Preventive cardiology: Setting the stage for integration of lipids, diabetes and the heart
PHILADELPHIA — In recent years, preventive cardiology has spontaneously emerged as its own “subspecialty” across multiple disciplines, including cardiology, endocrinology, internal medicine and primary care, but there remains no consensus on the boundaries of preventive cardiology, Sergio Fazio, MD, PhD, said at the third annual Heart in Diabetes conference.
Fazio, who is director of the Center for Preventive Cardiology at Knight Cardiovascular Institute at Oregon Health and Science University, addressed the issue of lipid management and its purview under the endocrinology and cardiology disciplines. Fazio, along with others in the field, has proposed that preventive cardiology should be its own subspecialty. But the question remains: to which medical specialty would preventive cardiology belong?
“The practice of cardiometabolic medicine is part of a larger preventive cardiology umbrella,” said Fazio, who is an endocrinologist and preventive cardiologist. “In both academic and private settings, preventive cardiology best serves the needs of patients by being part of a cardiology enterprise.”
However, there are a number of biases when it comes to this discussion, including “perceptions that lipid metabolism is an endocrine domain ... [and also that] some don’t see the difference between preventive cardiology and the lipid clinic,” Fazio said.
During his presentation, Fazio argued that “deep knowledge of lipid metabolism is not an endocrine domain. It is also not a cardiology domain. It is the domain of committed preventive cardiologists.
“Preventive cardiology is a lot more than managing lipids and diagnosing dyslipidemia. Cardiology has contributed to the field [of preventive cardiology] from its inception and has secured its title as the home for this discipline.”
However, challenges remain. Lipid and glucose disorders are common, underdiagnosed and undertreated, Fazio said. Expertise in lipid and glucose metabolism is not only for the heart. Patients need expert lipid and glucose management as well as expert CVD risk assessment and management. But, without consensus, many hospitals have diabetes centers, lipid clinics and preventive cardiology services as competing enterprises, he said.
“The field faces a tremendous opportunity to finally acquire status as a subspecialty, and trademark confusions and redundancies should be addressed urgently and with clarity and consensus,” Fazio said.
What does the future hold?
“It’s our obligation to create a structure for the next generation of people who want to do what we do, but we need to agree on what we call it, and I think that should be preventive cardiology, not cardiometabolic medicine,” Fazio told the audience at Heart in Diabetes.
Fazio highlighted his own path to preventive cardiology, which started with a lipid program in an endocrine division, changed focus to CVD prevention in an integrated practice of cardiologists and endocrinologists, and ultimately led to the launch of the preventive cardiology program at Knight Cardiovascular Institute. In his preventive cardiology program, cardiologists and endocrinologists work together to offer lipid, biomarker and genetic testing; noninvasive imaging for CVD risk assessment; dietary services; cardiac rehabilitation; LDL apheresis; clinical trials; a PCSK9 inhibitor clinic; clinical pharmacy services; education and training of students, residents and fellows; and outreach activities.
“The future of the [preventive cardiology] subspecialty relies on creating a structure for education and training that passes muster with ABIM-style certification,” he said.
Fazio emphasized the importance of training cardiology fellows with an educational curriculum that integrates aspects of prevention, diabetes and lipids. These should not be “guest topics” for cardiology fellows, he said. Another proposal is for third-year fellows to have preventive service as a choice for continuity clinic and for clinical or basic research opportunities. Fazio also suggested that preventive cardiology services partner with fellowship directors to obtain accreditation and structuring of the preventive component in the education curriculum. Overall, he proposed that endocrinologists, cardiologists and internists should collaborate in current preventive cardiology programs.
“The future is for a model of preventive cardiology that takes on both clinical lipidology, cardiometabolic medicine staying in the beginning on the ischemic side of things, but then expanding into the other components of cardiology that have an important element of preventability and early detection/early treatment, such as atrial fibrillation, congestive heart failure, valve disease, etc.,” he said. – by Earl Holland Jr.
Fazio S. Expert in Cardiabetes Should be Preventive Cardiologist. Presented at: Heart in Diabetes CME Conference; July 12-14, 2019; Philadelphia.
Disclosure: Fazio reports serving as an advisor to Amarin, Amgen, AstraZeneca, Esperion and Novartis.