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Nurse strategies in HF and CKM
Reinforcing Key Points in CKM Care: Nurse-Led Strategies for Connecting Early Signals, GDMT Continuation, and Patient Trust

Released: July 23, 2026

Stephanie Barnes
Stephanie Barnes, DNP, AGNP-C, CHFN
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Key Takeaways
  • CKM syndrome expands our understanding of cardiorenal disease by further connecting heart, kidney, and metabolic risk.
  • Subtle symptoms, such as fatigue, reduced exercise tolerance, edema, and orthopnea, often present early, before hospitalization for heart failure and deserve structured assessment.
  • Nurse-led education and monitoring are critical for preserving GDMT and building patient trust.

A central message in cardiovascular-kidney-metabolic (CKM) care today is that healthcare professionals (HCPs) must stop thinking in silos. The heart, kidneys, vasculature, endocrine system, and other metabolic drivers are constantly interacting with one another in the body. Therefore, patient care needs to reflect that same level of connection. For nurses and advanced practice providers, this is especially important because we are often the first HCPs to recognize symptom drift, treatment concerns and adherence gaps, and early signs of decompensation in patients.

In addition, CKM syndrome gives us a broader framework from which to work. Whereas the older concept of “cardiorenal disease” only focused mainly on the heart–kidney interaction generally within the setting of heart failure. CKM syndrome includes this same interaction, but it also considers diabetes, insulin resistance, obesity and inflammation, hypertension, cardiovascular disease (CVD), and chronic kidney disease (CKD) as part of 1 interconnected continuum.

Recognizing Early Signals Before Hospitalization
A major theme in CKM syndrome and heart failure care is early and upstream recognition. That means HCPs should not wait for the first hospital admission in patients with heart failure to determine they are at high risk. Rather, many patients give us clues earlier, including persistent fatigue, edema, orthopnea, wheezing later in life, reduced exercise tolerance, or a gradual decline in what they can do day to day.

These symptoms are easy to attribute to aging, weight gain, deconditioning, or simply diabetes. But in patients with CKM syndrome features, these symptoms should prompt HCPs to complete a more structured assessment. That may include monitoring natriuretic peptides, echocardiogram imaging such as left atrial enlargement or diastolic dysfunction, kidney function markers like estimated glomerular filtration rate and urine–albumin-to-creatinine ratio, and structured CVD risk scores when appropriate.

For nurses, asking patients about their function/abilities in concrete terms can be powerful. For example, “How far could you walk 6 months ago?” “Are you stopping more often?” “Are you sleeping on more pillows?” Those details can uncover heart failure much earlier.

Preserving GDMT While Monitoring Safely
Another key point is that guideline-directed medical therapy (GDMT) is often underused, delayed, or stopped too early in heart failure and CKM syndrome. This is largely due to clinical inertia among HCPs, but some patient and health system factors play a role, too. Clinical inertia refers to HCPs’ failure to initiate or intensify GDMT in eligible patients. That is why HCPS need to maintain self-awareness by asking themselves whether they are underusing the key pillars of GDMT despite availability. In turn, GDMT may be underused, delayed, or stopped too early because patients are afraid of the risks (ie, kidney injury, urinary tract infections, and hyperkalemia) or polypharmacy; others may lack trust in their care teams or face cost barriers. And sometimes it happens due to variable communication among care team members or a lack of a team-based approach to care.

To overcome the many factors of clinical inertia, nurse-led education and monitoring are essential. Patients must know why therapies are being added, what side effects to monitor, when labs will be checked, and why/when they should call the office before stopping a therapy. A simple script can help: “These medications protect your heart and kidneys over time. We will monitor you closely. If something feels off, call us first so we can adjust safely.”

Volume Depletion Is Not GDMT Intolerance
Of note, a key distinction here is volume status. I will illustrate this point through a patient case. The patient has heart failure with reduced ejection fraction, type 2 diabetes, and stage 3 CKD. He was started on an SGLT2 inhibitor, ACE inhibitor, β-blocker, MRA, and loop diuretic. At follow-up, he reported experiencing light-headedness and had blood pressure of 94/60 mm Hg, stable creatinine, potassium of 4.9 mEq/L, and no dyspnea or edema.

The best next step for this patient is to reduce or hold the loop diuretic and reassess his volume status. His stable creatinine and acceptable potassium levels do not support automatically stopping the MRA, and his low blood pressure does not mean the SGLT2 inhibitor should be stopped first, either. Furthermore, in patients without congestion, orthostatic symptoms may reflect overdiuresis. So adjusting the loop diuretic can improve symptoms while preserving foundational GDMT.

Reviewing FAQs
As part of this education program, we held a symposium titled “Connecting the Dots in CKM Care: Empowering Nurses to Drive Cardio–Kidney–Metabolic Outcomes.” Here I will quickly address the questions that were asked.

How should HCPs explain small creatinine increases to patients after GDMT initiation?

I like to prepare patients in advance by letting them know that their labs may change and that we will interpret those changes within context. The message should be: “Do not stop the medication on your own. Call us so we can review the numbers and your symptoms together.”

How should HCPs preserve trust with patients when another HCP advises them differently?

In these cases, I will acknowledge patients’ concerns without criticizing the other HCP. That includes explaining the rationale, documenting the plan clearly, and closing the loop with the larger care team when possible. This latter point is critical because CKM care is a team sport.

What if risk calculators do not work in patients with a very high BMI?

Remember, risk calculators are tools, not replacements for clinical judgment. Patients with class III obesity and diabetes, CKD, hypertension, or heart failure features are at high risk and deserve more proactive assessment.

How can nurses help overcome clinical inertia? Nurses should normalize treatment escalation when needed; reinforce the “why” behind GDMT; identify barriers like cost or health literacy; monitor patients’ blood pressure, weight, symptoms, and other lab values; and help patients contact their care team before stopping therapy.

Your Thoughts
Early recognition, connected thinking, and confident follow-through are essential components of modern CKM care. And nurses play a critical role in identifying subtle heart failure signals early, supporting GDMT initiation and continuation, addressing patients’ fears and barriers, as well as coordinating HCP communication across specialties. The goal is not simply to manage patients’ symptoms today—it is to prevent the next potential hospitalization and improve long-term CKM outcomes.

What is one nurse-led workflow that has helped your team identify CKM risk earlier or keep patients safely on GDMT? You can get involved in the conversation by answering the poll question and posting a comment below.

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What is one nurse-led workflow that has helped your team identify CKM risk earlier or keep patients safely on GDMT?

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