Porter Health
CKM Staging System
Understanding the Cardiovascular-Kidney-Metabolic Health Framework
The Cardiovascular-Kidney-Metabolic (CKM) staging system is a framework developed by the American Heart Association in 2023 to assess your progression from metabolic risk factors toward cardiovascular disease.
Unlike traditional risk calculators that estimate probability, CKM staging categorizes where you are on the pathway from health to disease, helping guide prevention and treatment strategies.
The CKM framework uses a 5-stage progression from health (Stage 0) to established cardiovascular disease (Stage 4):
Stage 0: Optimal CKM Health
Criteria: No excess adiposity (BMI <25, waist circumference in normal range) and optimal levels of all metabolic and cardiovascular risk factors
Clinical Implication: Focus on maintaining health through lifestyle behaviors (Life's Essential 8)
Stage 1: Excess Adiposity or Dysfunctional Adipose Tissue
Criteria: Excess or dysfunctional adiposity (elevated BMI or waist circumference, increased visceral fat) and/or prediabetes (impaired fasting glucose, impaired glucose tolerance, or HbA1c 5.7-6.4%)
Clinical Implication: Intensive lifestyle intervention to prevent progression. Consider metabolic syndrome screening.
Note for South Asians: Lower BMI and waist circumference thresholds apply (BMI ≥23, waist ≥80cm for women, ≥90cm for men)
Stage 2: Metabolic Risk Factors or CKD
Criteria: Metabolic risk factors (hypertension, dyslipidemia, metabolic syndrome) and/or moderate CKD (eGFR 30-59 or UACR ≥30 mg/g), and/or type 2 diabetes
Clinical Implication: Guideline-directed medical therapy plus lifestyle. Consider SGLT2 inhibitors or GLP-1 agonists for diabetes/CKD. Annual UACR screening recommended.
Stage 3: High Risk — Subclinical CVD
Criteria: Evidence of subclinical cardiovascular disease (coronary artery calcium >0, carotid plaque, ankle-brachial index <0.9, left ventricular hypertrophy) without clinical symptoms, and/or severe CKD (eGFR <30 or albuminuria >300 mg/g)
Clinical Implication: Aggressive risk factor modification. High-intensity statin therapy. Consider advanced imaging. Intensified medical management.
Stage 4: Advanced — Clinical CVD
Criteria: Symptomatic cardiovascular disease (myocardial infarction, stroke, heart failure, atrial fibrillation, peripheral artery disease)
Clinical Implication: Comprehensive secondary prevention. Guideline-directed medical therapy for specific CVD conditions. Cardiac rehabilitation. Multidisciplinary management.
It's common to have a high Health Score (LE8) of 80+ while being in CKM Stage 3 or 4. This happens because these tools measure different dimensions of your cardiovascular health.
Health Score (LE8) Focuses On:
- •Current modifiable behaviors: Your diet, physical activity, sleep quality, and tobacco use today
- •Well-controlled metrics: Blood pressure, cholesterol, glucose, and BMI can score well when managed with medications
CKM Staging Adds:
- •Disease presence: Diabetes, established kidney disease, or past cardiovascular events automatically place you in higher stages, even if well-managed
- •Structural changes: Subclinical disease like coronary artery calcium (CAC >0), left ventricular hypertrophy, or carotid plaque indicates CKM Stage 3, regardless of current lab values
- •Advanced biomarkers: Elevated NT-proBNP, troponin, or severe kidney dysfunction (eGFR <30) signal organ damage not captured by LE8
What This Means: A high Health Score with an elevated CKM stage shows you're successfully managing your risk factors and maintaining healthy behaviors—that's excellent! Your CKM stage reflects underlying disease or structural changes that require ongoing medical treatment. Both metrics guide your personalized care: LE8 shows what you're doing well, and CKM staging ensures we're addressing disease-specific interventions.
Your Porter Health dashboard automatically determines your CKM stage based on your health profile, lab results, and medical history:
Assessment: We analyze your BMI, waist circumference, blood pressure, cholesterol, glucose, kidney function, and cardiovascular history
Stage Assignment: You're assigned the highest applicable CKM stage based on your current health status
Personalized Recommendations: Your action plan is tailored to your CKM stage with evidence-based interventions to prevent progression
Primary Source
Ndumele CE, Rangaswami J, Chow SL, et al. Cardiovascular-Kidney-Metabolic Health: A Presidential Advisory From the American Heart Association. Circulation. 2023;148(20):1606-1635.
DOI: 10.1161/CIR.0000000000001184
Supporting Evidence
Ndumele CE, Neeland IJ, Tuttle KR, et al. A Synopsis of the Evidence for the Science and Clinical Management of Cardiovascular-Kidney-Metabolic (CKM) Syndrome: A Scientific Statement From the American Heart Association. Circulation. 2023;148(20):1636-1664.
DOI: 10.1161/CIR.0000000000001186