Cardiovascular–Kidney–Metabolic Syndrome Stages, Echocardiographic Characteristics, and Heart Failure Risk: The Atherosclerosis Risk in Communities Study

BACKGROUND: Suboptimal cardiovascular–kidney–metabolic (CKM) health is highly prevalent in the United States, especially among older adults, but whether the CKM syndrome staging framework is predictive of incident heart failure (HF) in this population remains uncertain. METHODS: Participants from the ARIC Study (Atherosclerosis Risk in Communities; visit 5, 2011–2013) who underwent echocardiography were categorized according to the American Heart Association CKM syndrome staging framework, which is based on excess or dysfunctional adiposity, metabolic risk factors, kidney disease, subclinical cardiovascular disease (CVD), and clinical CVD. We evaluated the association between CKM stage and prevalence and progression of cardiac remodeling and longitudinal risk of incident HF. RESULTS: Of the 5646 participants who had data available for CKM staging (age range, 66 to 90 years; 3271 women [57.9%]), 24 (0.4%) were stage 0 (optimal CKM health), 104 (1.8%) stage 1, 460 (8.1%) stage 2, 3197 (56.0%) stage 3, 1842 (32.3%) stage 4a, and 19 (0.3%) stage 4b. Higher CKM stage was incrementally associated with adverse left ventricular remodeling, worse left ventricular systolic and diastolic function, and greater progression of adverse remodeling by visit 7 (2018–2019). Among participants without prevalent HF at visit 5 (n=4827), the risk of incident HF during follow-up (656 events; median follow-up time, 9.0 years) increased with higher CKM syndrome stage: stage 0/1, 0 events per 1000 person-years; stage 2, 2.9 events/1000 person-years (referent due to no events in stage 0/1); stage 3, 15.1 events/1000 person-years (adjusted hazard ratio, 3.6 [95% CI, 2.1–6.0]); stage 4, 37.4 events/1000 person-years (adjusted hazard ratio, 8.3 [95% CI, 4.9–14.2]; P trend <0.001). CONCLUSIONS: Poor CKM health was widespread among community-dwelling older adults, with higher CKM stage associated with adverse myocardial remodeling and increased risk of incident HF.