Cardiometabolic Medicine: Development of a New Subspecialty

David R. Saxon; Cara Reiter-Brennan; Michael J. Blaha; Robert H. Eckel

Disclosures

J Clin Endocrinol Metab. 2020;105(7):2095-2104. 

In This Article

Current Landscape of Caring for Patients With Established Cardiovascular Disease and Diabetes

For the patient with established ASCVD, heart failure, obesity, T2DM, chronic kidney disease, and progressive forms of nonalcoholic fatty liver disease, in a world where subspecialists use an overlapping set of medications for multiple disease states, will the patient require the close care of a primary care physician, cardiologist, endocrinologist, nephrologist, or even hepatologist? Or perhaps there is potential for receiving comprehensive multimorbidity care that is less burdensome to the patient with T2DM and CVD?[36] Will endocrinologists feel comfortable adding SGLT2i to patients already on multiple other heart failure medications? Will cardiologists, seeing benefits in GLP-1 RAs and SGLT2i for specific patients, take on the role of managing blood glucose levels and adjusting other glucose-lowering agents when one of these agents is prescribed? Thus far, despite cardiologists' considerable interest in these medications' benefits[37] and FDA labels supporting their cardiovascular benefit, prescription rates of liraglutide and empagliflozin to patients with T2DM by cardiologists has been low.[38,39] Specifically, from 2013 to 2017, only 4.5% of all SGLT2i prescriptions came from cardiologists (whereas 45.2% and 22.7% came from endocrinologists and primary care, respectively) and prescribing practices did not change substantially in the year after the addition of the CV indication for empagliflozin.[39] Similarly, an evaluation of US-based administrative claims data from 2013 to 2018 showed that less than 0.5% of SGLT2i and GLP-1 RA prescriptions were initiated by cardiologists, and their prescribing remained low even among the subgroup of patients with established CVD.[40]

Currently few clinicians are trained or work in practice environments that allow them to comprehensively treat patients who have multiple metabolic comorbidities and established CVD (or are at high-risk for cardiovascular events). While some may argue that primary care physicians could and should deliver much of the secondary preventive care for patients with established ASCVD, the reality is that their ability to focus on this time-intensive and changing paradigm of care is likely to often be overshadowed by other concerns that arise during routine primary care visits. Competing interests in primary care practice already challenge their ability to counsel on weight management and lifestyle.[41] Furthermore, because insurance approval of newer medications often requires prior authorizations, many practice environments may not have the systems in place or time to support the routine use of certain medications.

Although cardiologists may be well positioned to participate in diabetes care given their numbers and distribution of T2DM cases,[42] there is substantial and understandable reluctance by cardiologists to manage T2DM. In one model of care, it has been suggested that cardiologists perform routine, systematic measurement of glycated hemoglobin in all patients with established CVD and refer to primary care physicians and endocrinologists for consideration of SGLT2i and GLP-1 RAs, or to initiate SGLT2i and refer to these providers.[43] However, in addition to the already mentioned limitations that primary care faces, the availability of endocrinologists to keep pace with the rising T2DM epidemic is severely limited and this shortage of endocrinologists is expected to grow.[44] Presently there are <7500 board-certified endocrinologists but nearly 30 000 board-certified cardiologists. One recent analysis of the Yale–New Haven Hospital System in 2017 found that cardiologists were more than 5 times as likely than endocrinologists to have had a visit from patients with T2DM and CVD.[45] Furthermore, while development of expertise in diabetes management is a major aspect of all endocrinology training programs, training remains glucose-centric with a focus on HbA1c reduction, new diabetes technologies, and mastery of insulin adjustment, continuous glucose monitoring, time in range and hypoglycemia avoidance; much less time is spent learning about cardiovascular comorbidities (ie, atrial fibrillation and heart failure), optimization of lipids, obesity management, and cardiovascular imaging used to make nuanced decisions about cardiovascular risk reduction.

There appears to be a growing interest amongst clinicians in receiving training that focuses on chronic metabolic disease management. Obesity Medicine, a field that developed through the merger of 2 prior certification pathways and has offered board certification since 2012, has seen a rapid rise in the number of physicians sitting for the board certification examination.[46] However, despite almost 900 physicians taking the exam in 2019, only about 10 formal training programs exist in the United States. A small number of subspecialty training programs also exist in preventive cardiology, clinical lipidology, hypertension, and diabetes; however, most people who receive certification in these areas do so through self-directed practice experience and various continuing medical education formats. Overall, these programs—and their associated established fields—slice-and-dice the management of patients with metabolic disease so that trainees and practicing clinicians develop expertise in 1 or, perhaps, a few areas at the intersection of metabolic and cardiovascular diseases, but truly comprehensive clinical training in this area is lacking. We believe there should be a dedicated medical home for cardiometabolic patients—the current fragmented model of care among various specialties must be improved upon.

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