The future of cardiovascular and metabolic medical practice: evidence-based winds of change.

Abstract

In a recent issue of the journal, we proposed the recognition of a new clinical subspecialty termed cardiometabolic medicine [1]. This broad term usefully encompasses diabetes, cardiovascular disease and associated major modifiable risk factors, that is, excess adiposity, dysglycaemia, hypertension and dyslipidaemia. In this themed issue, we are pleased to present a series of articles written by world class authorities that explore aspects of this proposal in more detail. Common themes that unite voices calling for the new subspecialty are (1) the high – and increasing – prevalence of cardiometabolic disease and (2) the multimorbid nature of noncommunicable chronic metabolic and vascular diseases [1–4], including chronic renal impairment and nonalcoholic fatty liver disease/nonalcoholic steatohepatitis (NAFLD/NASH). In his 2020 presidential address, Robert Eckel, President of Medicine & Science at the American Diabetes Association noted that ‘the overlap of [these] metabolic disorders with cardiovascular disease is graded, strong and contributes in a major way to reversing the decades-long trend of reduced cardiovascular disease mortality’. New and effective therapeutic approaches to the prevention and treatment of common cardiometabolic disorders are now available, yet remain underutilized. A series of mandated cardiovascular outcome trials have served to reinforce the intimate association that exists between type 2 diabetes and cardiovascular disease. These studies have demonstrated myriad cardiometabolic benefits, including renoprotective actions, of drugs from the sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonist classes [5–8]. These considerations, alongside other therapeutic developments, have prompted clinicians in different specialties to recognize the need for more co-ordinated approaches to care for the high volumes of patients with complex cardiometabolic diseases [1–4]. Details of how the proposed new clinical discipline of cardiometabolic medicine might be developed and certified will vary according to local circumstances. In his article, Nathan Wong considers the options of preventive cardiologist versus specialist in preventive cardiology or cardiometabolic medicine from a US perspective [9]. This theme is developed by Carla Reiter-Brennan who with Robert Eckel and colleagues set out suggestions for a comprehensive curriculum that includes epidemiology, biostatistics, behavioural science and psychology alongside essential knowledge of cardiovascular medicine and human metabolism [10]. Dennis Bruemmer and Steve Nissen [11] consider the barriers to achieving guideline-recommended treatment goals and outline opportunities for improving on the current situation. Of note, the pathophysiological intersection of diabetes and cardiovascular disease brings patients under the care of clinical specialists focussed on one disease or the other; opportunities exist for exploiting the cross-over between these disciplines, as recently reported by Felona Gunawan et al. [12]. Alan Sinclair and Ahmed Abdelhafiz [13] focus on the burden of cardiometabolic disease in the older patient, highlighting the importance of frailty and sarcopenia. Gerardo Rodriguez [14] an update on the relevance of NAFLD/NASH to specialists in diabetes and cardiology. Bringing clinicians and researchers in endocrinology and cardiology is a core aim of Cardiovascular Endocrinology & Metabolism. We hope that this timely collection of thoughtful articles will not only inform but will also stimulate interest in the notion of designating a new clinical subspecialty. This should reflect the existing evidence base, recognize unmet need, and make an optimal use of limited healthcare resources for the benefit of individuals living with, or at risk of, cardiometabolic disease. Acknowledgements Conflicts of interest There are no conflicts of interest.