Q&A: Cardiometabolic Care Cascade Failure Points, with Rishi Wadhera, MD, MPP, MPhil

Despite decades of therapeutic advances, the cardiometabolic care cascade remains fractured at nearly every stage.

Awareness deficits are substantial: among adults aged 20 to 44 with hypertension, nearly 40% are unaware of their diagnosis, and only 1 in 3 adults with diabetes knows they have the condition.

Novel cardioprotective and nephroprotective therapies have widened the gap further. SGLT2 inhibitors and GLP-1 receptor agonists reach only about 1 in 5 eligible patients with diabetes. The barriers are multilayered: coverage limitations, out-of-pocket costs, and clinical inertia each contribute, and no single intervention will close them.

The gap between what evidence recommends and what clinicians deliver has never been wider. Closing it requires simultaneous action at the clinician, health system, community, and policy levels from EHR-embedded decision support and AI-guided care tools to population health dashboards, remote monitoring, and community health worker deployment.

At the 10th Annual Heart in Diabetes Meeting, Rishi Wadhera, MD, MPP, MPhil, associate professor of medicine at Harvard Medical School and associate director of the Smith Center for Outcomes Research at Beth Israel Deaconess Medical Center, sat down with HCPLive to discuss where the cardiometabolic care cascade is failing most consequentially and what a multifaceted response must include.

Q&A: Cardiometabolic Care Cascade Failure Points, with Rishi Wadhera, MD, MPP, MPhil

HCPLive: Where in the cardiometabolic care cascade do you see the most consequential failure point today?

Rishi Wadhera, MD, MPP, MPhil: We see failures across the cardio metabolic care cascade in every dimension, and it varies from condition to condition. If you think about hypertension, the burden is staggering — 1 in 2 adults in this country has hypertension, and among young adults aged 20 to 44, almost 40% aren't aware they have it. With diabetes, only about 1 in 3 adults with the condition knows they have it. On awareness, we can do better. Across the treatment and control spectrum, we can do better too. Where we are doing better for conditions like hypertension and diabetes is treatment — a lot of people are on therapies. But where we're failing is control: up-titration of therapy, getting people to guideline-recommended goals for blood pressure or hemoglobin A1c, is a major gap right now.

HCPLive: Despite highly effective therapies across diabetes, lipid control, blood pressure, and weight loss, why do population-level control rates remain persistently suboptimal?

Rishi Wadhera, MD, MPP, MPhil: About 70% of US adults with diabetes receive some sort of treatment — that's pretty good compared to many other cardio metabolic risk factors. But it's not about whether they're getting therapy; it's about what type of therapy they're getting, and that's where we're facing challenges. When you think about novel therapies — SGLT2 inhibitors and GLP-1 agonists, newer therapies we know protect the heart and the kidneys and can meaningfully improve outcomes for patients with diabetes — only about 1 in 5 eligible patients are getting them. That is a coverage problem, an out-of-pocket cost problem, and to some degree a clinical inertia problem. Any strategy addressing gaps in novel therapy use needs to be multifaceted: targeting clinical inertia, health system inertia, and the broader policy issues around access and affordability.

HCPLive: How should clinicians navigate the disconnect between guideline-directed cardiometabolic care and real-world implementation?

Rishi Wadhera, MD, MPP, MPhil: The gap between what we know and what we're actually delivering has never been wider, and it is problematic. Some of it is access and affordability for novel therapies — but that is not the case for antihypertensives, so we do have a pure implementation gap when it comes to blood pressure control. Only 1 in 4 adults with hypertension achieves adequate blood pressure control — that's a health system failure, an implementation failure. Addressing those gaps has to be multifaceted. At the clinician level: EHR-embedded decision support tools, and increasingly AI-guided approaches to enhance care delivery. At the health system level: population health dashboards and remote monitoring technologies. At the community level: deploying community health workers and meeting patients where they are for screening and diagnosis. At the policy level — which I think of as one of our most powerful cardiovascular interventions — making novel therapies more accessible and affordable.

Editor’s Note: This transcript has been edited for grammar and clarity using artificial intelligence tools.

References

1. Anderer S. More Than Half of US Adults With Uncontrolled Hypertension Don’t Know They Have It. JAMA. 2024;332(17):1417. doi:10.1001/jama.2024.20117

2. Kalyani RR, Neumiller JJ, Maruthur NM, Wexler DJ. Diagnosis and Treatment of Type 2 Diabetes in Adults: A Review. JAMA. 2025;334(11):984–1002. doi:10.1001/jama.2025.5956