Introduction

Cardiovascular disease (CVD) is the leading cause of death in the United States. About 2,200 Americans die from CVD-related causes each day with an average of one death every 40 seconds.¹ Focusing on prevention has a central role in reduction of CVD-related morbidity and mortality. The annual CVD expenditures exceed $300 billion in direct medical expenditures and could rise to >$800 billion by 2030 as per current estimates.²

Cardiologists and primary care providers play an important role in the delivery of preventive care but most of this experience comes "on the fly" during training. There are, however, certain recommendations, requirements, and resources available for CVD preventive training for physicians. Below, we review and summarize some of them.

Why is Preventive Cardiology Training Important?

Over the last two to three decades there have been significant advances in the knowledge and management of specific CVD risk factors. Consequently, there has been a rapid influx of new guidelines addressing various atherosclerotic CVD risk factors, for example in lipids, hypertension, diabetes mellitus, and thrombosis. Implementation of appropriate diet, exercise, smoking cessation programs, and optimal management of glucose intolerance/insulin resistance, hypertension, and dyslipidemia remain of utmost importance in optimizing cardiovascular (CV) prognosis. Additionally, in the evolving world of CV medicine and an ever-growing importance of cost-effective and high quality health care, prevention and promotion of health has become critically important as most preventive strategies have been shown to have the lowest cost per quality-adjusted life-years.³

In 2012, a survey of cardiology fellowship training programs in the United States revealed that only 24% of the surveyed programs met the Core Cardiovascular Training Symposium (COCATS) guidelines recommendation of a dedicated 1-month rotation in preventive cardiology.⁴ Twenty four percent of these programs had no formalized training in preventive cardiology and 30% had no faculty with expertise in the field of CVD prevention.⁴ The program directors and chief fellows who responded to this survey cited "lack of a developed curriculum in prevention" as one of the most prominent barriers to training in CVD prevention.⁴ Following this survey, the COCATS Task Force 2 recommended a dedicated 1-month training in atherosclerotic CVD (ASCVD) prevention with weekly exposure in cardiac rehabilitation, diabetes mellitus, hypertension, and lipid disorder clinics, or alternatively, a 3-month (or longer) clinical CV rotation with concomitant exposure to a comprehensive CV rehabilitation program at least once a week.⁴

No Central Resource for Prospective Trainees

Although level I training in CVD prevention is required of all cardiology fellows,⁵ this experience is not sufficient for trainees interested in pursuing academic careers and leadership positions in CVD prevention. These individuals likely need an additional year of formalized training. However, there are no centralized "ERAS" like application portals or a consolidated catalogue of training opportunities for fellows or residents to refer to or apply from. Similarly, for candidates with interests to pursue preventive cardiology training out of internal medicine or family practice residencies, there is no clear guidance for applying to a program nor a central board or society with such resources. Candidates on training or work-permit (J1 or H1) visas face the additional burden of finding out which training facilities may support their training.

Current Programs

Several societies (e.g., American Society for Preventive Cardiology, National Lipid Association, American Society of Hypertension, American Diabetes Association) provide guidance on specific aspects of CVD prevention. Similarly, most formalized CVD prevention training programs facilitate learning and expertise in one or two specific CVD risk factors rather than preventive cardiology as a whole.

Various training options are available in preventive cardiology which may cover, but are not limited to, the general outline described below:

• Primary and secondary CVD prevention with emphasis on management of lipid disorders or hypertension or cardiac rehabilitation.
• Cardiovascular genomics.
• Research based (design and conduct of clinical trials, outcomes research training, biostatistics and epidemiological training in CVD).

Pack et al. published a consolidated list of preventive cardiology programs which were clinical and research oriented.⁶ This list, published in 2012, included fifteen preventive cardiology training programs and can serve as a starting point for applicants. However, given that this was published five years ago, changes in program websites, application deadlines, and training descriptions are likely. We have outlined some of the current existing programs in preventive cardiology in Table 1, which have mixed clinical and research training for fellows.

There is also a comprehensive list of the National Heart Lung and Blood Institute (NHLBI) funded Epidemiology and Statistical training programs for MDs and PhDs in CVD Prevention on the NHLBI official website.⁷ These programs, which are primarily research-oriented and aimed towards training pre-doctoral and post-doctoral applicants, are only open to US citizens or non-citizen nationals or green card holders, while those on temporary or student visas are not eligible to apply (some of these programs are listed in Table 2). A complete list for the NHLBI funded training programs can be found at https://www.nhlbi.nih.gov/research/training/epi-bio.

