Considering a Cardiometabolic Subspecialty

Robert H. Eckel, MD; Ryan Syrek, MA


July 31, 2018

The possibility of recognizing a distinct cardiometabolic subspecialty has been the subject of increasing discussion. We spoke with Robert H. Eckel, MD, a professor at the University of Colorado School of Medicine, Anschutz Medical Campus, to hear his thoughts on the subject.

Medscape: Thanks for speaking with me, Dr Eckel. First off, what specifically would a cardiometabolic subspecialty entail?

Eckel: I think this subspecialty would be driven both by scientific rationale and by clinical rationale in terms of the increasingly obese diabetic and aging population, where cardiovascular disease is very common.

The program that I envision is a 2-year internal medicine residency program, then a 4-year training program in metabolic diseases and cardiovascular disease prevention. I think internal medicine first, rather than family practice, because board specialization by the American Board of Internal Medicine would require an internal medicine specialty training before the subspecialty.

The metabolic training would be in the areas of diabetes, lipid and lipoprotein disorders, obesity, and lifestyle (nutrition, physical activity), with the underpinning of genetics to rule out and expand the horizon that relates to these common metabolic diseases. Unlike the classic endocrinology training program, there would be no formal emphasis on pituitary, thyroid or adrenal disease, reproductive medicine, or metabolic bone disease.

On the cardiology side, there would be no procedural training. These candidates would not have experiences in interventional cardiology, meaning no cardiac catheterization. They would not be involved in advanced heart failure or transplantation-related cardiology. There would be no electrophysiology, meaning training in cardiac arrhythmias and related therapeutics. Their training would be inpatient cardiology consults and inpatient coronary care unit experiences, managing acute myocardial infarction, acute coronary syndromes, and related complications. The trainee would also be schooled in electrocardiography and echocardiography.

Hypertension training would cross over between metabolic diseases (a touch of endocrinology) and cardiology.

Medscape: Given the crossover that already occurs, why the need for a separate subspecialty now?

Eckel: Well, for example, I'm not sure cardiologists are ready to give glucagon-like peptide 1 (GLP1) receptor agonists or sodium-glucose cotransporter 2 (SGLT2) inhibitors to patients, despite the cardiovascular disease outcome trials that show benefit of these agents in patients with diabetes. And metabolic specialists are not in a position go beyond what they've learned as internists in interpreting and billing for ECGs and then echocardiograms. I think we're not going to optimally meet the cardiometabolic patient's need in the current setting. Perhaps "need" is too strong of a word, but I think this is an area that would be right for serious consideration of training people who are going to be overlapping their skill set in both metabolic diseases and cardiovascular disease.

Issues related to cardiovascular disease come up in almost every visit in patients with diabetes. Preventing cardiovascular disease relates to lots of issues. It relates to risk factors, including metabolic issues. I think the Venn diagram between metabolic diseases, such as diabetes, and heart disease has closed increasingly over time. I think that's why it's timely right now. Having doctors explicitly trained in this crossover between these two medical subspecialties really makes a lot of sense.

And there's got to be momentum. I've begun conversations with people at the American College of Cardiology, the American Diabetes Association, and soon with the American Heart Association, where I had the privilege of serving as president a decade ago. I have not formally presented this concept yet, but I don't think there would be any resistance.

The question is, what you do with such organizations as the Obesity Society and the National Lipid Association in terms of bringing them into the fold? I think this is an area where many people within these groups would be very interested, and have historically been very interested in getting this type of concentrated and formalized training.


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