Cardiometabolic medicine in practice: a way forward


The recent Amgen Australia Cardiometabolic Assembly, held in July 2022, featured an address by Professor Robert Eckel from the Division of Endocrinology, Metabolism and Diabetes Division of Cardiology at the University of Colorado on what cardiometabolic medicine could look like in practice.

“One of the impacts of obesity is on insulin resistance and the metabolic syndrome,”1 began Prof. Eckel. “Looking at projections for diabetes prevalence, the future is now as the incidence is expected to double,”2 he explained. He noted the vicious cycle between type 2 diabetes mellitus (T2DM), nephrology disease and cardiovascular disease. “What has changed is the increased discussion of cardio-renal metabolic medicine as a result of the cardiovascular (CV) outcome trials,”3 noted Prof. Eckel. “What we see now is indication-specific recommendations for diabetes medications for CV outcomes,” he said.

Whose role is it in the management of patients with cardiometabolic syndrome to take charge of patient care?

Prof. Eckel explained some challenges facing clinical care teams across the globe. “In the United States (U.S), there are around 34.2 million patients with diabetes yet only 8,524 endocrinologists, 33,701 cardiologists, 9,007 nephrologists and 486,400 primary care physicians. This equates to around 4,012 patients with diabetes per endocrinologist. This kind of patient distribution is so impractical when we need more emphasis in this space,”4 he explained.

What are the barriers to use of new therapies?

“There are patient factors, including polypharmacy, cost and patient motivation,” began Prof. Eckel. “Physician factors include a lack of awareness of trial findings or perception of outcomes. Structural inequalities include access to specialists and compliance to recommended changes to guidelines. Coverage decisions and drug availability can be a challenge as well.”

So, how well are specialties other than endocrinology taking up the baton for cardiometabolic management? Prof. Eckel presented data from his recent paper published in the Journal of the American Heart Association that found around 2% of prescriptions of sodium-glucose cotransporter-2 inhibitors (SGLT2i) and around 4% of glucagon-like peptide receptor agonists (GLP-1 RAs) are coming from cardiologists. Looking at the data over time, this uptake is miniscule across cardiology and nephrology in comparison to the bulk of prescriptions coming from primary care physicians and endocrinology.5 “So, how are we going to deal with this problem?” asked Prof. Eckel. He proposed the following as options to increase the engagement of clinicians managing patients with cardiometabolic disease.

  1. Cardio-renal metabolic certificate program: “This route is accessible to all clinicians and allows for rapid uptake of training by more providers,” suggested Prof. Eckel. “However, it’s limited in its scope and therefore unlikely to result in systemic changes to patient care.” Prof. Eckel shared a recent course he has developed in the U.S.
  2. One-year fellowship: “This is best suited after completion of a general cardiology fellowship or endocrinology, nephrology or general internal medicine residency,” suggested Prof. Eckel. “The first 6 months would be core rotations followed by adjunctive rotations. This focussed approach could have flexibility in the curricula and be applicable to a broad range of trainees. However, a year is a prolonged training period and again may be unlikely to result in systemic changes to patient care”
  3. Three-year cardio-renal metabolic fellowship: “This would be a dedicated fellowship after internal medicine training to gain a depth of exposure to a breadth of relevant topics,”6 noted Prof. Eckel. “The geriatric medicine space tried to develop these programs and it took over a decade. So, the time is now to get this up and running and look to a future of board-certified clinicians.”

“The development of cardiometabolic clinics is the next step to changing the patient care paradigm,” noted Prof. Eckel. His framework of a clinic included multidisciplinary care across lifestyle and pharmacological interventions.7

 

“There is a dire need to treat this epidemic of cardiometabolic disease with quality healthcare. Prevention, treatment, and management are best achieved with less siloed management and specialties working collaboratively,” concluded Prof. Eckel.

Disclosure

This article was commissioned by Amgen. The content is based on studies and the presenter’s opinion. The views expressed do not necessarily reflect the views of the sponsor. Before prescribing please review the full product information of relevant products via the TGA website. Treatment decisions based on these data are the responsibility of the prescribing physician.

References

  1. Eckel RH, et al. Lancet 2005;354:1415.
  2. Schuchleib-Cung A, et al. Bariatric Times 2018;15:14.
  3. Ferro EG, et al. Card Clinics 2021;39:335.
  4. Centers for Disease Control. National diabetes statistics report 2020. Available at: https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf (accessed 26 July 2022).
  5. Adhikari R, et al. J Am Heart Assoc 2022;11(9):e023811.
  6. Saxon DE, et al. J Clin Endocrinol Metab 2020;105(7):dgaa261.
  7. Reiter-Brennan C, et al. Cardiology Rep 2021;23:22.

 

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