Further, all of these programs are not sponsored or accredited by the American Council of Graduate Medical Education (ACGME) or by the American Board of Medical Specialties (ABMS). Nearly all of them are sponsored by their local state medical board. Finally, there are opportunities for taking board exams certified by independent organizations including the American Society for Preventive Cardiology (ASPC), National Lipid Association (NLA), and American Society of Hypertension,⁵ and obtaining certification.

In summary, while prevention of CVD remains one of the major goals for reducing CVD burden, training resources, although available, are scant and not readily apparent. The American College of Cardiology (ACC) COCATS guidelines provide a general framework and recommendations for basic training in CV prevention required of all training programs in cardiovascular medicine. However, several programs still lack in meeting the trainee requirements for basic training in CV prevention. Moving forward, it would be important for the ACC to collaborate with other central CVD educational bodies like the American Heart Association (AHA), NLA, and others, to not just provide training recommendations but also resources for fellowship programs which may be used to set-up CVD prevention-focused training as well as resources for trainees pursuing CVD prevention careers without available means at their training programs to do so.

By creating a central resource for the training opportunities in preventive cardiology (which may extend well beyond what has been covered this article), central educational bodies like ACC/AHA can aid and direct trainees to these training programs. In addition to providing up-to-date information on existing training programs, the ACC/AHA could develop programs to offer an online curriculum focusing on resources that are commonly lacking in training programs (e.g., smoking cessation guidance, management of resistant hypertension, and cardiac rehabilitation). By providing such a forum, the ACC and the AHA could significantly help further the mission of preventing ASCVD events by emphasizing both primordial and primary CVD prevention.

Table 1: Clinical Cardiovascular Disease Prevention Fellowship programs available for trainees considering a career in cardiovascular disease prevention. US citizens, nationals, and green card holders are eligible for all listed programs. These programs also sponsor international medical graduate applicants requiring visas (typically J1), although this is subject to change.

Program Name	Program Director/ Co-Director	Prerequisites	Number of Fellows		Website/ Program Email Contact
Baylor College of Medicine Houston, TX	Vijay Nambi, Christie Ballantyne	Internal Medicine or Cardiology or Endocrinology Training	1-2	https://www.bcm.edu/departments/medicine/ sections-divisions-centers/atherosclerosis-and- vascular-medicine/education/lipid-and-atherosclerosis-fellowship dhunt@bcm.edu
Brown University Providence, RI	Wen-Chih Wu, Gaurav Choudhary	Internal Medicine or Cardiology Training	1-2	https://www.brown.edu/academics/ medical/education-programs/fellowships debora.mcauliffe@va.gov
Cedars Sinai – Women's Heart Disease and Health Fellowship Los Angeles, CA	Noel Bairey-Mertz, Predeman K. Shah	Internal Medicine or OB/GYN or Family Medicine Training	1	http://www.cedars-sinai.edu/Education/ Graduate-Medical-Education/Fellowship-Programs/Womens-Health/ kremsd@cshs.org
Emory University Atlanta, GA	Laurence Sperling, Terry Jacobsen	Internal Medicine or Cardiology Training	1-2	http://medicine.emory.edu/cardiology/ lsperli@emory.edu
Hartford Hospital Hartford, CT	Paul Thompson, Antonio Fernandez	Internal Medicine or Cardiology Training	2	https://hartfordhospital.org/health-professionals/education/ residencies-fellowships/noninvasive-cardiology-fellowship/applications-contacts Michelle.Bradby@hhchealth.org
Mayo Clinic Rochester, MN	Kyle Klarich, Stephen L. Kopecky	Internal Medicine or Cardiology Training	1-2	http://www.mayo.edu/mayo-clinic-school-of-graduate-medical-education/ residencies-fellowships/internal-medicine-and-subspecialties/cardiology- preventive-fellowship-minnesota olson.ashley@mayo.edu
New York University New York City, NY	Arthur Z. Schwartzbard, Howard S. Weintraub	Internal Medicine or Cardiology Training	1	https://med.nyu.edu/medicine/cardiology/center-prevention-cv-disease/education/education/research ania.coats@nyumc.org
Saint Luke's Mid America Heart Institute Kansas City, KS	James H. O'Keefe	Internal Medicine or Cardiology Training	1	https://www.saintlukeshealthsystem.org/preventive-cardiology-fellowship
Veterans Affairs Hospital Bronx New York City, NY	Clive Rosendorff	Internal Medicine Training	1	Indrawattie.naipal@va.gov
University of Minnesota Minneapolis, MN	Daniel Duprez	Internal Medicine or Cardiology Training	1	https://www.dom.umn.edu/divisions/cardiovascular/ education/subspecialties/preventive-cardiology cvfellow@umn.edu

Table 2: Postdoctoral NIH Funded T-32 Grant Fellowship Programs in Cardiovascular Disease Epidemiology and Prevention. T-32 Grant positions are only available for US citizens, non-citizen nationals or, Green Card holders. Full list available at: https://www.nhlbi.nih.gov/research/training/epi-bio.

