Author + information
- Roger S. Blumenthal, MD, FACC, Chair,
- C. Noel Bairey Merz, MD, FACC,
- Vera Bittner, MD, MSPH, FACC and
- Tyler J. Gluckman, MD, Fellow-in-Training Member
The missions of the American College of Cardiology and the American Heart Association have been to ensure optimal care to those with or at risk for developing cardiovascular disease (CVD). The cardiovascular specialist is expected to contribute significantly to the treatment and prevention of CVD in the setting of a rapidly growing field of knowledge ranging from molecular and cellular mechanisms to clinical outcomes. Over the past 2 decades, there have been dramatic increases in knowledge concerning specific risk factors in atherosclerosis, hypertension, thrombosis, and other forms of vascular dysfunction. Clinical trials have proven that strategies aimed at the appropriate detection and modification of risk factors can slow progression of atherosclerosis and hypertension and reduce the occurrence of clinical events in both primary and secondary prevention settings. More recently, it has been shown that atherosclerosis can be stabilized or even modestly reversed. Finally, the growing knowledge base of molecular genetics applied to the study of the cardiovascular system has a potentially great relevance to the future clinical practice of preventive cardiovascular medicine.
Despite the fact that clinical outcomes can be improved by promotion of favorable life habits and behaviors and by the proper use of drug treatment, the application of preventive interventions in the clinical practice of cardiovascular medicine is not optimal. Prevention of CVD, in both the primary and secondary prevention setting, must no longer be peripheral to the practice of the cardiovascular specialist. The cardiovascular specialist must become proficient in the primary and secondary prevention of CVDs, including the ability to recommend specific primary and secondary preventive measures and to identify patients with subclinical CVD who may benefit from more aggressive risk factor modification.
It is imperative that cardiovascular training programs provide the necessary education and training to promote best practices among their trainees, who bear the responsibility to provide optimal preventive services to their patients. This report outlines specific areas of knowledge and skills necessary to achieve this goal and also defines required and recommended standards to achieve this goal.
General Standards and Environment
There should be adequate faculty, both in number and experience, to conduct a training program in preventive cardiovascular medicine. In addition to this, it is highly desirable for at least some of the faculty to have expertise in vascular biology, atherosclerosis, hypertension, disorders of lipid metabolism, obesity and weight management, diet and nutrition, smoking cessation, diabetes mellitus, thrombosis, clinical epidemiology, cardiac rehabilitation, clinical pharmacology, genetics, and the psychosocial aspects of CVD. Ideally, specific faculty in the cardiovascular medicine training program should be able to serve as topic-area experts in one or more of these specified areas. This is important because the faculty should be able to function as preventive cardiovascular medicine role models. Mentoring is important for cardiovascular trainees in their formative years, and prevention-oriented role models should function in this capacity.
Content of the Training Program
Optimal knowledge and skills required for the practice of CVD prevention are extensive and can be divided into 3 levels.
Level 1 training should be required of all cardiovascular specialists and includes exposure to the following topics.
General Content Areas
1. Cardiovascular biology
• Cellular mechanisms of atherosclerotic vascular disease
2. Clinical epidemiology
• Analytical methods
• Software for basic analyses
4. Clinical trials
• Statistical analyses (tracking experimental data)
• Study design (including calculation of sample size) and understanding of methodology
• Data collection
• Data safety and monitoring
5. Outcomes research
• Medical economics
• Cost/benefit analyses
• Policy and legislation
6. Cardiovascular pharmacology
• Mechanism of action
• Safety profile
• Efficacy and indication
7. Behavioral and psychosocial aspects of CVD (3)
• Affective disorders (depression, anxiety)
• Behavior modification (coping)
8. Risk assessment
• Traditional risk factors
• Nontraditional risk factors (e.g., high-sensitivity C-reactive protein , apolipoprotein B, lipoprotein [a])
• Advanced risk assessment (renal, hepatic, inflammatory, and autoimmune related)
9. Assessment of subclinical atherosclerosis
10. Risk factor management
• Pre-diabetes, insulin resistance, metabolic syndrome, and diabetes mellitus
• Atherosclerosis reversal
11. Disease management
• Multidisciplinary approach
• Education of primary care physicians
Specific Content Areas
Exposure to specific content areas in CVD prevention is essential. These specific areas, outlined in an ABC format (16,17), must encompass diagnosis and treatment in both primary and secondary prevention settings.
