Author + information
- George A Beller, MD, FACC*
- ↵*Reprint requests and correspondence: George Beller, MD, FACC, Cardiovascular Division, Department of Internal Medicine, Health System, University of Virginia, P.O. Box 800158, Health Sciences Center, Charlottesville, Virginia 22908-0158
The importance of managing peripheral vascular disease
For decades, cardiologists either have been uninterested or have ignored their role as vascular medicine specialists as well as experts in the diagnosis and management of heart disease. Even though board certification from the American Board of Internal Medicine is designated for cardiovascular disease, many cardiologists are deficient in their training for evaluation and management of noncoronary vascular disease, and those who received some training during their fellowships are less proficient in this area of their specialty than they are in treating cardiac disorders. In recent years, there has been a reawakening to the cardiologist’s obligations to see patients with peripheral vascular disease and not only manage their vascular disease but also reduce their risk of future cardiac events, which is the predominant cause of death in patients who initially present with aortic, peripheral vascular, or carotid arterial atherosclerotic disease. Atherosclerosis is a generalized disease, and cardiologists must direct their efforts in attenuating or reversing it no matter how a patient initially presents. Dr. John W. Hirshfeld, Jr., Chair of the American College of Cardiology (ACC) Cardiac Catheterization and Intervention Committee, has stated, “Because noncardiac vascular disease is currently underdiagnosed and undertreated, cardiologists as a professional group should hold a more comprehensive core knowledge base of vascular medicine than they currently do.”
Today, cardiologists are often asked to perform a preoperative risk assessment of patients with peripheral vascular disease undergoing noncardiac surgery (e.g., aortic aneurysm resection). Many patients with peripheral vascular disease, however, are not seen by cardiologists at all and directly undergo either vascular surgery or vascular intervention by vascular surgeons or interventional radiologists, respectively. The screening and medical management of the risk factors promoting the development of atherosclerotic peripheral vascular disease (and obviously coronary artery disease) are not adequately undertaken. Evaluation of patients with peripheral vascular disease should be a fundamental obligation of the cardiologist, and comprehensive cardiovascular care for such patients includes the treatment of hyperlipidemia, hypertension, and other risk factors for atherosclerosis. These are important risk factors for both coronary and peripheral vascular disease. For cardiologists performing vascular intervention procedures in their patients, attention to the concomitant medical therapy for risk-factor elimination or reduction is mandatory.
Fellowship training in vascular medicine
The issue regarding the improvement in the training of fellows in vascular medicine is being addressed by a task force of ACC members (Dr. Mark A. Creager, Chair; and Drs. John P. Cooke, Jeffrey W. Olin, and Christopher J. White) that is writing the revised guidelines for training that will be part the ACC Core Cardiology Training Symposium-2 (COCATS-2). In the original COCATS-1 document (1), no specific sections on training in vascular medicine and peripheral catheter-based interventions were included. Dr. Creager and his writing group state that not only are vascular diseases encountered frequently by cardiovascular physicians but also technological advances in imaging techniques and catheter-based interventions have brought management of vascular diseases firmly into the sphere of the cardiovascular specialist. This task force is proposing three levels of training in vascular medicine, where Level I will be basic training that all cardiology fellows receive to acquire a sufficient knowledge base to care for the many patients with vascular disease they will encounter in a general cardiology practice. Level II training will be composed of additional training for fellows wishing to develop special expertise in evaluating and managing patients with peripheral vascular disease. Level III training will be directed to cardiologists who wish to become skilled in noncoronary, catheter-based vascular interventions. This third level will contain training elements aimed at ensuring that trainees develop both the cognitive and the technical skills required for making the appropriate decisions regarding invasive and interventional treatment of patients with noncoronary vascular disease.
In the COCATS document, the task force writing group will emphasize that trainees who plan a vascular medicine track as part of their cardiovascular specialty should have sufficient exposure to the diagnosis and treatment of peripheral vascular disease, aortic diseases, cerebral vascular disease, renal artery stenosis, venous thromboembolic diseases, chronic venous disorders, lymphatic diseases, vasculitides, atheromatous embolization, vasospastic disease, chronic venous insufficiency, and other uncommon vascular diseases. They will need to spend time on an inpatient vascular medicine consultation service, in the noninvasive vascular laboratory, in the peripheral vascular catheterization laboratory, and on the vascular surgery service. They will need to acquire knowledge of magnetic resonance imaging as it relates to the diagnosis of vascular disease. Specific details regarding this training curriculum will be published when the entire COCATS-2 document is reviewed and approved by the College’s Board of Trustees.
Organizations working together for vascular disease guidelines
Because the field of vascular medicine is multidisciplinary, there are societies that have been working together on several levels to identify the characteristics required for establishing Vascular Centers of Excellence. Organizations involved in the vascular minisummit held in Chicago in April 2000 included the ACC, the Society of Vascular Surgery, the Society of Cardiovascular and Interventional Radiology, and the Society of Vascular Medicine and Biology. This event highlighted numerous models of care that could be used to organize peripheral vascular disease management for optimal patient outcomes.
In collaboration with the American Heart Association (AHA), the College is planning a practice guideline on peripheral vascular disease. Also in development by the ACC, the AHA, and the American College of Physicians–American Society of Internal Medicine is a clinical competence statement on peripheral vascular disease. The writing group for this document is being chaired by a peripheral vascular specialist, with co-chairs appointed by the AHA to represent the fields of vascular radiology and vascular surgery. Also included on the writing group are members of the Society of Cardiovascular Interventional Radiology, the Society of Vascular Surgery, and the American Association of Vascular Surgery. Clearly, this undertaking will bring together the expertise of many specialists from different training backgrounds, all of whom have skills that are relevant to the high-quality care required for management of patients with peripheral vascular disease. The document to be generated from this task force will deal with all aspects of vascular medicine, including vascular interventional procedures.
Issues relevant to vascular intervention
Several issues should be recognized regarding vascular intervention in patients with peripheral vascular disease. The operator who performs noncoronary vascular interventional procedures should have sufficient cognitive knowledge concerning the particular pathophysiologic state being treated, in addition to technical expertise for performance of the procedure. Certainly, this is highly relevant in renovascular obstructive disease, in which the cognitive knowledge base concerning the appropriateness of case selection is quite complex and the ocular stenotic reflex for stenting any obstructive lesion must be avoided. Of particular concern is a growing trend for some operators to perform “total body angiography” as an adjunct to diagnostic cardiac catheterization. There is concern with the growing number of insurance claims submitted for multiple angiograms at one sitting. Some of these diagnostic studies are being performed on 35-mm cine film using 9-inch intensifiers without subtraction. The diagnostic quality of the studies is often suboptimal. If adjunctive peripheral angiography is not clinically indicated, then patients are subjected to an excessive amount of contrast agent without benefit. Thus, for cardiologists performing these procedures, they should be performed not only in a high-quality manner but also for the appropriate clinical indications, and they should be done according to evidence-based practice guidelines.
Peripheral vascular disease is in many ways a unique area for treatment because it presents such wide-ranging opportunities for physician collaboration. Although its scope makes many different models of care possible, the only models that should be on the table are those that put the highest-quality patient care first. The cardiovascular specialist has a major role for providing comprehensive medical care for the patient with atherosclerosis, whether such a patient presents with vascular disease, coronary artery disease, or both.
I am grateful to Dr. John Hirshfeld, Jr., who provided me with his insights into the issues pertaining to vascular medicine and intervention.
- American College of Cardiology