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Task
Force 10: Training in Preventive Cardiovascular Medicine
Jay M. Sullivan, MD, FACC - Chairman
Edward D. Frohlich, MD, FACC
Richard P. Lewis, MD, FACC
Richard C. Pasternak, MD, FACC
The application of the techniques of molecular biology
to the study of the cardiovascular system has resulted
in the creation of an enormous and growing new knowledge
base of clinical as well as investigative relevance
that demands a sufficient amount of time to master.
It has now been shown that atherosclerotic plaques can
be stabilized or even reversed, with a clinically significant
impact on outcome. Because cardiologists provide most
of the care for patients with symptomatic or advanced
cardiovascular disease, it is imperative for cardiovascular
specialists to become proficient in the primary and
secondary prevention of cardiovascular diseases. This
also includes the ability of the cardiologist to identify
patients at high risk for cardiovascular disease and
to recommend specific primary preventive measures. A
copy of the policy statement on preventive cardiology
and atherosclerosis approved by the American College
of Cardiology is appended. This report outlines specific
areas of knowledge necessary to achieve these goals.
General
Standards and Environment
The training institution must have the appropriate facilities
and staff to conduct a general training program in clinical
cardiovascular medicine. Trainees and staff should have
opportunities for research in the basic biomedical science
departments of the training institution as well as in
the cardiovascular division. It is desirable for this
training to take place in an academic medical center
or an institution with a strong commitment to academic
training and appropriate certification.
Trainees must meet the criteria required for admission
to an adult cardiology training program and should have
adequate preparation in the biologic, physical and epidemiologic
sciences basic to medicine.
The faculty of the institution must be adequate in number
and experience to conduct a training program in clinical
cardiovascular medicine. It is desirable for certain
members of the faculty to have special expertise in
vascular biology, atherosclerosis, hypertension, disorders
of lipid metabolism, peripheral vascular disease, thrombosis,
thrombolysis, preventive cardiology, clinical epidemiology
and the clinical pharmacology of cardiovascular drugs
(1).
Content
of the Training Program
Knowledge in this field can be obtained at three levels.
Level
1
Level 1 includes training that should be part of the
knowledge base of all clinical cardiologists and includes
exposure to the following general and specific areas.
General content areas
- Vascular
biology of the heart and blood vessels. (It is important
for future cardiovascular medicine trainees to understand
the language of molecular biology so as to continue
self-study and critical review of published medical
reports).
- Clinical
epidemiology and biostatistics.
- Principles
of clinical trials and outcomes research.
- Principles
of clinical pharmacology.
Exposure to the following specific content areas is
also essential:
- Diagnosis
and treatment of primary and secondary hypertension.
- Diagnosis
and treatment of primary and secondary dyslipidemias.
- Diagnosis
and treatment of thrombosis and hypercoagulable states.
- Management
of smoking cessation and nicotine addiction.
- Cardiac
rehabilitation.
- Exercise
physiology.
- Nutrition
and its effects on the cardiovascular system.
- Psychosocial
and behavioral aspects of cardiovascular diseases.
- Diagnosis
and treatment of peripheral vascular disease (1).
Training
in these areas should be integrated into consultative,
inpatient and outpatient rotations and didactic components
of core cardiovascular medicine programs. The time allotted
should be equivalent to 1 month of full-time training.
Alternatively, this goal could be met by 1 month of block
time followed by experience in continuity clinics.
Level
2
Level 2 training should achieve a level of expertise
for the cardiovascular specialist so that the trainee
could serve as an independent consultant to other cardiovascular
practitioners in the management of cardiovascular risk
factors. This should involve 6 to 12 months of training
within the 36 months of a cardiovascular training program
and include block time for direct evaluation of patients
with advanced atherosclerosis, resistant hypertension
or hyperlipidemia or recurrent thrombosis.
This could involve block time in hypertension and lipid
clinics or services, or both, coagulation laboratories,
peripherial vascular laboratories, clinical and cardiac
rehabilitation services and additional exposure to behavioral
medicine, exercise physiology, clinical epidemiology,
outcomes research and vascular biology.
