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Preventive cardiology or cardiometabolic medicine: a new and emerging subspecialty?

Wong, Nathan D.

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Cardiovascular Endocrinology & Metabolism: May 18, 2020 - Volume 9 - Issue 3 - p 66-69
doi: 10.1097/XCE.0000000000000206
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While we have seen great reductions in cardiovascular disease (CVD) morbidity and mortality over the past few decades, the rate of these declines has recently diminished, and there is even evidence that CVD mortality may be on the rise once again [1]. Much of this is fueled by the epidemic of obesity, metabolic syndrome and type 2 diabetes [2]. There is a wealth of evidence regarding the efficacy of cholesterol-lowering medications (particularly statins), blood pressure control, and most recently the treatment of diabetes with newer medications that positively impact CVD outcomes [2]. Yet recent data continue to demonstrate inadequate adherence to preventive medications and inadequate control of risk factors [3,4]. Even in the case of diabetes, where CVD is the major cause of morbidity and mortality, while many patients are at reasonable targets for HbA1c, blood pressure, and low-density lipoprotein-cholesterol individually, 20% or fewer are at all three targets simultaneously, suggesting a lack of coordinated care and understanding of the priorities that should be placed to reduce CVD risk in such persons [5]. Moreover, there is a continued rise in obesity both in developing and developed nations, with this closely linked to other cardiometabolic risk factors such as blood pressure and dyslipidemia, as well as being a strong determinant of type 2 diabetes. Consequently, there is an urgency for healthcare providers from different specialties to come together to address together the CVD risks common in many patients if we are to reduce, or at least prevent an imminent rise in CVD morbidity and mortality moving forward. While clearly there has been great progress made in the treatment of persons with known CVD, if we are to make further progress in the next few decades, there needs to be a shift in focus in cardiovascular medicine towards promoting cardiovascular health and prevention. A specialized field of preventive cardiology or cardiometabolic medicine [2] is meant to address this need.

Development of the foundations for preventive cardiology

While there is no formal subspecialty of preventive cardiology or cardiometabolic medicine in the USA, such a field has already naturally developed with many providers and researchers already actively engaged in different aspects of its practice. For instance, the Framingham Heart Study originally championed the term ‘risk factors’ establishing the importance of a number of both traditional and nontraditional risk factors in the development of CVD [6,7] and the development of global risk assessment through its creation of the Framingham Risk Scoring [7]. These and other efforts began the fields of cardiovascular epidemiology and preventive cardiology. Subsequent decades provided clinical trial evidence documenting the efficacy of blood pressure control initially, followed by lipid control with statins and more recently nonstatin therapies, as well as most recently trials of newer glucose lowering therapies showing improvements in cardiovascular outcomes, thus providing the scientific evidence for control of key risk factors for the prevention of cardiovascular events. And with published guidelines for both primary and secondary prevention of cardiovascular disease (CVD) [8,9], the foundations of and rationale for the practice of preventive cardiology (or cardiometabolic medicine) are obvious. Most recently with the proof of newer nonstatin therapies for dyslipidemia and antidiabetic sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists shown to improve cardiovascular and even renal outcomes, and even recently tested and proven anti-inflammatory therapies, together with a base of proven nonpharmacologic regimens in nutrition and physical activity, opportunities remain great for improving our ability to prevent both initial and recurrent atherosclerotic cardiovascular disease events through a rapidly expanding field of preventive cardiology or cardiometabolic medicine. Finally, over the past few decades, professional education opportunities in the field have increased greatly. In fact, for more than a half century the American Heart Association has provided an annual mainly research-focused conference on cardiovascular epidemiology and prevention (now called Epi Lifestyle), and more recently, clinically focused meetings catering to clinicians have been sponsored by the National Lipid Association and American Society for Preventive Cardiology, and other groups such as the Preventive Cardiology Nurses Association and American Association of Cardiovascular Prevention and Rehabilitation. The European Association of Preventive Cardiology, part of the European Society of Cardiology, also has provided for more than a decade an annual conference on preventive cardiology with a special focus on cardiac rehabilitation. While the term ‘preventive cardiology’ is clearly more recognizable and traditional than ‘cardiometabolic medicine’, one could equally argue for the appropriateness of either term.

Need for subspecialty training in preventive cardiology or cardiometabolic medicine

While there exist neither official subspecialty nor certification for preventive cardiology or cardiometabolic medicine in the USA, the growing field of clinical lipidology in the USA remains its closest relative, and in fact many such clinical lipidologists also claim to and actually practice preventive cardiology by nature of managing the myriad of lipid-associated risk factors. While not associated with the American Board of Internal Medicine, the American Board of Clinical Lipidology does provide form training and certification for clinical lipidologists. It is also open to physicians from all backgrounds (primary care, cardiology, endocrinology, or other subspecialties). Moreover, certain short ‘expert’s courses’ such as the 2-day program offered annually by the American Society for Preventive Cardiology provides a solid set of lectures in the field but do not have a formal process for examining and certifying attendants. Ideally, a short-term goal might be to expand such courses to provide more comprehensive training and to create an official ‘American Board of Preventive Cardiology (or Cardiometabolic Medicine)’ that would operate much the same way in examining and certifying individuals as the American Board of Clinical Lipidology does for clinical lipidology. A further goal might be to have Preventive Cardiology housed as an official specialization within cardiology, like how intervention cardiology, electrophysiology, or echocardiography currently is. Such a specialization if certified by the American Board of Internal Medicine as a cardiology subspecialty would only be open to cardiologists, or if certified by an ‘American Board of Preventive Cardiology’ would be open to the broader base of physicians (e.g. internists, family practice providers, endocrinologists, as well as cardiologists) currently engaged in preventive cardiology. This latter approach would clearly be most inclusive and a natural progression for the current multidisciplinary group of physicians practicing preventive cardiology. Finally, and considered most desirable by some [10] would be to have the American College of Cardiology oversee the training and certification of such specialists, in collaboration with other societies such as the American Society for Preventive Cardiology and American Diabetes Association given their expertise, interest, and experience with such certifications. This would ensure a training program that would be of high quality with the diversity of competencies needed.

