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Posted on Sunday February 22, 2026 in News
An article written by Dr Edward Leatham, Consultant Cardiologist © 2026 E.Leatham
For busy people, or to tune in when on the move, Google Notebook AI audio podcast and an explainer slide show are available for this story beneath.
Cardiovascular disease remains the leading cause of morbidity and mortality in the UK. Yet much of what drives coronary disease, atrial fibrillation, heart failure and hypertension is no longer primarily a mystery of lipids or genetics. It is cardiometabolic dysfunction — particularly visceral adiposity, insulin resistance and chronic low-grade inflammation.
For GPs and referring clinicians, the challenge is no longer identifying risk. It is managing the growing cohort of patients who sit between:
These patients often present with:
They do not yet meet criteria for overt disease, but risk is accumulating.
The key question is: how do we intervene intelligently, proportionately and safely?
Historically, prevention has been framed in binary terms:
In reality, cardiometabolic risk develops along a continuum.
A 48-year-old with:
does not require the same intervention as a 62-year-old with established coronary plaque and diabetes.
But neither should be managed with a generic leaflet.
What is needed is a structured escalation model.
At SCVC, cardiometabolic management is approached as a staged process rather than a single decision.
The stages typically include:
This is not about replacing lifestyle with medication. It is about ensuring that lifestyle advice is sufficiently supported — and that escalation occurs before irreversible disease.
Many patients can improve risk parameters with focused intervention, provided it is structured.
Core elements include:
The aim is reduction of visceral adiposity, not simply weight.
In early risk states, modest VAT reduction can:
For motivated individuals, this stage may be sufficient.
But many plateau.
Patients frequently believe they are improving when objective data suggests otherwise.
Guided monitoring may include:
Where appropriate:
The aim is not over-investigation. It is clarity.
For GPs, this stage often clarifies which patients require more aggressive intervention.
Where lifestyle optimisation is insufficient, structured nurse-led input is invaluable.
This may involve:
At this stage, subtle medication adjustments may also be appropriate:
Importantly, escalation occurs before overt disease manifests.
When risk factors cluster, specialist assessment may be indicated.
Common referral scenarios include:
Specialist review focuses on:
This prevents both under-treatment and premature over-medicalisation.
GLP-1 receptor agonists and dual incretin agents have transformed metabolic medicine.
However, their role requires nuance.
They are not:
They are:
In carefully selected patients — particularly those with:
GLP-1 therapy can materially reduce cardiometabolic burden.
But they should sit within a structured framework — not as isolated prescriptions.
When considering referral for cardiometabolic review, red flags include:
These patients often require more than advice.
They require coordinated strategy.
Visceral adiposity is not cosmetic.
It drives:
The consequence is increased risk of:
Early structured intervention alters trajectory.
Late intervention manages consequence.
1. Reassurance without measurement
Patients with “normal cholesterol” but high visceral fat often remain high risk.
2. Premature pharmacology
Medication without behavioural support frequently produces modest and unsustained gains with ‘rebound’.
Structured escalation prevents both.
Cardiometabolic dysfunction increasingly underpins:
Addressing only the coronary lesion without addressing metabolic substrate limits long-term outcome.
Integrated cardiometabolic pathways are therefore not optional — they are necessary.
Primary care remains the frontline.
Key opportunities include:
Early referral is not failure of primary care. It is appropriate risk management.
If you have:
You are not “fine until diabetic.”
You are on a trajectory.
That trajectory can be altered.
A modern cardiology clinic should not only treat:
It should also manage the metabolic environment that drives them.
This requires:
Not every patient needs GLP-1 therapy.
Not every patient needs imaging.
But many patients need more than general advice.
For a more detailed exploration of the molecular and metabolic drivers linking visceral fat, PCSK9 expression, inflammation and atherosclerosis, see our technical analysis on VAT-Trap:
PCSK9, Visceral Fat and the Modern Metabolic Environment
👉 https://www.scvc.co.uk/vat-trap/pcsk9-visceral-fat-and-the-modern-metabolic-environment/
This companion article examines how adipose biology influences lipid handling and vascular risk beyond conventional cholesterol measurements.
Cardiometabolic risk develops gradually but accelerates silently.
A tiered intervention model — from self-management to specialist escalation — allows proportionate response.
For referring clinicians, the goal is not aggressive treatment of every mildly abnormal parameter. It is intelligent identification of those whose risk trajectory is shifting.
For patients, the goal is not perfection. It is measurable improvement.
The future of cardiology lies not only in stents and ablation, but in structured metabolic strategy delivered before disease becomes irreversible.
In cardiometabolic medicine, muscle is not a cosmetic tissue but a metabolic organ. Evidence consistently shows that strength, not muscle mass, predicts insulin resistance, cardiovascular risk, and survival. Many older adults are not losing muscle tissue — they are losing muscle function, and that is the pathology that matters.
At SCVC we use low dose CT to measure visceral adipose tissue (VAT). With a radiation dose of 1mSv - equivalent to 1/4 of the dose used in a mammogram. The test determines what proportion of an expanded waistline is visceral (metabolically dangerous) versus subcutaneous (metabolically benign) fat. When combined with other anthropometrics such as weight, height, waist we use AI to calculate a metabolically healthy target waist and weight to aim for. A example of a repeat scan after 3 months of GLP-1 mimetic is also shown.
When blood sugar levels are consistently high, causing prediabetes and diabetes, the risk of conditions such as heart disease and type 2 diabetes increase in the long-term. It is easy to understand why the phenomenon of glucose spiking, where blood sugar levels surge and then fall back into the normal range after a meal, is also widely considered to be harmful.
Since 2016, cardiologists have been utilising the HeartFlow Analysis in conjunction with cardiac CT scans to enhance the accuracy and predictive value of noninvasive coronary imaging. This technology allows many patients to avoid unnecessary invasive angiography, reducing the associated risks and stress.