What is the best way to assess cardiometabolic health?

Assessing Cardiometabolic Health

The best way to assess cardiometabolic health is through measurement of BMI and waist circumference as primary screening tools, followed by evaluation of blood pressure, fasting lipid profile (total cholesterol, LDL-C, HDL-C, triglycerides), and fasting glucose, with subsequent 10-year cardiovascular risk calculation using validated risk scores. 1, 2

Primary Anthropometric Measurements

BMI and waist circumference should be measured in all adults as the foundation of cardiometabolic assessment. 1, 2

• BMI (calculated from height and weight) is the most studied and standardized approach for primary screening, requiring minimal training and providing good reproducibility 1
• Waist circumference should be measured in all patients with BMI <35 kg/m² to identify central adiposity that may be missed by BMI alone 1
• Measure waist circumference halfway between the last rib and iliac crest 1
• Thresholds indicating increased cardiometabolic risk: ≥102 cm (40 inches) in men and ≥88 cm (35 inches) in women 1
• The combination of BMI and waist circumference provides superior risk assessment compared to either measure alone 1

Essential Laboratory Parameters

Obtain fasting measurements of glucose and a complete lipid profile as core laboratory assessments. 1, 2, 3

Lipid Assessment

• Fasting lipid profile must include: total cholesterol, LDL-C, HDL-C, triglycerides, and apolipoprotein B 1
• These measurements identify dyslipidemia patterns characteristic of cardiometabolic risk 1, 3

Glucose Assessment

• Fasting glucose is essential for detecting prediabetes (impaired fasting glucose) and diabetes 1, 2, 3
• Consider 2-hour oral glucose tolerance test in patients with prediabetes for more comprehensive assessment 3

Blood Pressure

• Measure blood pressure at every clinical encounter 1, 2
• Elevated blood pressure (≥130/85 mmHg) is a core component of cardiometabolic risk 1

Cardiovascular Risk Stratification

Calculate 10-year atherosclerotic cardiovascular disease (ASCVD) risk using validated risk calculators after obtaining baseline measurements. 1, 2

• The 2019 ACC/AHA atherosclerotic cardiovascular disease risk score provides comprehensive patient-centered risk assessment 1
• Risk calculation determines treatment targets for lipid-lowering and other interventions 1, 3
• Patients at high risk (≥20% 10-year risk) require aggressive treatment regardless of metabolic syndrome presence 4

Metabolic Syndrome Identification

Screen for metabolic syndrome as a secondary assessment tool, particularly in patients at intermediate cardiovascular risk. 1, 3

The metabolic syndrome requires ≥3 of the following five components 1:

• Central obesity: waist circumference ≥102 cm in men, ≥88 cm in women
• Elevated triglycerides: ≥1.7 mmol/L (150 mg/dL)
• Low HDL cholesterol: <1.03 mmol/L (<40 mg/dL) in men, <1.29 mmol/L (<50 mg/dL) in women
• Elevated blood pressure: systolic ≥130 mmHg and/or diastolic ≥85 mmHg, or treatment for hypertension
• Impaired fasting glucose: ≥5.6 mmol/L (100 mg/dL) or previously diagnosed type 2 diabetes

The metabolic syndrome is most useful for identifying non-diabetic individuals at increased risk for developing diabetes and for reclassifying cardiovascular risk in those at intermediate risk. 1, 4

Additional Assessments for Comprehensive Evaluation

Clinical History

• Document family history of cardiovascular disease, diabetes, and obesity 1, 2
• Assess personal history of cardiovascular events, diabetes symptoms, and obesity duration 1
• Evaluate smoking status, physical activity patterns, and dietary habits 1, 2

Physical Examination Beyond Anthropometrics

• Perform cardiovascular examination searching for signs of heart failure and vascular disease 1
• Use appropriately sized blood pressure cuff in obese patients 1
• Consider electronic stethoscope in extremely obese patients to improve cardiac auscultation 1

Baseline ECG

• Obtain ECG to check for evidence of coronary heart disease and establish baseline for future comparisons 1

Monitoring Frequency

The frequency of reassessment depends on baseline risk factor presence and medication status. 1

• More frequent monitoring is required when initiating or adjusting cardiometabolic therapies 1
• Patients with identified risk factors require monitoring every 3-4 months initially 1
• Annual reassessment is appropriate for patients with stable, optimally controlled risk factors 2

Advanced Assessments (Not Routine)

While more sophisticated body composition methods exist (DEXA, MRI, CT, bioimpedance), there is insufficient evidence to justify their routine use in clinical practice 1

• DEXA may be considered for longitudinal assessment in specific populations: older adults with muscle loss, those undergoing bariatric surgery, or competitive athletes 1
• No longitudinal studies demonstrate that changes in body composition measured by advanced techniques improve prediction of clinical events beyond standard measurements 1

Critical Pitfalls to Avoid

• Do not rely solely on BMI in muscular individuals or those with normal BMI but excessive central adiposity 1
• Do not overlook waist circumference measurement, as it identifies central obesity missed by BMI alone 1
• Do not assess cardiovascular risk in isolation without considering the clustering of metabolic risk factors 1, 3
• Do not delay intervention until traditional risk factors cross diagnostic thresholds—earlier detection enables primordial prevention 5
• Do not ignore ethnic differences in risk thresholds, particularly for waist circumference and BMI interpretation 1