• Clopidogrel (P2Y12 receptor antagonists)
• Warfarin sodium: use in patients with atrial fibrillation and/or left ventricular thrombus
Angiotensin Converting Enzyme Inhibitor (ACE-I)/Angiotensin Receptor Blocker (ARB) Therapy
• ACE-I and ARB combination therapy
• Beta blockers
• Calcium channel blockers
• Novel antianginals (i.e., ranolazine)
• Hypercoagulable states/thrombosis
• Peripheral arterial disease
Blood Pressure Control
• Familiarity with the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines (18)
• Antiarrhythmic, antianginal and sympatholytic effects
• Secondary prevention of CVD in patients with a myocardial infarction, heart failure/left ventricular systolic dysfunction or hypertension
• Familiarity with National Cholesterol Education Program guidelines for low-density lipoprotein-cholesterol, high-density lipoprotein-cholesterol, and triglycerides (19)
Cigarette Smoking Cessation
• Role of tobacco in the development and progression of CVD and as a predictor of future cardiovascular events in persons with established coronary artery disease (20)
• Familiarity with combination, long-term behavioral support and pharmacologic therapy with or without nicotine replacement for smoking cessation
Diet and Weight Management
• Diet: Familiarity with appropriate cardiovascular dietary choices and interventions for change in dietary habits
• Weight Management: Familiarity with definitions of normal, overweight, and obese states and measures to define abnormal weights (body mass index, waist:hip ratio); association of weight and increased rates of cardiovascular events, death, and development of comorbid conditions (diabetes mellitus, hypertension, hypercholesterolemia); caloric reductions and increased activity to reach ideal body weight
Diabetes Mellitus and the Metabolic Syndrome
• Familiarity with these terms (as they relate to patients with and without CVD); guidelines for diagnosis and recommended interventions (lifestyle changes, clinical pharmacotherapy)
• Role of diabetes mellitus as a potential risk factor for CVD and accelerated rates of atherosclerosis (21)
Exercise/Cardiac Rehabilitation (22–24)
• Association of inadequate levels of exercise with risk of cardiovascular events
• Role of cardiac rehabilitation for patients with chronic stable angina pectoris, recent myocardial infarction, recent coronary artery bypass graft surgery, noncoronary heart surgery, cardiac transplant, and/or left ventricular systolic function
• Assessment for patients with known CVD
• Role of adjunctive therapies (aldosterone blockade, digitalis, etc.) in patients with left ventricular systolic function
Although detailed, it is important to realize that this list of key measures should not be considered all-inclusive. The field of cardiovascular prevention is ever changing, as epidemiologic and clinical trial data accumulates. Because of this, training programs should be oriented toward providing the most up-to-date guidelines for all risk factors in the primary and secondary prevention of CVD.
Level 1 training in these areas should ideally be undertaken in a 1-month (or longer) rotation dedicated to preventive cardiovascular medicine (Table 1). An acceptable alternative would be a 3-month (or longer) clinical cardiology rotation that allows concomitant exposure to a comprehensive cardiovascular rehabilitation program at least 1 day each week. This would allow incorporation of a broad range of preventive approaches in addition to the predominant rehabilitation focus of physical exercise (11). Ideally, the 1-month rotation should include weekly attendance at a cardiac rehabilitation program, a diabetes mellitus or endocrinology clinic, and a lipid disorders clinic.
As an alternative, training in these areas could be obtained in consultative, inpatient, and outpatient rotations, with additional didactic sessions focusing on cardiovascular prevention topics. If the latter approach is taken, the time allotted should be equivalent to at least 1 month of full-time training. Training program directors may also consider supplementing clinical experiences with short courses devoted exclusively to preventive cardiovascular medicine or risk factor evaluation and management.
