“Cardiabetes”: Is It Time for a New Subspecialty?

Cardiovascular disease (CVD) and diabetes are fundamentally related. Does their relationship — and the growing number of patients who suffer from both — warrant a new medical specialty?

A debate with leading experts in the field aimed to address this question at the 3rd Annual Heart in Diabetes Conference, held July 12 to 14, 2019, in Philadelphia, Pennsylvania.

In support of a specialty created for cardiometabolic medicine was Robert H. Eckel, MD, Professor of Medicine in the Division of Endocrinology, Metabolism, and Diabetes, and Cardiology at the University of Colorado School of Medicine in Aurora, Colorado. In his argument, Dr Eckel stated that after decades of decreasing CVD mortality in the United States, the overlap of metabolic disorders and CVD has reversed this trend in recent years. In what he described as “the cardiometabolic dilemma,” CVD risk persists in patients beyond good glycemic control and weight loss, even with newer antidiabetic medications that have proven CV benefit.¹

In his presentation, Dr Eckel questioned whether the cardiology practice was willing and capable of assuming responsibility for the care of a patient with cardiometabolic disease, particularly regarding management of hemoglobin A1c targets, time in range goals, and insulin regimens.

He proposed a 3-year program outline for cardiometabolic medicine fashioned after geriatrics/gerontology or hospice and palliation subspecialty training programs, including components of endocrinology (obesity, diabetes, lipid disorders), cardiology (electrocardiogram, echocardiogram, rehabilitation, vascular medicine), and internal medicine (lifestyle, smoking cessation, hypertension).¹

Other experts suggested that this specialty already exists in the form of preventive cardiology. “Deep knowledge of lipid metabolism is not an endocrine domain,” said Sergio Fazio, MD, PhD, Professor of Medicine and Physiology & Pharmacology and Director of the Center for Preventive Cardiology at Oregon Health and Science University in Portland, Oregon. “It is also not a cardiology domain. It is the domain of committed preventive cardiologists.”²

Preventive cardiology, a subspecialty of cardiology that emerged somewhat spontaneously — currently there are no clear boundaries between the disciplines — encompasses the practice of cardiometabolic medicine and more, Dr Fazio argued. Clinicians with a special interest in cardiology with a focus on lipid and glucose management are those who pursue this area of medicine.

According to Dr Fazio, the focus should not be on creating a new specialty, but on implementation of a structured education and training program for preventive cardiology through the collaboration of endocrinologists, cardiologists, and internists. Diabetes, lipids, and prevention should become an integrated part of the education curriculum for cardiology fellows, and preventive service should be an option for continuity clinic and research.

“Cardiology has contributed to the field from its inception and has secured its title as the home for this discipline,” said Dr Fazio. “In both academic and private settings, preventive cardiology best serves the needs of patients by being part of a cardiology enterprise.”²

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References

1. Eckel RH. Cardiometabolic medicine: time for a new subspecialty. Presented at: 3rd Annual Heart in Diabetes Medical Conference; July 12-14, 2019; Philadelphia, PA.
2. Fazio S. Cardiometabolic medicine or preventive cardiology? Presented at: 3rd Annual Heart in Diabetes Medical Conference; July 12-14, 2019; Philadelphia, PA.