Risk factors

ADA president gives Australia a roadmap for cardiometabolic subspecialty

Prof Robert Eckel

It may take another decade for Australia to develop a hybrid speciality of cardiometabolic medicine straddling endocrinology and cardiology, but the first steps should be made now, the president of the American Diabetes Association (ADA) has told local clinicians.

Speaking as a guest on a limbic webinar to discuss the highlights of the recent ADA 2020 virtual sessions, Professor Robert Eckel, an endocrinologist at the University of Colorado, said the concept of cardiometabolic medicine had been ‘brewing’ for 25 years, but was now gaining momentum due to the increasing overlap of metabolic disease and cardiovascular disease.

As previously reported in the limbic, Professor Eckel used the plenary sessions of the ADA 2020 meeting to challenge the audience as to which speciality would be best suited to treat a middle aged female patient who had Type 2 diabetes, obesity and ischaemic heart disease that required stents.

To address the overlap of these conditions, Professor Eckel is collaborating with preventive cardiology colleagues such as Dr Michael Blaha from John Hopkins, to develop a training program that will provide clinicians with the ability to deliver more comprehensive care to the growing number of people with complex cardiometabolic disease.

Watch the webinar with Prof Eckel here:

“It’s a much-needed new speciality and this new training program will be an overlap between metabolic disease education from the endocrine perspective and all preventive cardiology from the cardiac perspective,” he said.

The training program will include non-invasive imaging, reading ECGs and echocardiographs, as well as managing lipids, obesity and lifestyle management. From the endocrine side it will include such as insulin pump education and taking care of the cardiovascular complications of diabetes. It will also involve trainees having rotations in nephrology and hepatology, said Professor Eckel.

“This is now gaining momentum but … it takes 10-15 years to develop adequate training programs that ultimately gain board of medicine approval as a subspecialty – the analogy is geriatrics and gerontology.”

“These types of training programs are starting to sprout up but unfortunately it’s not a subspecialty where we can guarantee anyone anything more than a certificate at the end of training in the near future. However, we are hopeful that in a decade from now this will be a new area of medicine where a physician can be competent in both the metabolic space and the preventive cardiology space.”

The concept was welcomed by webinar participant Professor Richard MacIsaac, Director, Department of Endocrinology & Diabetes, St Vincent’s Hospital, Melbourne, who said Australia was still some way behind the US in developing training and models of care in cardiometabolic medicine.

“One way in which we may be able to chip away at this concept is to have a clinic for people with diabetes who have cardiovascular diseases [and] discharged from hospital, just to make sure they are on the cardioprotective medications that we have available at the moment,” he said.

“One of the issues we have is starting some [cardioprotective] medications in hospital when people are unstable, such as starting a SGLT2 inhibitor after a procedure such as having a stent. And just to make sure that people are followed up properly, by someone who has got an interest in the two areas and even ticking off the boxes such as are they on a high dose statin, are they on an ACE inhibitor or ARB … just making sure they are meeting those basic requirements,” said Professor MacIsaac

Professor Eckel said the cardiovascular complications of diabetes were becoming even more important as people with type 1 diabetes are now living into old age.

“As you get into the later years there’s a lot more hyperglycaemia even with CGM and so I think that’s a cautionary note to overzealous[ly] control patients with T1D for 50-60 years,” he said

“The evidence we have from data such as DCCT  clearly shows that glycaemia is really relevant to macrovascular complications in patients with type 1, but I don’t think T1D gets enough attention in terms of cardiovascular outcome trials. So as the adolescent becomes an adult he/she needs to realise that [glucose] control is part of their future life expectancy,” he said

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