#528 - CKM Syndrome, Shingrix Effectiveness, Immunity to Change
Take 3 – Practical Practice Pointers©
From the Literature and the American Heart Association (AHA)
1) Improving Cardiovascular-Kidney-Metabolic (CKM) Healt
This past October, the American Heart Association (AHA) issued a Presidential Advisory introducing the term cardiovascular-kidney-metabolic (CKM) health and providing rationale and staging for CKM syndrome. CKM syndrome is defined by the AHA as “a systemic disorder characterized by pathophysiological interactions among metabolic risk factors, CKD, and the cardiovascular system leading to multiorgan dysfunction and a high rate of adverse cardiovascular outcomes. CKM syndrome includes both individuals at risk for CVD due to the presence of metabolic risk factors, CKD, or both and individuals with existing CVD that is potentially related to or complicates metabolic risk factors or CKD.…” The Advisory also provides a more simplified and patient-facing definition of CKM syndrome for use in the lay public: “CKM syndrome is a health disorder due to connections among heart disease, kidney disease, diabetes and obesity leading to poor health outcomes.”
Current evidence indicates that CKM syndrome is a progressive condition that commonly begins in early life with biological, social and environmental exposures or pressures leading to the accumulation of excess and dysfunctional adipose tissue, with resultant inflammation, oxidative stress and insulin resistance. Excess and dysfunctional adipose tissue frequently progresses to the development of metabolic risk factors (eg, HTN, hypertriglyceridemia, metabolic syndrome [MetS], T2D) and CKD. Over time, these often confluent comorbidities result in the development of subclinical coronary atherosclerosis (reflected by coronary artery calcification) and subclinical abnormalities of myocardial structure and function, as well as progressive declines in kidney function, which predispose to a high risk for clinical CVD, kidney failure, disability and death.
The Advisory provided a CKM staging construct that reflects the pathophysiology, spectrum of risk, and opportunities for prevention and care optimization:
- stage 0, no CKM risk factors (normal BMI, waist circumference, normoglycemia, normotension, normal lipid profile, no evidence of CKD or subclinical/clinical CVD).
- stage 1, excess or dysfunctional adiposity (BMI >25 (or >23 if Asian ancestry), waist circumference >88/102 in men/women (or if Asian ancestry >80/90) or fasting blood glucose >100-124 or HbA1c between 5.7%-6.4%).
- stage 2, metabolic risk factors (hypertriglyceridemia >135), hypertension, diabetes, metabolic syndrome) or moderate- to high-risk chronic kidney disease.
- stage 3, subclinical CVD in CKM syndrome or risk equivalents (high predicted CVD risk or very high-risk CKD. NOTE: Subclinical ASCVD Dx by coronary artery calcification and/or catheterization/CT angiography. Subclinical HF diagnosed by elevated cardiac biomarkers (NT-proBNP >125, hs-troponin t >14 in women and >22 in men.
- stage 4, clinical CVD in CKM syndrome (CAD, HF, stroke, PAD, A-fib) among individuals with excess/dysfunctional adiposity, other CKM risk factors, or CKD stages 4a or 4b.
Management of patients with CKM syndrome Stages 1-3 (Modified from Figure 3):
Life’s Essential 8 referenced above were reviewed in the July 8, 2022 Edition of Take 3.
Mark’s Comments:
Given the prevalence of these disorders, the CKM syndrome and advancement of CKM health would certainly seem to be something we who practice primary health care should become experts in rather than having these patients managed by the Cardiologist, Endocrinologist, and Nephrologist (with Gastroenterologist/Hepatologist waiting in the wings).
The AHA followed-up this Advisory in November with the introduction of a new
This calculator is intended for primary prevention patients (those without coronary heart disease, stroke, or heart failure) who are between the ages of 30-79 years. I will cover this with a Pointer in next week’s Take 3
References:
- Ndumele C, et al. Cardiovascular-Kidney-Metabolic Health: A Presidential Advisory From the American Heart Association. Circulation. 2023;148:1606–1635. Originally published 9 October 2023. Link
A Question from a Colleague
2) How long Does the Shingles Vaccine Last?
In 2018, the Advisory Committee on Immunization Practices recommended the recombinant zoster vaccination (RZV) for immunization against herpes zoster over the previous live virus zoster vaccine (ZVL). RZV was shown to have a higher vaccine effectiveness than ZVL and had the additional advantage of not being a live virus. The initial studies for vaccine approval (including over 30,000 participants) showed initial vaccine effectiveness (VE) rates of 96-97% and persisting VE rates of at least 84% for an average of 3 ½ years across all eligible age groups. The vaccine also reduced post-herpetic neuralgia (VE 88-91%). Cost effectiveness analyses favored use of RZV over ZVL because of its better effectiveness. At the time of the recommendation, the ACIP opined that the vaccine would “likely continue to provide substantial protection beyond 4 years as recipients age.”
