What is the clinical evidence from this study?

Study design: Cohort. Population: Cardiovascular-Kidney-Metabolic (CKM) syndrome stages 0-3 (n=6991). Intervention: Cardiometabolic index (CMI) vs. Lowest quartile (Q1). Primary outcome: Incident cardiovascular disease (CVD) (HR 1.347, 95% CI 1.161-1.563, p=0.0001).

What question did this study set out to answer?

To examine the impact of cardiometabolic index on the risk of cardiovascular disease in older adults with CKM syndrome.

March 21, 2026Open Access

Association of cardiometabolic index with incident cardiovascular disease in middle-aged and older adults with cardiovascular-kidney-metabolic syndrome stages 0–3: evidence from CHARLS (2011–2020)

Key Result

Elevated baseline cardiometabolic index (highest quartile) increased the risk of incident cardiovascular disease by 34.7% compared to the lowest quartile (HR 1.347) over a 10-year follow-up.

Key Points

To examine the impact of cardiometabolic index on the risk of cardiovascular disease in older adults with CKM syndrome.
Data derived from CHARLS (2011-2020) with 6,991 participants aged ≥ 45 years.
Participants categorized into quartiles based on baseline and cumulative average cardiometabolic index.
Cox proportional hazards regression models used for risk assessment of incident cardiovascular disease.
Restricted cubic spline models analyzed non-linear associations between cardiometabolic index and cardiovascular disease risk.
1,599 participants developed cardiovascular disease over a median follow-up of 10 years.
The highest baseline CMI quartile showed a 34.7% increased risk of cardiovascular disease compared to the lowest quartile.
Each 1-SD increase in baseline CMI correlated with an 8.0% higher cardiovascular disease risk.
Cumulative average CMI quartile showed a 40.9% higher cardiovascular disease risk compared to the lowest quartile.

Study Design

Type

Cohort (n=6,991)

Multicenter

Yes

Structured PICO

Does an elevated cardiometabolic index increase the risk of incident cardiovascular disease in middle-aged and older adults with CKM syndrome stages 0-3?

Population

Chinese adults aged ≥ 45 years with Cardiovascular-Kidney-Metabolic (CKM) syndrome stages 0-3, mean age 58.83, 47% male

Intervention

Elevated baseline and cumulative average Cardiometabolic Index (CMI) (highest quartile, Q4)

Comparator

Lowest quartile (Q1) of Cardiometabolic Index (CMI)

Outcome

Incident cardiovascular disease (composite of self-reported physician diagnosis or treatment for heart disease or stroke)composite

Elevated baseline and cumulative cardiometabolic index are independently associated with an increased risk of incident cardiovascular disease in adults with CKM syndrome stages 0-3, exhibiting a non-linear threshold effect.

Main Result

Effect estimate: HR 1.347 (95% CI 1.161-1.563)

Absolute Event Rate: 26.79% vs 17.79%

p-value: p=0.0001

Limitations

CVD outcomes were based on self-reported physician diagnoses and treatment, subject to recall bias or misclassification
Self-reported heart disease was not subdivided into specific clinical subtypes
CMI was measured at only two time points, potentially missing short-term fluctuations
Potential measurement error in waist circumference and height
Residual confounding from unmeasured lifestyle factors such as diet and physical activity
Limited generalizability to younger populations or other ethnic groups

Abstract

To examine the association between cardiometabolic index (CMI), including baseline CMI and cumulative average CMI (CumCMI), and the risk of cardiovascular disease (CVD) among Chinese middle-aged and older adults with Cardiovascular-Kidney-Metabolic (CKM) syndrome stages 0-3, and to explore its potential utility for risk assessment in this population. Data were derived from the China Health and Retirement Longitudinal Study (CHARLS, 2011-2020). A total of 6,991 participants aged ≥ 45 years with CKM syndrome stages 0-3 were included. Participants were categorized into quartiles according to CMI and CumCMI levels. Cox proportional hazards regression models with sequential adjustments were used to assess associations with incident CVD. Restricted cubic spline (RCS) models were applied to explore dose-response relationships. Subgroup and sensitivity analyses were conducted to assess the consistency of the findings. During a median follow-up of 10 years, 1599 (23.14%) participants developed CVD. In fully adjusted models, participants in the highest baseline CMI quartile (Q4) had a significantly higher risk of CVD compared with those in the lowest quartile (Q1) (HR = 1.347, 95% CI: 1.161-1.563; P for trend = 0.0001). Each 1-SD increase in baseline CMI was associated with a 8.0% higher CVD risk (HR = 1.080, 95% CI: 1.031-1.131). For CumCMI, Q4 versus Q1 was associated with a 40.9% higher CVD risk (HR = 1.409, 95% CI: 1.124-1.768), with a 11.5% increase in risk per 1-SD increment (HR = 1.115, 95% CI: 1.039-1.196). Restricted cubic spline (RCS) analyses revealed a significant non-linear association between CMI and CVD risk (Poverall < 0.001; Pnonlinear = 0.003), with a threshold value of 0.462. CMI showed statistically significant associations with incident stroke, but not with incident heart disease. Both baseline CMI and cumulative average CMI are independently associated with incident CVD among middle-aged and older adults with CKM syndrome stages 0-3, demonstrating a non-linear threshold relationship. Cumulative exposure to elevated CMI shows a stronger association with CVD risk, supporting the value of longitudinal assessment of cardiometabolic status for CVD risk assessment in this population.

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