Dr Robert J Mentz (Duke University Medical Center, Durham, NC, US) joins us to discuss decision-making in cardio-kidney-metabolic (CKM) disease, focusing on how to sequence and individualise guideline-directed therapy when heart failure, renal dysfunction and metabolic disease coexist.

Dr Mentz examines how competing priorities — decongestion, blood pressure and renal function — shape the order in which loop diuretics, SGLT2 inhibitors, ARNI and beta blockers are introduced, and why a staggered approach is sometimes warranted. He considers the case for accepting short-term shifts in creatinine and blood pressure for long-term gain, outlines the role of finerenone and routine albuminuria (UACR) assessment, and shares the practical checklist he applies across HFrEF and HFpEF.

Interview Questions:

1. What makes CKM heart failure decisions feel so high-stakes in everyday practice?
2. In a CKM patient who is congested, hypotensive, and has renal dysfunction, what do you treat first, and how do you sequence therapies?
3. When are you willing to accept a fall in blood pressure or a rise in creatinine for long-term benefit, and when is that a red line for you?
4. Can you share one trial result that has clearly changed how you treat a specific CKM patient profile in your clinic?
5. What simple decision framework do you use for CKM patients that colleagues could copy in tomorrow's clinic?

Recorded on-site at Heart Failure 2026, Barcelona.
Editors: Jordan Rance
Videographer: David Ben-Harosh, Tom Green
Support: This is an independent interview produced by Radcliffe Cardiology.