COMMENTARY

Who Is the 'Cardiometabolic Specialist'?

Cardiologists and Endocrinologists Are Playing in the Same Diabetes Sandbox

Jay H. Shubrook, DO; Robert H. Eckel, MD; Mikhail N. Kosiborod, MD

Disclosures

September 11, 2018

Jay H. Shubrook, DO: Hello. I am Jay Shubrook, family physician and professor at Touro University California in Vallejo. We are at the 78th Scientific Sessions of the American Diabetes Association in Orlando, Florida. We are going to discuss the complexities of managing patients with type 2 diabetes and cardiovascular (CV) disease. Joining me for this discussion are two colleagues.

Mikhail N. Kosiborod, MD: Hi. I'm Mikhail Kosiborod, professor of medicine and director of cardiometabolic research at Saint Lukeʹs Mid America Heart Institute in Kansas City, Missouri.

Robert H. Eckel, MD: And I am Bob Eckel, professor of medicine in the Division of Endocrinology, Metabolism, and Diabetes, and the Division of Cardiology at the University of Colorado Anschutz Medical Campus in Aurora. I am also privileged to have been the president of the American Heart Association (AHA) a decade ago.

Who Should Manage Patients With Type 2 Diabetes and CV Disease?

Kosiborod: The care of patients with diabetes and CV disease is really a team sport. We have stayed in our own silos for a long time, but it's time for us to come together and make sure it is not each specialist running their own target organ system, but rather that we are thinking of ways to improve all of the key outcomes for people with diabetes to make them live longer and feel better, which ultimately is what they care about.

Eckel: You know, the term "cardiometabolic" was highly criticized when it was born about 15 years ago, but now we are living in a cardiometabolic age. I believe that we need to pause here for a second. I view endocrinologists as either reproductive/glandular-focused, metabolic bone disease–focused, or diabetes/lipids/obesity/CV disease–focused.

But based on the recent outcomes trials looking at the GLP-1 receptor agonists[1] and the SGLT2 inhibitors,[2,3] how much of a role should the cardiologist be playing in the diabetes sandbox, and how much of a role should the metabolic physician who is interested in preventive cardiology play in going beyond simply metabolic management of patients? And remember, I am in your space; I am in the cardiology clinic. Mikhail?

If reducing cardiovascular death and prolonging life is not in our domain, then I don't know what is.

Kosiborod: Excellent question. I would say, from a cardiologist’s standpoint, that when you talk about interventions such as the ones you mentioned—the GLP-1 receptor agonists, the SGLT2 inhibitors, and perhaps additional agents that have been shown to have CV benefit—if you are talking about agents that provide robust CV benefit, and in some cases reduction in CV death, it becomes instantly important to a CV specialist.

If reducing CV death and prolonging life, preventing myocardial infarction, stroke, and heart failure—if that is not in our domain, then I donʹt know what is. That is what we do; we manage CV risk in people with type 2 diabetes.

Just because there are additional classes of medications that we need to learn about does not mean that we would necessarily relegate that to others to manage. Now, it does mean that we need to learn. We need to understand how the medications work. We need to understand how they interact with other aspects of diabetes care. That is where we need a lot of help and collaboration with endocrinology colleagues.

Eckel: Well, is metformin always the number-one drug now to treat patients with type 2 diabetes? I am in the endocrine space now. I am going to say it is, but is it really? I think the new trials ask us to make new inquiries about evidence-based medicine going forward.

Kosiborod: Absolutely. I believe the question you raise about metformin is one of the key questions being asked in the field. We finally are at the point of asking this fundamental question of whether metformin remains foundational therapy for all patients with type 2 diabetes. Some studies that are being conducted will try, for the first time, to truly understand the CV implications and the effect that metformin has on CV outcomes in the appropriately powered studies. It will take many years to answer those questions, but at least that process has started.

For many cardiologists, as they enter the space and want to learn more, the fundamental issue is to figure out whether they want to be in the management model—which is where I am; for example, I am very comfortable using these medications in my own practice—or whether they will be more in the consultative model, if you will, where they perhaps bring up the issue of management with the patientʹs primary care doctor or endocrinologist and recommend certain interventions but donʹt actually write the prescription or initiate the medications themselves. I think there is room for both models in the CV space.

