CVD Prevention: Perspective For FITs
The incremental understanding of cardiovascular disease over the past three decades has led to advances in its risk factor modifications and treatment strategies. Therefore, newer guidelines on prevention and treatment measures related to lipids, hypertension, diabetes, obesity, thrombosis and vascular diseases have exponentially increased.
However, cardiovascular disease remains the leading cause of morbidity and mortality worldwide. Yet, the journey from initial atherosclerotic plaque formation to an atherosclerotic cardiovascular disease (ASCVD) event is a process that may be largely modifiable.
Education in cardiovascular disease prevention – including familiarity and the use of newer diagnostic modalities – are key to a more comprehensive detection of high-risk cardiovascular disease populations.
As with other areas in cardiovascular disease training, perhaps the best strategy to implement prevention education is at the core training level during residency or fellowship.
Previously, Quinn R. Pack, MD, et al., showed that amongst the U.S. cardiology fellowship training programs, only 24 percent of the surveyed programs met the Core Cardiovascular Training Symposium (COCATS) guidelines, with a dedicated one-month rotation in cardiovascular disease prevention.
In approximately 24 percent of the programs, there was no formalized training and "30 percent lacked faculty with expertise in the field." In this survey, the program directors and chief fellows cited "lack of time" and "lack of a developed curriculum in prevention" as the biggest barriers to the training in cardiovascular disease prevention.
As per the COCATS 4 Task Force 2 guidelines, endorsed by the American Board of Internal Medicine and Accreditation Council of Graduate Medical Education (ACGME), three levels of training are described and currently applicable:
- Level I: Basic training required for all physicians to become competent cardiologists. This level of training can be achieved by at least one month of training dedicated to cardiovascular disease prevention medicine.
This one-month rotation should encompass weekly attendance at a cardiac rehabilitation program, diabetes or endocrinology clinic, hypertension clinic, and dyslipidemia management clinic.
An alternative to the one month dedicated to cardiovascular disease prevention is a three-month (or longer) training in comprehensive cardiac rehabilitation with at least weekly attendance.
- Level II: Additional training in "one or more areas that enable cardiologists to perform or interpret specific procedures or render more specialized care for specific patients and conditions."
For prevention, the Task Force identified no specific competencies for Level II training.
- Level III: For trainees who are interested in seeking expertise to attain program director-level positions in clinical, research or combined programs.
At this time, no formal level III training program or curriculum has been identified for cardiovascular disease prevention.
To attain level III in cardiovascular disease prevention training, Fellows in Training (FITs) are encouraged to attain additional (non ACGME-accredited) fellowships.
Allotting significant resources for cardiovascular disease prevention training and management in the clinical setting has its challenges, which include but are not limited to lack of financial reimbursements and health policy.
As a result, several organizations and institutions have taken it upon themselves to introduce independently funded fellowships aimed at the so-called "preventive cardiology" or "prevention of cardiometabolic diseases" fellowship programs.
Some of the main challenges in pursuing a career in cardiovascular disease prevention include the absence of a formalized curriculum. Similarly, there is no centralized board examination for certification in cardiovascular disease prevention.
Efforts have been previously made to design such a curriculum/fellowship training structure and to enlist the currently available programs offering training positions for those residents/FITs interested in gaining specialized cardiovascular disease prevention training.
With recent advances in medications to modify risk factors like hypercholesterolemia, hypertriglyceridemia, diabetes and associated ASCVD events, the time is now more than ever to focus energies into expanding the field of cardiovascular disease prevention.
With recently growing presence of FIT bodies in institutional organizations like the ACC and others, there are several forums to explore the niche of cardiovascular disease prevention, allied training and educational opportunities to get involved at the grass root level.
In addition to these training programs where interested trainees can apply for formal one- to two-year training in cardiovascular disease prevention, opportunities to be involved in various position in the national councils exist.
The enormous threat of cardiovascular disease is likely to be faced by all of us, everywhere. However, we should not forget that ASCVD is a lifelong process – one which we already have the tools to slow down, if not eradicate.
The framework for the training in cardiovascular disease prevention and to train future generations in the field is already present, though scattered. More interest and dedicated training in cardiovascular disease prevention can certainly enable us to lead the path to discovery and one day eliminate ASCVD.
The crucial question is, are we ready to allot significant resources to research training and funding, clinical training, education, and reimbursements in cardiovascular disease prevention?
It is an imperative question – one that is be hoped to be met with an emphatic "yes."
Visit the Prevention Clinical Topic Collection on ACC.org and the ACC Prevention of Cardiovascular Disease Section page for the latest science and news.
This article was authored by Anum Saeed, MD, Fellow in Training (FIT) at the University of Pittsburgh in Pittsburgh, PA.