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HF gaps in CKM syndrome
Closing Heart Failure Gaps in CKM Care: A Cardiologist’s Perspective

Released: May 15, 2026

Pam R. Taub
Pam R. Taub, MD, FACC, FASPC
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Key Takeaways
  • Certain CKM conditions predispose patients to heart failure and should be recognized as early warnings before advanced heart failure occurs.
  • If there is an applicable indication and no contraindication present, HCPs should promptly initiate GDMT and then coordinate CKM care with other specialties as needed.
  • Nurses are central members of the care team who can help educate and monitor patients with CKM conditions like heart failure to improve outcomes.

As a cardiologist, I see cardiovascular–kidney–metabolic (CKM) care as one of the most promising opportunities to intervene early and change the trajectory of heart failure. Too often, heart failure is recognized after symptoms become obvious or a hospitalization has occurred. Yet, in many patients, the warning signs of heart failure present much earlier, with CKM conditions like diabetes, chronic kidney disease (CKD), obesity, hypertension, and dyslipidemia predisposing patients to heart failure. In addition, biomarkers, such as albuminuria and increased natriuretic peptides, as well as symptoms of subtle fatigue, reduced exercise tolerance, and/or mild congestion, can help identify those with early signs of heart failure. The issue with the latter is that patients may normalize these symptoms. Therefore, the opportunity is to identify these signals in CKM care sooner and move from watchful waiting to timely intervention in certain patients. 

Gaps Persist in Heart Failure Care
I think the biggest diagnostic gap is not that healthcare professionals (HCPs) overlook advanced heart failure. Rather, they miss the early trajectory of this disease. Patients with CKD, diabetes, obesity, and progressive dyspnea may be seen by multiple HCPs before anyone identifies heart failure as a risk. Heart failure with preserved ejection fraction (HFpEF) comprises a population that is especially vulnerable to delayed diagnosis because of their preserved ejection fraction, nonspecific symptoms, and difficulty interpreting natriuretic peptide levels in those with obesity or CKD. Therefore, an HFpEF diagnosis should not reassure HCPs if the clinical story suggests risk. This is critical because renal and metabolic comorbidities are not background conditions in CKM care; they are part of the larger heart failure signal.

The treatment gap in heart failure care is equally important. Even when heart failure is identified, guideline-directed medical therapy (GDMT) remains underused as clinical inertia quietly shapes care. I often hear other HCPs say their patients are “stable,” but they do not realize that “stable” does not always mean optimized. If patients with heart failure with reduced ejection fraction (HFrEF) are eligible for foundational GDMT but you have only prescribed 1 or 2 low-dose agents, there is still work for you to do. If patients with HFpEF and increased CKM risk are eligible for therapy that can reduce their heart failure event risk, HCPs should not delay treatment simply because patients’ symptoms are familiar or they are not currently in crisis. The questions I ask myself at every clinic visit include: What therapy is missing? What dose is below target? And what barrier can we address today?

From a treatment standpoint, the message is clear and practical: Early recognition should trigger timely action. In HFrEF, that means promptly moving toward optimized GDMT with an ARNI (or ACE inhibitor/ARB as needed), an evidence-based beta-blocker, an MRA, and an SGLT2 inhibitor. HCPs should not wait months to sequence quadruple therapy to target doses in patients with HFrEF. Then, in HFpEF and heart failure with mildly reduced ejection fraction, especially among those with increased CKM risk, SGLT2 inhibitors should be considered early. These patients also require careful volume management and treatment of obesity, diabetes, hypertension, CKD, atrial fibrillation, and obstructive sleep apnea if applicable. In addition, MRAs and other CKM-related therapies may have a role in heart failure care based on patients’ phenotype, kidney function, potassium levels, albuminuria status, and present comorbidities.

The idea is not to simply prescribe more therapies; it is to match the right therapy to the right patient, while explaining the “why” and building a monitoring plan that gives both patients and HCPs confidence.

Multidisciplinary Strategies to Overcome Barriers
Of course, barriers to GDMT are real. Patients often worry about treatment-related adverse effects, kidney function, potassium levels, infection risk, cost, pill burden, and whether polypharmacy is truly necessary. Although HCPs may worry about many of the same things, we commonly face unclear patient ownership across cardiology, nephrology, endocrinology, and primary care in multidisciplinary practice, and that uncertainty can lead to diagnostic and treatment delays. HCPs might agree that a patient is at high risk, but no one is sure who should initiate or intensify their therapy. In my opinion, if the indication is present and there is no true contraindication, the HCP with the patient should proceed with the necessary treatment and coordinate from there. For example, CKD should prompt thoughtful monitoring, not automatic deferral.

This is where nurses can help because they play a central role in patient management. Nurses often hear about the earliest signs of change from patients. For example, they might hear patients say, “I cannot walk as far,” “I need another pillow,” “My weight is creeping up,” “I stopped that medication,” or “I was afraid to start that medication.” These conversations are where we can begin to close gaps and address barriers in heart failure care. In doing so, nurses can identify symptom drift, flag CKM risk, prompt treatment escalation, reinforce the purpose of therapy, support adherence, and help patients identify what to watch for at home.

Nurses are also the bridge between evidence-based recommendations and what patients are able to accomplish in their daily lives. They can make therapy safer and more successful by checking patients’ labs, blood pressure, and volume status, while addressing adherence, prescription access, safety, and patient concerns between visits. With nurses as central members of the care team, we can turn GDMT from a one-time prescribing decision into an ongoing treatment process.

For cardiology teams, the practical path forward is to partner more deliberately with nursing staff. That means teams must define escalation triggers, such as worsening dyspnea, orthopnea, edema, or kidney function; rapid weight gain; rising diuretic needs; missing refills; low blood pressure symptoms; abnormal potassium; or patient hesitation about therapy. In addition, clear workflows are needed for laboratory monitoring, early follow-up, treatment education, refill support, and protocol-driven titration when appropriate. When these pathways are in place, nurses can act quickly and confidently rather than simply documenting their concerns for a future visit.

Finally, the language we use with patients also matters. It is imperative that HCPs respectfully acknowledge patients’ concerns and provide further education on the “why.” For example, to those who feel well and question my intended treatment changes, I might say, “Feeling okay today does not mean your heart failure risk is gone. These medications are designed to help prevent future hospitalizations and protect your heart over time.” For those who are worried about kidney function, I might say, “We will monitor your labs closely. A small, early change does not always mean harm, and our goal is to protect both your heart and kidneys.” For patients who are concerned about treatment-related adverse effects, I might say, “Your concerns are valid. Let us talk about what you should watch for, what we can prevent, and when you should call us.”

Your Thoughts
I am optimistic about where CKM care is headed because the solution is not theoretical. We already know what gaps persist and the changes that intentionally need to be made to improve heart failure care. When cardiologists and nurses work together to address these gaps, CKM care will become less fragmented, heart failure care will become more proactive, and patients will have a better chance of avoiding preventable decompensation.

What gap in heart failure care do you also see most often in CKM care—delayed recognition, GDMT underuse, patient hesitation, unclear ownership, or workflow barriers? You can join the conversation by answering the poll question below and posting 1 practical step your team could take to close this gap.

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What gap in heart failure care do you also see most often in CKM care?

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