However, there are alternatives to having such a specialty housed in cardiology. Eckel and Blaha have recently offered that cardiometabolic medicine could be a new subspecialty training track within internal medicine. Thus, one would complete 2–3 years of traditional internal medicine followed by 3 years of further combined training in cardiology and endocrinology [2]. Perhaps more than preventive cardiology, there would be a greater endocrine component that would be ‘metabolism centric’ even including training in obesity pharmacology and the use of insulin pumps and glucose sensors. Such a model would be more inclusive than preventive cardiology being a further specialization within cardiology (thus requiring all to have completed regular cardiology fellowship training), but perhaps less inclusive than the other option presented above that would also be open to family practice providers and specialists outside of endocrinology and cardiology. Their proposal for this to be a subspecialty within the auspices of the American Board of Internal Medicine, of course, has both challenges and benefits.

Certainly, there are pros and cons to where such specialization in preventive cardiology or cardiometabolic medicine is based. If such a program is a specialization within cardiology, would all the practicing physicians need to be board-certified cardiologists, or trainees having to have completed or be enrolled in a traditional clinical cardiology fellowship program? Probably not and in fact, most clinicians claiming to practice preventive cardiology are not clinical cardiologists. And one must remember that the field of lipidology was traditionally in the domain of endocrinology.

Designation of a preventive cardiologist versus specialist in preventive cardiology or cardiometabolic medicine

It has been proposed that the designation ‘preventive cardiologist’ belongs in the domain and infrastructure of cardiovascular medicine [10], where such an individual would have general cardiology training through completion of a fellowship in clinical cardiology, but also the ability to manage all aspects of primary and secondary prevention, including advanced training in lipid metabolism and management, hypertension, diabetes, anticoagulation, obesity, nutrition, and atherosclerosis imaging that would be part of a preventive cardiology fellowship. Nonetheless, others participating in such a fellowship program (fellows and residents from other fields) could still be considered specialists in preventive cardiology, as would nonclinical research experts focusing in the field of preventive cardiology (e.g. cardiovascular epidemiologists or other scientists). A cardiometabolic medicine specialist as proposed [2]; however, would require the completion of 2–3 years of traditional internal medicine residency and would require a fellowship that would comprise of key features related to prevention and cardiometabolic medicine found in both cardiology and endocrinology fellowship programs. Competencies for preventive cardiology or cardiometabolic medicine, therefore, span a much wider range than that of clinical lipidology; however, the later would still remain its own discipline given it may cover certain areas (e.g. complex genetic disorders of lipid metabolism) in greater depth than preventive cardiology in the same way that specialists in clinical hypertension or obesity medicine would have more in-depth experience in their respective areas [10].

Components of a preventive cardiology or cardiometabolic medicine center of excellence

The ideal preventive cardiology or cardiometabolic medicine ‘center’ would be academic-based or with strong academic affiliations, and consist of a multidisciplinary staff consisting of physicians in several fields, especially cardiology, endocrinology, and primary care, as well as lifestyle experts (including registered dietitian nutritionists, exercise physiologists, stress management specialists, and genetic counsellors), clinical pharmacists, and nursing staff. A myriad of services to address primordial, primary, and secondary prevention, focusing on comprehensive risk factor management and including cardiac rehabilitation would be provided. A range of diagnostic testing, professional and public education, as well as basic/epidemiological, clinical, and translational research opportunities for trainees and faculty, should be provided as well (Table 1). A wide variety of services ranging from cardiovascular risk assessment to laboratory and imaging, genetic, and clinical trial services should also be available in the ideal comprehensive preventive cardiology center (Table 2). While individual hospitals, healthcare systems, and even private practice providers can and currently often do provide a sufficient range of such services that they can appropriate designate themselves as preventive cardiology providers, an academic-based center would additionally provide advanced clinical training (as described above) in a residency or fellowship setting, along with research training that may involve the conduct of epidemiologic, clinical trial, or other clinical or translational research projects, ideally with opportunities to publish in the field [10].

Table 1
Table 1:
Components of a preventive cardiology or cardiometabolic medicine program (adapted and modified from Shapiro et al., 2019)
Table 2
Table 2:
Components of preventive cardiology or cardiometabolic medicine services (adapted and modified from Shapiro et al., 2019)

Conclusion

With the continuing epidemic of CVD as the leading cause of death in both developing and developed countries, the need for a preventive cardiology or cardiometabolic medicine specialty remains as great as ever. While it is not clear whether one term is better than the other, what is clear is that there is significant overlap in the practice of either, although depending on the model used, certain providers (e.g. family practice providers) may or may not be included or certain training (e.g. cardiology fellowship) required or not. While there have been significant advances in cardiovascular risk assessment as well as newer strategies to manage dyslipidemia, hypertension, and diabetes, in particular, gaps in coordinated care and comprehensive risk factor control remain significant. The preventive cardiology or cardiometabolic medicine specialist of the future must have training in a wide range of competences to provide the skills needed to optimize cardiovascular outcomes both in the primary and secondary prevention setting. The formalization of specialized training programs as well as greater resources from the healthcare sector to develop specialized centers of excellence in preventive cardiology or cardiometabolic medicine are required to address these needs.

Acknowledgements

Conflicts of interest

There are no conflicts of interest.

References

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