Editor's Corner | The Evolving Role of the Cardiovascular Professional in Cardio-Diabetology and Cardio-Oncology

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We continue to experience exponential growth in cardiovascular medicine with ever-expanding roles for the cardiovascular professional. This issue of Cardiology highlights the evolving practice of cardio-diabetology and cardio-oncology and the expansion in needed competencies generated by the explosive growth in translational science.

We've seen a revolution in preventive cardiology spurred by advances in lipid and diabetes management, with implications for primary and secondary prevention of atherosclerotic coronary artery disease.

Diabetes is increasingly being considered as a cardiovascular disease – with nearly 30 million Americans having the ailment where the majority will die from complications of cardiovascular disease.

Patients with undiagnosed diabetes, insulin resistance or metabolic syndrome frequently present to the cardiac catheterization laboratory or coronary care unit where care is assumed by the cardiovascular professional.

Remembering to test for diabetes and initiate cardioprotective glucose-lowering therapy should be part of optimal medical management because new therapies may substantially reduce cardiovascular complications in these patient cohorts as part of comprehensive risk management.

Cardiovascular professionals have learned to effectively manage hyperlipidemias and hypertension. This prevention treatment paradigm can now be extended to diabetes management for cardiovascular protection.

The emerging discipline of cardio-diabetology is highlighted by Payal Kohli, MD, FACC, in this month's cover story that highlights a new focus for cardiovascular professionals to treat patients with diabetes with new medications associated with cardiovascular benefit.

The "paradigm of cardiovascular risk reduction has shifted more and more to embracing the concept of treating the patient, not the disease," she writes. "We're no longer considered "internists," "cardiologists" or "endocrinologists." Instead we've become true "physicians," crossing interdisciplinary lines and blurring boundaries between diseases."

This new focus on cardio-diabetology is being driven by two new classes of glucose-lowering drugs, sodium glucose co-transporter-2 inhibitors (SGLT-2i) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs), shown to have cardiovascular benefit – leading to a more comprehensive cardiovascular risk reduction strategy.

SGLT-2i drugs inhibit the SGLT-2 transporter in the proximal tubule of the kidney and lower blood sugar by reducing the resorption of glucose and promoting glycosuria.

These medications include canagliflozin, dapagliflozin and empagliflozin, which are administered orally. Empagliflozin and canaglifozin were shown to reduce the composite endpoint of cardiovascular death, nonfatal myocardial infarction or nonfatal stroke. Empaglifozin reduces hospitalization for heart failure.

GLP-1 RAs stimulate the GLP-1 receptors and include exenatide, lixisenatide, liraglutide and dulaglutide. GLP-1 agonists are administered subcutaneously and mimic the actions of the glucagon-like peptide.

By binding and activating GLP-1 receptors, GLP-1 agonists reduce blood glucose levels, helping patients with type 2 diabetes achieve glycemic control.

Kohli highlights this new era of cardiovascular care as we move from risk reduction to risk factor optimization in a comprehensive patient-centric interdisciplinary approach. The Diabetes Collaborative Registry, developed as an interdisciplinary effort led by the ACC, brings together real-world data from primary care physicians, endocrinologists, cardiovascular professionals and other diabetes care providers.

The ACC has also developed physician and patient education resources on diabetes and cardiometabolic disease, highlighted in the cover article, and the Diabetes and Cardiometabolic Disease Collection on ACC.org is an ongoing resource of news, tools and resources.

The profile of Bonnie Ky, MD, MSCE, FACC, the new editor-in-chief of JACC: CardioOncology, launching in September, reinforces the importance of the emerging discipline and subspecialty of cardio-oncology in response to the rapidly growing number of patients with cancer at risk of or with comorbid cardiovascular disease.

Over 14 million cancer patients and survivors are believed to have significant heart disease risk. Cardiovascular disease and cancer intersect on multiple levels, sharing common causal mechanisms and epidemiological risk factors, and are the two leading causes of death in the U.S. Research has shown the link between cancer and heart disease.

Patients with cancer may have a higher risk of developing cardiovascular disease as cancer therapies may affect the heart and vascular systems.

The discipline of cardio-oncology will depend on collaboration with oncologists and cardiovascular professionals to define competencies for training in this new paradigm of care to address the complex cardiovascular effects of cancer and mitigate the long-term risk of cardiovascular disease in cancer survivors.

As new disease management paradigms move into our domain of practice, our profession will continue to expand. The continued evolution of population-based medicine to personalized medicine will continue to challenge cardiovascular professionals as bench-to-bedside paradigm shifts change the practice of medicine and requires new competencies. Health promotion focused on changing health behaviors to prevent cardiovascular disease will be part of these paradigm shifts.

A patient-centered approach is required. This concept was stated most eloquently by Francis W. Peabody, MD, in a speech he gave to medical students at Harvard Medical School on October 21, 1926:

"…Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient…"

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John Gordon Harold, MD, MACC, is professor of medicine at Cedars-Sinai Smidt Heart Institute, and David Geffen School of Medicine at UCLA, and a past president of the ACC.

Keywords: ACC Publications, Cardiology Magazine, Glucagon-Like Peptide 1, Blood Glucose, Risk Factors, Diabetes Mellitus, Type 2, Coronary Artery Disease, Metabolic Syndrome, Cardiovascular Diseases, Glucose, Coronary Care Units, Secondary Prevention, Cardiovascular Agents, Insulin Resistance, Physicians, Primary Care, Cause of Death, Peptides, Venoms, Immunoglobulin Fc Fragments, Benzhydryl Compounds, Recombinant Fusion Proteins, Glucosides, Glycosuria, Myocardial Infarction, Hypertension, Heart Failure, Stroke, Hyperlipidemias, Registries, Risk Reduction Behavior, Health Behavior, Health Behavior, Hospitalization, Health Promotion, Risk Management, Lipids, Cardiac Catheterization, Symporters, Sodium

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