Eckel: Two questions: First, what percentage of cardiologists are in that space with you?; and second, what about glycemic control? Is that no longer important for you as a preventive cardiologist?

Kosiborod: Those are a couple of loaded questions! First, what proportion of cardiologists actually think about this and what proportion actually act on it? I would say that a growing number of my colleagues are beginning to think about recommending agents such as SGLT2 inhibitors and GLP-1 receptor agonists. They may not yet be comfortable enough to actually initiate the treatment or prescribe these drugs. But I believe the tide is starting to shift.

Much of this movement has to do with the fact that we cannot ignore interventions that provide this degree of benefit—in many cases, the types of benefits we have not seen before, including reductions in all-cause mortality. That is not easy to show with any agent for type 2 diabetes, and we have had more than one example of that.

Still, this is a small number of cardiologists and an even smaller number of those who are actually comfortable managing patients. I believe that is an indication that we need to develop a new cadre of people who are cross-trained in CV disease and managing some of the endocrine aspects of type 2 diabetes. As you said, technically speaking, it is one field—the cardiometabolic field. The traditional training concepts are still siloed, as is the way training programs work right now for fellowships in cardiology and endocrinology. Trying to break those silos and cross-train people will be very important.

Eckel: And glycemia?

The message to cardiologists is that they are not doing it for glucose control; they are doing it for risk reduction.

Kosiborod: As far as glycemia is concerned, we all acknowledge that prevention of microvascular complications is still very important. In fact, when you ask patients with diabetes what is most important to them, they always pick retinal disease and kidney disease as issues of critical importance.

So we continue to recognize that, but I believe that for the cardiologist to embrace this, it is important to point out that their role is not to manage blood glucose but to manage CV risk. You cannot completely decouple one from the other because the medications we are talking about will affect both. But the good news is that these medications donʹt tend to cause hypoglycemia, at least when they are not coupled with medications such as insulin or sulfonylureas, for example.

Cardiologists are ultimately educatable and they can learn very quickly how to manage these medications in a most effective and safe way. The message to cardiologists is that glucose control remains important for microvascular disease prevention, but in order to engage the specialty, I think it's important to keep in mind that they are not doing it for glucose control; they are doing it for risk reduction.

Eckel: So, Jay, Mikhail and I have discussed this, and we have discussed it with other members of the American Diabetes Association and the American College of Cardiology, and less so with the AHA at this point. Future training for the cardiometabolic specialist may include 3 years of internal medicine followed by a 4-year program that will include 2 years of cardiology and 2 years of metabolic diseases, dismissing the reproductive, thyroid, pituitary, and metabolic bone disease areas; in the cardiology space, there would be no electrophysiology, no transplantation-related instruction, no interventional cardiology. This would be someone who is trained in cardiology for electrocardiography, and perhaps echocardiography, who could cross-fertilize this space we now call cardiometabolic medicine.

Shubrook: With these specialists, how do we maximize care of the patient? As we start to have diseases that overlap and treatments that overlap, how do we prevent duplication of services? How do we make sure that we are doing the best together for the patient? Any insights?

Eckel: I think the primary care physician needs to be engaged in primary prevention, knowing issues that relate to metabolic-centered phenotypes, with blood pressure, lipids, glycemia, fasting plasma glucose, postprandial glucose metabolism, and A1c as a marker for those. Do your best to prevent those heart attacks with guidelines used to achieve goals. Once that patient transitions into more complicated care or has an infarct, you need one or both of us.

Kosiborod: For really complex patients who already have established disease, you really need to try to create a team of specialists. That could include cardiologists and endocrinologists, and in some cases, there could be a nephrologist as well, if the patient has renal disease. The team needs to reach consensus about the best way to manage the patient.

Several programs around the country have successfully achieved that model. This is what Bob does in his practice every day, and it works extremely well. As I said, the tide has started to turn toward making this the new standard of care. My hope is that it is only going to accelerate. It absolutely should if our goal is to improve important outcomes in people with type 2 diabetes—not just making their numbers look better, but making sure they live longer, feel better, or, best of all, a combination of both.

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