A Need for Prevention
For many decades, cardiologists have treated critically ill patients and pioneered procedural and medical therapies to heal the severely compromised heart. Medication to prevent disease progression, new generations of coronary stents, and robust mechanical circulatory support are staples of modern cardiac training. However, just as aggressive as these therapies are in treating existing atherosclerotic vascular disease and/or impaired ventricular function, a strong need exists for equally aggressive primary and secondary prevention strategies.

As personalized strategies for prevention arise, there is a clear demand for a specialized training in Preventive Cardiology. In their recent article, Shapiro and colleagues highlight in detail the rising demand and future direction of Preventive Cardiology training.¹

The Past and Present of Prevention
In their article entitled Preventive Cardiology as a Subspecialty of Cardiovascular Medicine, the authors describe the natural ascent of Preventive Cardiology as a specialty. The Framingham study set the framework for identification of risk factors for atherosclerotic cardiovascular disease (ASCVD).

Since then a variety of cohorts such as the Multi-Ethnic study of Atherosclerosis (MESA) and the Atherosclerosis Risk in Communities study (ARIC) have allowed for further risk stratification in the primary prevention setting.^2,3 Similarly, in secondary prevention, we have learned a great deal about who the highest risk patients are and who will most likely benefit from aggressive preventive therapies.

Numerous clinical trials have provided direction on tailored preventive therapies. Recent clinical trials, such as those for aspirin use in primary prevention or in older patients, sodium glucose cotransporter-2 (SGLT2) inhibitors in individuals with cardiovascular risk factors, and proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors in individuals with dyslipidemia, have changed the clinical landscape in Preventive Cardiology. These results have fueled the desire for further risk reduction strategies, and importantly a need for translating science into direct patient care.

Translating Research into Practice
Preventive Cardiology is emerging naturally as a field, given the enormous breadth and depth of research that focuses on the prevention of cardiovascular disease. Historically, Cardiology fellowship training had focused largely on secondary prevention and management of acute illness. As indications for a variety of primary prevention interventions become more complex with the availability of new data, focused training in Preventive Cardiovascular medicine has become even more critical.

Though this type of preventive care can be practiced by general cardiologists, general internists, or family physicians, designating a new subspecialty will allow for standardization of training and expected level of care. Furthermore, designating a specialty as the responsible group for practicing Preventive Cardiology allows for directed referrals by other health care providers for further management that would include a great emphasis on sustained lifestyle changes.

Preventive Cardiology Fellowship
Shapiro and colleagues describe a need for collaborative training with a variety of clinical specialists such as dietitians, pharmacists, and lifestyle counselors.¹ This would permit a comprehensive approach for the management of metabolic syndrome, diabetes, hypertension, dyslipidemia, and smoking cessation with the ultimate goal of cardiovascular risk reduction.

There are currently no set competency standards for Preventive Cardiology training. Further inter-disciplinary discussion will help determine the most productive structure for a training program. Of the prevention areas that are frequently discussed there is an under-recognized need to focus on vascular medicine, complex dyslipidemias, and a strong research skill set.

Vascular Medicine
Many patients who develop coronary heart disease also develop vascular disease such as peripheral artery disease (PAD) or thoracic or abdominal aortic aneurysm. Training should include the screening and diagnosis and medical management of vascular disease. Antithrombotic therapy is a key topic in both prevention and vascular medicine. The role of exercise is critical in the prevention and treatment of cardiovascular diseases including PAD.

It is important to have exposure to Vascular Medicine during training so that patients with these illnesses can receive appropriate management. The evidence for use of antiplatelet therapies, novel therapies for dyslipidemia, and cardiovascular benefits of diabetes medications is ever-changing and continually progressing towards tailored therapies. Data-driven prevention and management of vascular disease should be within the skillset of fellows in training (FITs) and early career cardiologists.

Lipidology
Lipidology and new medicines for lipid disorders have transformed management of primary and secondary prevention well beyond prescription of statin monotherapy.⁴ FITs should be exposed to recognition, management, and cascade screening for familial hypercholesterolemia and other genetic lipid disorders. Unfortunately, only 10% of patients with familial hypercholesterolemia are diagnosed, stemming in part from inadequate training of clinicians to recognize the disorder.