Level 2 training should achieve a level of expertise such that the trainee could serve as an independent consultant to other cardiovascular practitioners in the management of cardiovascular risk factors. This should involve 6 to 12 months of training within the 36 months of a cardiovascular training program and should include time for direct evaluation of patients with advanced atherosclerosis, hypertension, hyperlipidemia, recurrent thrombosis, cardiac rehabilitation, or related subspecialty conditions.
Level 2 training should involve blocks of time spent in hypertension, lipid, and diabetes clinics or services, peripheral vascular laboratories, and clinical and cardiac rehabilitation services with additional exposure to behavioral medicine, exercise physiology, clinical epidemiology, outcomes research, and vascular biology. To achieve training at Level 2, aggregate training in preventive laboratories and services should account for a minimum of 6 months of a typical 3-year training program in cardiovascular medicine.
Level 3 requires advanced training to qualify as director of a clinical service, research program, or both. Examples include the director of a preventive cardiovascular medicine, hypertension or lipid service; director of a cardiac rehabilitation program, director of a vascular medicine laboratory; or a trainee who obtains an MPH degree in clinical epidemiology, outcomes research, or both.
Training at this level would require 1 year of a 36-month training program. This level of experience may require additional formal education and training beyond a basic 3-year program. Alternatively, 2 to 3 years in a vascular biology laboratory or health services outcomes research/clinical epidemiology program would be required to attain expertise in these fields which would possibly lead to achievement of an advanced degree.
The most effective preventive cardiovascular medicine services incorporate the skills and knowledge of multiple providers, including cardiovascular physicians, nurses, nurse practitioners, physician assistants, dietitians, behavioral medicine specialists, and exercise physiologists. They operate on principles of interdisciplinary and multidisciplinary teamwork, and they use systemic approaches to patient care. Although such programs are more effective than routine cardiovascular practice, few training programs offer opportunities to learn these new skills. Programs interested in offering Level 3 training should incorporate these new concepts into the training program and trainees interested in Level 3 training should seek programs that offer these advanced approaches to patient care.
Whereas knowledge of preventive interventions and mechanisms has blossomed in the past 10 years, clinical practice in this area lags behind in virtually all practice settings. Even academic centers, where most trainees are taught, fail to provide ideal preventive services to cardiovascular patients. Evaluation of the training in preventive cardiovascular medicine could logically include efforts by clinical programs to evaluate their own clinical inputs and outcomes and demonstrate commitment to ongoing quality improvement in clinical prevention. Programs could also use the Adult Clinical Cardiology Self-Assessment Program (ACCSAP) education programs and examinations to ensure trainees (and faculty) have acquired appropriate knowledge of preventive cardiovascular medicine.
This is a revision of the 2002 document that was written by Phillip Greenland, MD, FACC—Chair; Edward D. Frohlich, MD, FACC; C. Noel Bairey Merz, MD, FACC; and Richard C. Pasternak, MD, FACC. We are especially indebted to the valuable comments and suggestions by M. Dominique Ashen, PhD, CRNP, and Matthew J. Budoff, MD.
|Name||Consultant||Research Grant||Scientific Advisory Board||Speakers’ Bureau||Steering Committee||Stock Holder||Other|
|Dr. Vera A. Bittner||None||None||None||None||None||None||None|
|Dr. Roger S. Blumenthal||None||None||None||None||None|
|Dr. Tyler J. Gluckman||None||None||None||None||None||None||None|
|Dr. C. Noel Bairey Merz||None||None||None||None||None||Stock owned–|
This table represents the relationships of committee members with industry that were reported by the authors as relevant to this topic. It does not necessarily reflect relationships with industry at the time of publication.
|Name⁎||Affiliation||Consultant||Research Grant||Scientific Advisory Board||Speakers’ Bureau||Steering Committee||Stock Holder||Other|
|Dr. Rick A. Nishimura||None||None||None||None||None||None||None|
|Dr. Gregg C. Fonarow||None||None||None||None||None|
|Dr. Alan D. Forker||None||None||None||None||None|
|Dr. Rita F. Redberg||None||None||None||None||None||None|
This table represents the relationships of peer reviewers with industry that were reported by the authors as relevant to this topic. It does not necessarily reflect relationships with industry at the time of publication.
↵⁎ Names are listed in alphabetical order with each category of review.
- American College of Cardiology Foundation
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