A ”real-world” study of zoster vaccination has been published that provides information about how these vaccines are working in clinical care. The study is observational, using data from four health systems in the Vaccine Safety Datalink – a group of health systems that contribute EHR data to allow vaccine monitoring studies like this one. This network is an important component in the CDC’s vaccine safety program. This study compared the incidence of herpes zoster in patients who had the RSV vaccine compared with those who did not receive it in order to measure VE in clinical practice.
This study contained lots of careful definitions and measures for the variables they analyzed, as befits a good quality prospective cohort study. The investigators reviewed data from just under 2 million patients. The adjusted VE more than 30 days after a 2-shot series was 79% - almost 20 percentage points lower than the original studies. VE dropped slightly after 1 year but persisted into the fourth year post-vaccination at 73%. Single dose effectiveness 30 days after vaccination started at 70%, but quickly dropped into the 45-50% range after 1 year.
VE was adversely affected by age >= 65 years (74% vs. 81% in 50-65y), corticosteroid use prior to vaccination (65% vs. 77% for no use) but was NOT affected by time intervals even exceeding 1 year between the 1st and 2nd doses.
John’s Comments:
This principal limitation of this study was in ascertaining zoster rates – it’s possible the research team may have missed milder cases of zoster, or cases diagnosed elsewhere than in the patient’s health system. That may have contributed for lower VE rates than in the original studies, but, then again, most of our interventions work less well in “real life” than in controlled clinical studies. Zoster has traditional been a disease of older people, so moving the recommended vaccination age down to 50 worried some. But there’s no evidence we should worry just yet. The VE for ZVL was shown to drop significantly after 1 year and was <35% after 6 years, so RZV seems to be doing better, though more monitoring is required. Decisions about booster vaccinations would be made based on this data. There is at least one other study showing that protection from this RZV lasts for seven years. It is important to get that second shot and, fortunately, getting it even over a year late is OK.
References:
- Dooling KL. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR Morb Mortal Wkly Rep. 2018;67. Link
- Zerbo O, Bartlett J, Fireman B, et al. Effectiveness of Recombinant Zoster Vaccine Against Herpes Zoster in a Real-World Setting. Annals of Internal Medicine. Published online January 9, 2024. Link
From PeerRxMed ( www.PeerRxMed.org )
3) Is it Time to Suppress Your Immunity … to Change?
“Often, the very things we most wish to change are the most difficult to touch because they are protected by fears we have not examined." – Lisa Lahey, EdD, co-author of "Immunity to Change”
It was a statistic that immediately caught my attention. The overall best-selling book on Amazon for both 2021 AND 2023 was “Atomic Habits” by James Clear about building and changing habits. My surprise was not that the book was so popular (I have found his model helpful), but rather best expressed by that exasperated “little voice” in my head saying, “If this model so popular, where’s all the change happening!?” Despite all we “know” about change, “change resistance” continues to be tenacious and persistent. Why is it so challenging to alter habits or adopt new practices even when we anticipate positive benefits and have practical models to guide us?
For example, a seasoned physician sets a goal to become more technologically adept to enhance patient engagement and clinical efficiency. Or a colleague is determined to incorporate more patient-centered communication in their practice. Yet, despite their sincere efforts, they find themselves continually reverting to more ingrained methods. . These struggles are not unique; they mirror the many examples in healthcare alone where personal growth and professional effectiveness clash with ingrained habits and tenacious “invisible” forces.
This enigma is brilliantly addressed in the Immunity to Change model described by Robert Kegan, PhD and Lisa Lahey, EdD, which offers profound insights into our internal resistance to change. Their model suggests that our resistance to change is not just due to external barriers but even more so by internal psychological “immunity.” This resistance is composed of deeply held beliefs and hidden commitments that contradict our conscious goals and their accompanying powerful, though perhaps subconscious, emotions. In order to overcome these forces, they posit we must follow four key steps: identifying a commitment to change, uncovering the behaviors that work against this commitment, digging deeper to find the hidden competing commitments, and finally, challenging the underlying assumptions that support these commitments.
In the examples above, one might be committed to become more technologically savvy, but have subtle behaviors working against it – like avoiding training sessions or relying excessively on staff for digital tasks. The “hidden” commitment here might be the belief that these technologies could depersonalize patient care. The underlying assumption? "If I embrace technology fully, I might lose the personal touch in my practice." Or one might aim to be more empathic but subconsciously fear losing objectivity, thus creating an internal conflict. The “hidden” assumption could be the belief that emotional detachment is necessary for effective decision-making. By applying the Immunity to Change model, new skills which balance empathy with objectivity can be learned, thus aligning actions with aspirations.
This model is more than a tool; it's a mirror reflecting our deepest fears and assumptions when it comes to changing ingrained habits and beliefs. This week, consider a desired change, whether personal or professional, that has been persistently resistant to change. Click on the link above and work through the model to determine where your “change autoimmunity” might need some “immune suppression.” Consider sharing what you are discovering with your PeerRx partner so they can help provide you some encouragement as well as accountability as you take action to overcome this resistance. For those hard to change areas of your life, it might be just what the doctor ordered ….
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Mark and John
Carilion Clinic Department of Family and Community Medicine