Program Name	Program Director/ Co Director	Pre requisite	Number of Fellows	Website Email Contact
Brigham and Women's Hospital/Harvard Medical School Boston, MA	Paul Ridker	Postdoctoral	Data not available	http://www.brighamandwomens.org/research/ depts/medicine/Preventive_Medicine/ pridker@partners.org
Johns Hopkins Bloomberg School of Public Health Baltimore, MD	Josef Coresh, Elizabeth Selvin	Postdoctoral	5	http://www.jhsph.edu/academics/postdoctoral-training/ cardiovascular-disease-epidemiology-training-program/ coresh@jhu.edu
Northwestern University Chicago, IL	Philip Greenland, Mercedes Carnethon, Martha Daviglus	MD, PhD	4	http://www.preventivemedicine.northwestern.edu/ education/cardio-fellowship/programdetails.html p-greenland@northwestern.edu
Stanford Hospital Stanford, CA	Christopher Gardner	MD, PhD	8	http://prevention.stanford.edu/ education/fellowship/criteria.html Alana.koehler@stanford.edu
University of California San Diego, CA	Michael Criqui, Bess Marcus	Postdoctoral		http://cvdepit32.ucsd.edu/ mcriqui@ucsd.edu nsrogers@ucsd.edu
University of North Carolina Chapel Hill, NC	Wayne Rosamond, Gerardo Heiss	Postdoctoral	4	https://sph.unc.edu/epid/epidemiology-research/ cardiovascular-epidemiology-research/ Wayne_Rosamond@unc.edu
University of Pittsburg Pittsburgh, PA	Emma Barinas-Mitchell, Akira Sekikawa, Christina L. Wassel	Postdoctoral	2	http://www.cvdtraining.pitt.edu/ ejb4@pitt.edu
University of Rochester Rochester, NY	Charles J. Lowenstein, Robert Block	Postdoctoral	6	charles_lowenstein@urmc.rochester.edu
Wake Forrest University Winston-Salem, NC	David Herrington	Postdoctoral	Data not available	http://www.wakehealth.edu/School/Cardiology/ Fellowships/Clinical-Cardiology-Cardiovascular.htm dherring@wakehealth.edu

References

1. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics-2017 update: a report from the American Heart Association. Circulation 2017;135:e146-603.
2. Heidenreich PA, Trogdon JG, Khavjou OA, et al. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation 2011;123:933-44.
3. Cohen JT, Neumann PJ, Weinstein MC. Does preventive care save money? Health economics and the presidential candidates. N Engl J Med 2008;358:661-3.
4. Pack QR, Keteyian SJ, McBride PE, Weaver WD, Kim HE. Current status of preventive cardiology training among United States cardiology fellowships and comparison to training guidelines. Am J Cardiol 2012;110:124-8.
5. Smith SC Jr, Bittner V, Gaziano JM, et al. COCATS 4 task force 2: training in preventive cardiovascular medicine. J Am Coll Cardiol 2015;65:1754-62.
6. Pack QR, Keteyian SJ, McBride PE. Subspecialty training in preventive cardiology: the current status and discoverable fellowship programs. Clin Cardiol 2012;35:286-90.
7. National Heart Lung and Blood Institute, National Research Service Award Programs in Cardiovascular Epidemiology, Biostatistics, and Preventive Medicine. 2017. (Accessed March 30, 2017, at https://www.nhlbi.nih.gov/research/training/epi-bio.)

Clinical Topics: Arrhythmias and Clinical EP, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Dyslipidemia, Prevention, Genetic Arrhythmic Conditions, Lipid Metabolism, Diet, Hypertension

Keywords: Glucose Intolerance, Health Expenditures, Risk Factors, Insulin Resistance, Biostatistics, Cardiac Rehabilitation, Smoking Cessation, Lipids, Cause of Death, Cardiovascular Diseases, Diabetes Mellitus, Dyslipidemias, Hypertension, Outcome Assessment, Health Care, Thrombosis, Diet, Genomics, Prognosis, Health Promotion, Primary Health Care, Primary Prevention, Secondary Prevention

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