FITs should become comfortable in the detection of corneal arcus, xanthelasmata, and xanthomas. An understanding of lipid metabolism, along with commonly used lipid markers and their direct applications in patient care, will facilitate effective prevention strategies. Among those patients in whom secondary prevention is necessary, recognition of advanced lipid disorders will herald a rise in prompt referral for targeted therapies.

Diabetes
There has been an exponential growth in diabetes medications with the GLP-1 receptor agonists and SGLT-2 inhibitors showing clear benefits in reducing ASCVD events, heart failure, and progression of kidney disease.⁵ Given their cardiovascular and/or renal benefits, GLP-1 receptor agonists and SGLT2 inhibitors no longer necessarily belong to the sphere of endocrinologists alone, and many more clinicians will be prescribing these medications in their own practices. In-depth experience learning how to prescribe the medications, counseling patients about possible adverse effects of the medications, and troubleshooting difficulties using the medications, is essential.

GLP-1 receptor agonists are administered by devices and understanding how each device works is an essential skill. If a patient's glycemic control is not affected by the initiation of a GLP-1 receptor agonist, one possibility is that the patient is unaware of how to use the device correctly. Moreover, GLP-1 receptors agonists and SGLT2 inhibitors can cause hypoglycemia in the setting of sulfonylurea and/or insulin use, so understanding the caveats of prescribing these medications in this context is important.

Effective management of diabetes in collaboration with primary care providers and endocrinologists will be very important in the training of FITs. Perhaps in the future there will be joint Preventive Cardiology/Diabetes (Cardiometabolic) clinics that will guide patients on the use of advanced lipid-lowering strategies as well as GLP-1 receptor agonists.

Research Skillset in Epidemiology and Biostatistics
The practice of medicine is driven by evidence-based research. Much progress has been made in the realm of cardiovascular disease prevention, diagnosis, and management in the past decade. The treatment paradigm of antiplatelet therapy and hypoglycemic agents for prevention has changed drastically as a result of recent clinical trial data. However, these changes would be impossible without expert training in research. FITs should have exposure to epidemiology and biostatics so that they can not only take part in scholarly activities but also have the skills necessary for critical analysis of research.

Conclusion
The art and science of Preventive Cardiology is advancing at a rapid pace. Those who practice prevention now have more tools to be preventive interventionalists. There is an unrealized need for specialty training in this area so that future physicians can effectively translate science into clinical practice and continue to advance the field. The future Preventive Cardiology specialist will be able to engage in and parse through the numerous prevention studies, participate in interdisciplinary care, and efficaciously apply prevention strategies even in the most complex patient populations.

References

1. Shapiro MD, Maron DJ, Morris PB et al. Preventive cardiology as a subspecialty of cardiovascular medicine. J Am Coll Cardiol 2019;74:1926-42.
2. Bild DE, Bluemke DA, Burke GL, et al. Multi-ethnic study of atherosclerosis: objectives and design. Am J Epidemiol 2002;156:871-81.
3. The Atherosclerosis Risk in Communities (ARIC) Study: design and objectives. The ARIC investigators. Am J Epidemiol 1989;129:687-702.
4. Brown WV. Clinical lipidology and the prevention of vascular disease: time for personalized therapy. Clin Pharmacol Ther 2018;104:269-81.
5. American Diabetes Association. 10. Cardiovascular disease and risk management: standards of medical care in diabetes—2019. Diabetes Care 2019;42:S103-23.

Keywords: Aortic Aneurysm, Abdominal, Atherosclerosis, Biostatistics, Cardiovascular Diseases, Aspirin, Arcus Senilis, Coronary Disease, Counseling, Blood Glucose, Dyslipidemias, Diabetes Mellitus, Disease Progression, Critical Illness, Fellowships and Scholarships, Fibrinolytic Agents, Heart Failure, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hyperlipoproteinemia Type II, Hypertension, Hypoglycemia, Hypoglycemic Agents, Kidney Diseases, Life Style, Lipid Metabolism, Lipids, Insulins, Metabolic Syndrome, Patient Care, Nutritionists, Peripheral Arterial Disease, Physicians, Family, Primary Prevention, Pharmacists, Referral and Consultation, Primary Health Care, Risk Factors, Risk Reduction Behavior, Secondary Prevention, Smoking Cessation, Subtilisins, Stents, Sulfonylurea Compounds, Ventricular Function, Xanthomatosis, Sodium-Glucose Transport Proteins

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