also available now called Foundo, um, and it does not matter whether taken with or it can be taken with or without food. Um, so what are the other benefits besides just weight management and glycemic control? Um, we, there are a lot of investigational areas, um, that we're diving into and I hope continue to grow. Um, there's some emerging evidence that GLP ones are helping reduce the risk of Uh, peripheral vascular disease, addiction-related behaviors, type one diabetes, neurodegenerative disorders, and metabolic liver disease. And that's in addition to what we've already seen in the reduction of mace, reducing heart failure, um, with preserved EF, CKD progression, and CB death. Um, and in addition to that, um, there are some supportive endpoints of the select trial that showed that GLP ones, um, specifically, um, semaglutide showed a correlation and reduction. Of measures like on your lipid profile, um, blood pressure, A1C, and waist circumference, which we often use waist circumference as a measure of, uh, the amount of visceral fat mass or kind of risk to correlate with CBD. So what is Centeria Cardiology doing? This is the, this is kind of why I agreed to this talk. I'm, I'm excited about these things. Um, Centeria Cardiology recently in October began a cardio metabolic clinic out of our Princess Anne office. Um, and this is specifically for our, um, CAD patients within Center cardiology, and it's focusing on initiating appropriate GLP-1 therapy. We saw that gap in care that patients were consistently asking us as cardiologists to help them get their hands on the medications, saying that, um, either their primary care at least wanted our input or our blessing, or even their insurance companies were requiring cardiology input for these things. All of those rules with the insurance companies are constantly changing and we're only trying to keep up, but, um, I think this is a huge hole in that gap of care that we're trying to fill. Um. If you're older already, like, how do I get my patient enrolled in this? It's currently still, uh, only available to Centeria cardiology patients. However, if your patient is established with us, I would just encourage you to basket message or reach out to. Their doctor or their cardiologist or the APP on their care team message them, say, um, you know, I'm either not very comfortable with this or want your input and urge them to maybe consider referring. They would then place the order, uh, for referral to cardio metabolic clinic, uh, with Epic, and these qualifiers on the right are an example of what they would see. So the questions for our clinic specifically are, do they have a history of CAD? That's the group that we're focusing on most, mostly just because that's the access. Those are our highest risk patients we're trying to address first. If we could expand this to everyone, we'd love to. Um, does the patient have a BMI greater than an equal to 27? Um, are you a Centeria cardiology provider, um, and is the patient established with Centeria Cardiology? Is your patient on insulin and are they on dialysis? And those questions are important because we're definitely understanding that our, our, Forte is cardiology. So we don't really want to step on anybody's toes or guide a patient into incorrect management. So we're certainly going to delay or, or sorry, defer certain patients to endocrine, um, to Centerra Weight Loss Center, and so forth, um, if that may be more appropriate. Um, Sydney and Jacqueline are our two APPs who have been running the clinic thus far. They've kind of rotated coverage as Sydney was on maternity leave earlier this year, and I've been very much in the background supporting them, um, working with our industry reps, trying to make sure we're tracking specific metrics, um, and really making sure, uh, the word gets out to our cardiologists and you all. Um, I think our Long-term plan with this is to reach as many patients as possible, but also just get our group and other providers more comfortable doing this on their own. Um, this clinic can't manage everybody. It's not even hoping to do that. I think if we just treat these drugs as, as we have treated others in the past that have kind of emerged and found more and more indications for, we help the hard process of insurance coverage. Um, in the patients that others may have struggled with. And we have a little bit more time for the patients that might need a little bit more one on one coaching for these medications. So what would your patient expect during their first visit? They'll get that comprehensive history. Um, they'll go over weight history, exercise habits, diet, possible contraindications. We'll get baseline measurements that we try to track as metrics, weight, BMI, lipids, waist circumference, A1C. Um, and we'll go over, uh, minimally nutrition counseling, but also offer to them whether we can refer to a nutritionist, um, go over pen injection demonstrations, and then the appropriate referrals that may be needed. If a BMI is greater than 40 and we think that the patient may be better off, um, long term seeing the Centera Weight Loss Center, uh, we may go ahead and start them on the GLP-1 therapies, but also refer as they may be surgical subspecialties and other things. Um, Um, we'll consider whether sleep studies are indicated, and we'll settle, set up follow-up plans. So, um, we have an amazing nurse, Nick, and he has been helping us do monthly nurse phone visits with these patients. He collects, you know, their weight, how they're feeling, um, and then gives that information to myself, Sydney, or Jacqueline, and we'll titrate the medications appropriately. And then they're arranged for a three-month follow-up and longer if needed, if still titrating. Um, I wanted to share this. This is totally just extra information, um, but if you are hearing all this and thinking to yourself, you know, maybe I should start writing these meds myself, um, there is a little tool in Epic that anyone can steal. It's under my name, Kristen McElhaney, um, and it's an Epic smart phrase called Rex Cardi Metabolic clinic. Um, this is essentially part of our template to every note that we write. It has guidance on the measurements you should take. the tools that will help you get, um, your patients approved long term on these medications. The renewals make it easier on you. It also helps you each time they come in to be able to say, hey, look, you started it this way and now you're here, um, or your A1C has gone from this to this, your LDL has improved here, um, and it has all the poss or or I shouldn't say all, but many of the possible contraindications listed there so you can quickly get yourself comfortable with going through this with each patient. Um, and in summary, um, CK CKM is a syndrome. It's not a single disease. Um, we do need to treat each risk factor in isolation, but think about those long string long-term effects of each combined together. And I think that the best things to take away from this are that there are many new cardio and kidney protective medications that are emerging that we should be focusing on. Many of them will help reduce the risks and lower often numbers of hypertension, hyperlipidemia, um, and other risk factors with the weight loss that they provide. And this needs to be a, a team-based approach. So primary care, cardiology, nephrology, dietitians, um, pharmacists all need to be working together to really, um, make sure we fill in the gaps for care. All right. Thank you so much. Published June 30, 2026 Created by Related Presenters Kristen K. McElhaney, PAC Cardiology View full profile
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