Rethinking Cardiometabolic Risk: Deepak Bhatt, MD, MPH, MBA

The evolving concept of cardiac kidney metabolism (CKM) is changing how clinicians think about cardiometabolic disease. Rather than treating heart disease, kidney disease, diabetes, obesity, and even liver disease as isolated conditions, professional societies are increasingly recognizing them as deeply interconnected. This shift is driven in large part by the arrival of therapies that simultaneously affect multiple organs and disease pathways, underscoring the need for closer collaboration across specialties.

One example of this new era is the SURPASS-CVOT trial (NCT04255433), a head-to-head comparison between the glucagon-like peptide-1 agonist dulaglutide and tirzepatide. The trial demonstrated noninferiority of tirzepatide to dulaglutide for major cardiovascular outcomes, but several key end points appeared to favor tirzepatide. Patients on tirzepatide experienced greater weight loss, better glycemic control, and a lower rate of all-cause mortality.

Deepak Bhatt, MD, MPH, MBA, director of the Mount Sinai Fuster Heart Hospital and the Dr Valentin Fuster Professor of Cardiovascular Medicine at the Icahn School of Medicine at Mount Sinai, noted the statistical nuances of noninferiority designs, particularly the challenges of interpreting secondary end points when superiority is not formally established. He emphasized that the mortality signal is likely meaningful and “worth discussing further,” especially given his role on the trial’s executive committee.

Beyond pharmacotherapy, his recent discussion highlighted the importance of simple, practical tools for risk assessment in everyday practice. Although body mass index (BMI) remains a widely used measure, it can be misleading. Individuals with dense bone structure or high muscle mass may have an elevated BMI without increased cardiometabolic risk, while frail older adults with low BMI may still have significant risk due to low muscle mass and central fat.

Ethnic differences further complicate the picture. South and East Asian patients, for example, may present with a “normal” BMI yet carry substantial visceral adiposity, placing them at higher cardiometabolic risk.

For these reasons, Bhatt advocates treating waist circumference as an essential vital sign. Encouraging patients to regularly measure their waist with a tape measure and track their weight on a home scale offers a more direct window into excess visceral fat—particularly abdominal fat—that drives much of CKM-related morbidity.