Is there a need for a new cardiometabolic medicine subspecialty?
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The time is right to consider a formal training program in cardiometabolic medicine.
We know that obesity prevalence continues to increase, that metabolic syndrome follows and a higher incidence of type 2 diabetes is now before us.
The interactions between these metabolic diseases and CVD is increasingly important. Imagine you have a patient admitted to the hospital with acute MI, who may have had impaired glucose tolerance, and now has type 2 diabetes. Who sees this patient at discharge? The hospitalist cardiologist will certainly not see this individual. Instead, he or she will enter into a new space with a new cardiologist. Considering the new trials with GLP-1 receptor agonists or SGLT2 inhibitors, this patient may be a candidate for one of these therapies, not only to treat their type 2 diabetes, but also to reduce CV risk.
Metformin typically is utilized as the first oral glucose-lowering agent for type 2 diabetes, but with compelling new clinical data, this physician must consider these newer agents. I would contend that a cardiologist is not comfortable taking care of patients with diabetes, particularly when strategies go beyond metformin alone. The endocrinologist is certainly capable; however, what if the patient develops a cardiac rhythm disturbance or has chest pain? Then referral to cardiology is needed. In family medicine or internal medicine, the primary care physician may not be prepared or evidence-based in their therapeutic approach.
A post-internal medicine resident training program in cardiometabolic medicine would encompass metabolic elements of endocrinology — no emphasis on thyroid disease, bone disease, reproductive medicine or pituitary and adrenal disease — and focus instead on obesity, diabetes, metabolic syndrome, insulin resistance and lifestyle medicine. On the cardiology side, a preventive cardiologist who trained as a cardiometabolic physician would no longer need to be in the cath lab; no longer need to be in the coronary care unit, learn and practice electrophysiology or advanced heart failure, though this person would be extensively trained in imaging. We expect this kind of physician to be academically inclined and hopefully engaged in research that relates metabolic disease to CVD, but ultimately, be able to take care of an insulin infusion pump or a continuous glucose monitor, and also be able to read a very difficult ECG and echocardiogram.
This specialist, after a 2- or 3-year training program, would be entirely prepared to meet every aspect of this growing population of obese patients with type 2 diabetes who have or are at high CV risk.
Robert H. Eckel, MD, is emeritus professor of medicine in the divisions of cardiology and endocrinology, diabetes and metabolism, emeritus professor of physiology and biophysics and the Charles A. Boettcher II Chair in Atherosclerosis at the University of Colorado Anschutz Medical Campus, past president of the American Heart Association and president of medicine and science for the American Diabetes Association.
We must broaden the current curriculum.
No one disagrees that the prevalence of obesity, metabolic syndrome and type 2 diabetes has grown to epidemic proportions. So much so that it is not feasible for every patient with type 2 diabetes at high cardiovascular risk who needs to be prescribed, for example, a GLP-1 receptor agonist or an SGLT2 inhibitor — which is really the big driver behind this movement — to see a physician who is board certified in cardiometabolic medicine. It is not practical, given the burden of disease.
There are ways we can and should incorporate what we are learning, particularly from the new CV outcomes trials of diabetes drugs, as well as the increasing understanding of the links between diabetes, obesity, insulin resistance and cardiometabolic disease, into the curriculums of existing fellowships, such as endocrinology, cardiology and nephrology. A better model could include looking at the areas where internists and certain subspecialists need to be trained and making sure they receive that training during their residency or fellowships. We would certainly want to ensure this information is incorporated into training for endocrine fellows as well as cardiology and nephrology fellows.
I advocate for broadening the curriculum of multiple, overlapping specialties. Potentially, we could also consider a 1-year, unaccredited fellowship where an individual can gain additional expertise in a practice area. This could be modeled, for example, after the obesity medicine certification, an on-site clinical fellowship with an obesity component where the fellowship director attests to at least 500 hours on the topic of obesity, on top of training in general medicine, family medicine or a specialty such as endocrinology or cardiology. That could be a reasonable approach.
The creation of a new subspecialty would present many hurdles, not the least of which are multiple levels of approval, securing funding, and adoption of the curriculum by training programs and their accreditation agencies. The push, instead, should be to work with the existing boards and their oversight groups to ensure that this content is incorporated rigorously.
E. Dale Abel, MD, PhD, is chair of the department of internal medicine and director of the Fraternal Order of Eagles Diabetes Research Center at the University of Iowa Carver College of Medicine, where he holds the Francois M. Abboud Chair in Internal Medicine and the John B. Stokes III Chair in Diabetes Research, and immediate past president of the Endocrine Society.
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