Does preventive cardiology deserve its own subspecialty?

A council within the American College of Cardiology published a statement this month pushing for the implementation of a new, structured cardiovascular subspecialty dedicated to preventive cardiology.

Michael D. Shapiro, DO, MCR, and colleagues made the case that, seeing as how CV therapies are rapidly evolving and improving heart patients’ prognoses, it’s time to focus more on preventing CVD itself. The authors said in JACC that an “enormous” opportunity exists in 2019 to shift from intervention to primary, secondary and primordial prevention.

At least half of what’s been achieved in terms of improved CVD outcomes has to do with greater access to procedural interventions and tech advancements that have allowed patients with heart failure or ASCVD to survive and live fuller lives, Shapiro et al. explained. But while those individuals might avoid an earlier death, they’re also prone to disability and live in a world where obesity and type 2 diabetes are becoming the norm.

The council said preventive cardiology as a subspecialty is in its earliest stages, emerging “naturally and spontaneously as a separate discipline” in an area of CV medicine that sorely needs attention. The team called the current state of the subspecialty “fragmented and disorganized at all levels”—but, with a more structured approach, it holds promise.

A host of variables would be involved in a preventive cardiology subspecialty, the authors said, and any physician who wants to pursue a career path in the sector should be well-versed in hypertension, diabetes, dyslipidemia, obesity and lifestyle management. Preventive cardiologists would also need to be familiar with CV imaging and stress testing, biomarkers and genetics, nutritional guidelines and natural therapies.

“Preventive cardiology is in a critical growth spurt that will define its future structure and scope,” Shapiro and co-authors wrote. “Issues related to primary and secondary prevention are becoming increasingly complex, and more and more patients are seeking specialized advice on CVD risk assessment and management.

“Given the increasing intricacies in evaluating and managing CVD risk, there is a mandate for the formation of a new subspecialty of CV medicine.”

The council said subspecialty training for preventive cardiology should be an option for advanced training after students complete their general cardiology fellowship, ensuring they have a solid base of knowledge in cardiovascular medicine. It would be the same kind of extended training offered to physicians interested in advanced heart failure management, congenital heart disease, interventional cardiology or electrophysiology.

We’re still not sure what a preventive cardiology fellowship would look like, but Shapiro and his team said it should involve advanced training in lipid metabolism and management, hypertension, type 2 diabetes, anticoagulation, obesity and nutrition, supplemental therapies and atherosclerosis imaging. The authors proposed a non-traditional ACC certification as recognition that a fellow had completed her course of study.

“We are in the midst of a revolution in the prevention and management of CVD, with the emergence of new drugs and new targets associated with improved CV outcomes,” the council wrote. “At the same time, advances in risk assessment, including novel biomarkers, genetics and noninvasive subclinical atherosclerosis imaging represent major advances that will be implemented more widely in the coming years.”

The authors said the “preventive CV specialist of the future” will require expertise far beyond what’s currently available in standard fellowship programs. They acknowledged the ACC as an integral part of the transition, also noting professional societies like the American Heart Association, American Society for Preventive Cardiology, National Lipid Association and American Diabetes Association will be key players in bringing the idea to fruition.

“We propose that the culmination and validation of these efforts should be the formation of a standardized fellowship program and certification exam, endorsed by the ACC,” Shaprio et al. wrote.