The dominant driver paradigm of cardiometabolic care

In cardiometabolic care, the conventional paradigm is based on concurrent and independent management of different drivers (e.g., abnormal adiposity, dysglycemia, and hypertension) that are causally interconnected. Alternatively, epidemiological and mechanistic evidence supports a novel dominant driver paradigm, based on the determination of the earliest causative driver.

To determine the degree of discordance between the conventional paradigm (prevalence distributions of unprocessed cardiometabolic drivers) and the dominant driver paradigm (prevalence distributions of processed dominant drivers).

The cardiometabolic drivers at initial presentation of patients from a preventive cardiology center were retrospectively tabulated and an etiologic dominant driver was determined for each patient. Prevalence differences and agreement measures between the conventional tabulation of drivers and the dominant drivers were ascertained.

966 patients were included (mean age, 61.7 ± 16.0; 606 [63.0%] female). The prevalence of abnormal adiposity was similar in both paradigms (67.6% vs 66.5%; p = 0.637). However, the prevalence rates for dysglycemia (64.7% vs 14.5%; p < 0.001), hypertension (87.6% vs 16.0%; p < 0.001), and dyslipidemia (97.2% vs 3%; p < 0.001) were significantly higher in the conventional compared to the dominant driver paradigm. Globally, the two paradigms had only slight agreement (kappa=0.188; p < 0.001). Complications in patients with predisease (overweight body mass index range and prediabetes hemoglobin A1c range) were found in 90% and 91% of presentations, respectively.

Clinical targeting of dysglycemia, hypertension, and dyslipidemia would be drastically reduced with a dominant driver paradigm in which abnormal adiposity is the most frequent dominant driver. With the advent of novel and effective pharmacotherapies for the treatment of abnormal adiposity, simplification of cardiometabolic-based chronic disease treatment is possible.