The clinical application of information contributed
by newly emerging fields, such as vascular biology and
medicine, lends itself to the development of the clinician/scientist
and the expert teacher/clinician.
Level
3
Level 3 requires advanced training to qualify as a director
of a clinical service or research program, or both.
Examples include director of a preventive cardiology,
hypertension or lipid service; director of a cardiac
rehabilitation program; or director of a vascular biology
laboratory; or a trainee who obtains an MPH in clinical
epidemiology or outcomes research, or both.
Training to this level would require at least 1 year
of a 36-month program. Alternatively, 2 to 3 years in
a vascular biology laboratory or health services outcomes
research/clinical epidemiology program would be required
to attain expertise in these fields, possibly leading
to an advanced degree.
Evaluation
The basic science knowledge and clinical competence
of the trainees must be evaluated regularly by the cardiovascular
medicine program director. The evaluation should include
fund of knowledge; manual, clinical and decision making
skills; and clinical judgment, attitude and relations.
Trainees must be informed about the results of their
evaluations.
Appendix.
Policy Statement
Preventive
Cardiology and Atherosclerotic Disease
To fulfill its mission to foster "optimal cardiovascular
disease prevention," it is appropriate and necessary
that the American College of Cardiology develop a leadership
role in preventive cardiology. In 1980 Dr. Robert O.
Brandenberg, College President, expanded that aspect
of the mission statement as follows: "The mission of
the College is to ensure optimal care for persons with
cardiovascular disease or the potential for developing
it; and ultimately through education and socioeconomic
activities to contribute significantly to the prevention
of cardiovascular disease."
With increasing knowledge concerning the specific roles
of the various risk factors in atherosclerotic and thrombotic
diseases and vascular dysfunction, strategies aimed
at the appropriate detection and modification of these
risk factors now demonstrate the potential for slowing
the progress of atherosclerosis and even regressing
the process. Recent data suggest an important reduction
in adverse clinical sequelae in certain high risk groups.
The results of clinical experiences, clinical trials
and published consensus reports establish that outcomes
can be improved by promoting favorable life-style behaviors
and treating identified abnormalities. When interventions
are appropriately targeted, there is little debate that
they can be both clinically and cost-effective. Current
legislative and social initiatives favor health policies
based on the concept of "prevention." In contrast to
the prevention of cardiac diseases, such as rheumatic
fever and infective endocarditis, it is unlikely that
such measures truly prevent the development of atherosclerotic
disease, or the adverse events resulting therefrom,
although a reduction in disease incidence and severity
is probable, and fewer complications can be expected
in many patients. Therefore, this Committee recommends
that the College reaffirm and expand its policies regarding
prevention of cardiovascular diseases.
The College will actively promote 1) dissemination of
information relative to the prevention of atherosclerotic
cardiovascular diseases and of its adverse consequences;
2) development of educational programs specific to the
role of the cardiovascular specialist with regard to
prevention; 3) cooperative development of practice guidelines,
for consultative as well as rehabilitation services,
to deliver cost-effective preventive care; 4) policies
of fair reimbursement for effective services; 5) participation
in the assessment of clinical outcomes of such programs.
The College recommends that cardiovascular specialists
also promote preventive cardiac care by 1) endorsing
antismoking policies and programs; 2) encouraging healthy
dietary behavior by limitation of total calorie intake,
fat and cholesterol; 3) promoting prudent physical activity;
4) ensuring adequate control of arterial blood pressure;
5) managing patients with hyperlipidemia and with metabolic,
coagulative and other risk factors; 6) advising primary
care physicians with regard to risk reduction; 7) developing
a cardiovascular health promotion plan for cardiac patients
and their families. These actions of the American College
of Cardiology serve to define the opportunities and
responsibilities of cardiovascular specialists.
Reference
- Spittell
JA, Creager MA, Dorros G, et al. Recommendations for
peripheral transluminal angioplasty: training and
facilities. J Am Coll Cardiol 1993;21:546-8.
Copyright © 1995 American College
of Cardiology
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