What is the recommended management?

Management of Cardiorenal and Metabolic Diseases

The management of cardiorenal and metabolic diseases requires a comprehensive approach prioritizing lifestyle interventions as the foundation, followed by patient education and self-management, with pharmacological therapy tailored to specific risk factors and comorbidities. 1

Lifestyle Interventions (First-Line Foundation)

Lifestyle modifications form the cornerstone of management and should be implemented immediately for all patients with cardiorenal and metabolic diseases. 1

Physical Activity

• Recommend at least 150–300 minutes per week of moderate-intensity aerobic activity or 75–150 minutes per week of vigorous-intensity activity, combined with resistance training. 1, 2
• Emphasize reduction in sedentary time and engagement in at least light activity throughout the day. 1
• Any amount of physical activity provides benefit, so encourage patients who cannot meet targets to start with what they can achieve. 2

Sleep Optimization

• Ensure adequate sleep of 7–9 hours nightly to decrease insulin resistance, reduce inflammatory cytokines, and improve cardiovascular risk. 1, 2
• Screen for and treat sleep-related breathing disorders, as they worsen hypertension, hyperglycemia, and dyslipidemia. 1, 2
• Avoid pharmacotherapy for obstructive sleep apnea, as it is generally ineffective and can cause serious adverse effects. 1

Smoking Cessation

• Smoking cessation is the single most important component of lifestyle therapy. 1
• Provide clinician encouragement at every visit, as this is cited as a frequent motivator to quit. 1
• Use pharmacological support (nicotine-replacement therapy, bupropion, or varenicline) in all smokers ready to quit. 1
• Discourage e-cigarettes, as they are not harm-free and cause negative changes in vascular endothelial function. 1

Alcohol Limitation

• Limit alcohol consumption to ≤1 drink per day for women and ≤2 drinks per day for men (12 oz beer, 5 oz wine, or 1.5 oz distilled spirits). 1, 2
• Excess alcohol contributes to weight gain, hypertension, cardiomyopathy, atrial fibrillation, peripheral neuropathy, fatty liver, and dementia. 1

Dietary Modifications

• Recommend a Mediterranean diet high in vegetables, fruit, and wholegrains. 1
• Limit saturated fat to <10% of total calorie intake. 1
• Reduce sodium intake to manage blood pressure. 1

Weight Management

• Target and maintain a healthy weight with BMI 18.5–25 kg/m² and waist circumference ≤88 cm (35 inches) for women and ≤102 cm (40 inches) for men. 1
• Achieve weight reduction through recommended energy intake, increased physical activity, and consider pharmacological or surgical interventions in selected patients. 1

Patient Education and Self-Management (Essential Component)

All individuals with cardiorenal or metabolic diseases must receive structured patient education at every clinic visit to empower self-management. 1, 2

Core Educational Elements

• Teach patients to recognize their conditions as chronic diseases requiring lifelong management. 1, 2
• Educate on vascular complications, risk factor monitoring (BP, glucose, lipids, eGFR, UACR), and expected examinations for eyes, kidneys, heart, liver, feet, and hearing. 1
• Emphasize "Know Your Numbers": BMI, A1C, time in range (TIR), fasting plasma glucose (FPG), BP, LDL-C, ApoB, triglycerides, HDL-C, non-HDL-C, FIB-4, eGFR, and UACR. 1, 2

Target Values to Communicate

• BMI: Normal 18–25; risky ≥30 1
• BP: Normal <120/80 mmHg; risky >140/90 mmHg 1
• LDL-C: Normal <100 mg/dL; risky >55,70, or 100 mg/dL depending on risk category 1
• A1C: Normal <5.7%; risky >6.5% or 7% 1
• FPG: Target 70–140 mg/dL 1

Shared Decision-Making Approach

• Elicit patient priorities and emphasize early and aggressive treatment. 1, 2
• Ask open-ended questions and encourage belief that patients can control health outcomes. 1
• Do provide education at every clinic visit; don't try to cover all topics at once. 1
• Repeat and reinforce key messages without being judgmental. 1
• Evaluate health literacy and account for socioeconomic factors and social determinants of health. 1, 2

Risk Factor Monitoring and Assessment

Regular monitoring of key health parameters is essential to identify complications early and guide treatment adjustments. 2

Essential Monitoring Parameters

• Monitor BMI, waist circumference, BP, lipid profiles (LDL-C, HDL-C, triglycerides, non-HDL-C), glucose levels (A1C, FPG, TIR), eGFR, and UACR at appropriate intervals. 1, 2
• Assess for liver involvement using non-invasive tests like FIB-4, with appropriate follow-up based on risk stratification. 2
• Screen for sleep disorders that worsen insulin resistance and cardiovascular risk. 2

Pharmacological Management (Risk-Factor Specific)

Use shared decision-making when initiating pharmacological treatments, considering patient priorities and individual risk profiles. 2

Blood Pressure Management

• Initiate combination BP-lowering treatment for most patients with confirmed hypertension (BP ≥140/90 mmHg). 1
• Preferred first-line combinations: RAS blocker (ACE inhibitor or ARB) with dihydropyridine calcium channel blocker or diuretic (thiazide or thiazide-like). 1
• Target BP: 120–129/70–79 mmHg in routine practice. 1
• Use fixed-dose single-pill combinations to improve adherence. 1
• Consider renin-angiotensin system blockers when BP exceeds 140/90 mmHg. 2

Important caveat: ACE inhibitors like lisinopril are Pregnancy Category D—discontinue immediately when pregnancy is detected due to risk of fetal renal dysfunction, oligohydramnios, and death. 3

Lipid Management

• Use statins as first-line therapy for elevated LDL cholesterol. 2
• Target LDL-C <1.4 mmol/L (55 mg/dL) with ≥50% reduction from baseline in patients with established chronic coronary syndrome. 1
• Target levels should be adjusted based on individual cardiovascular risk. 2

Diabetes Management

• Target A1C <7.0% (53 mmol/mol) for most patients. 1
• Individualize targets based on comorbidities, hypoglycemia risk, and life expectancy. 1

Multidisciplinary Care and Referrals

Multidisciplinary behavioral approaches combined with appropriate pharmacological management are essential for achieving healthy lifestyles. 1, 2

Key Referrals

• Refer patients with diabetes to diabetes care and education specialists (CDCES) when available. 2
• Consider referral to hepatologist for patients with intermediate to high risk of liver fibrosis. 2
• Ensure medication reconciliation at each visit to address adherence issues. 2

Additional Preventive Measures

Immunization

• Vaccinate against influenza, pneumococcal disease, and other widespread infections (e.g., COVID-19). 1

Environmental Factors

• Avoid passive smoking and reduce environmental noise exposure. 1
• Minimize exposure to air pollution. 1

Psychosocial Management

• Avoid psychosocial stress when possible. 1
• Treat depression and anxiety with psychological or pharmacological interventions, as these conditions worsen cardiovascular outcomes. 1

Common Pitfalls to Avoid

• Do not delay lifestyle interventions while waiting to start medications—both should be implemented simultaneously. 1
• Do not overwhelm patients with all information at once—provide education incrementally at each visit. 1
• Do not use pharmacotherapy for obstructive sleep apnea—it is ineffective and potentially harmful. 1
• Do not prescribe e-cigarettes as smoking cessation aids outside formal tobacco cessation programs—they cause vascular endothelial dysfunction. 1
• Do not forget to screen for pregnancy before prescribing ACE inhibitors or ARBs in women of childbearing age—these medications cause severe fetal harm. 3
• Do not initiate monotherapy for hypertension in most patients—combination therapy is more effective for BP control. 1