COMMENTARY
`
`Cardiometabolic Medicine: A Call for a New
`Subspeciality Training Track in Internal Medicine
`
`The epidemic of obesity, metabolic syndrome, and type 2 dia-
`betes shows no sign of remission. Although each individually
`are costly important medical outcomes, it is the relationship of
`these metabolic maladies to cardiovascular disease that is
`graded, strong, and almost certainly responsible for reversing
`the decades-long temporal trends of reduced cardiovascular
`disease mortality.1
`Importantly, the landscape of drug therapies to treat these
`metabolic conditions has expanded dramatically.2 For example,
`3 cardiovascular outcome trials using glucagon-like peptide-1
`(GLP-1) receptor agonists, which also serve as effective weight
`loss drugs, have shown improvements in multiple cardiovascu-
`lar risk factors as well as important cardiovascular outcomes
`and total mortality.3 Three sodium-glucose co-transporter 2
`(SGLT2) inhibitors have shown benefits on cardiovascular
`risk factors and important cardiovascular outcomes including
`heart failure and cardiovascular mortality. Although the mecha-
`nisms for these cardiovascular benefits remain unclear, they ex-
`tend well beyond glycemic lowering,4 and therefore are
`probably best considered diverse “cardiometabolic” pharma-
`ceuticals rather than simply type 2 diabetes drugs.
`Yet to be clarified is who becomes the physician of record
`when patients who are obese, have type 2 diabetes mellitus
`treated with metformin, and glycosylated hemoglobin
`(HbA1c) of 8.2% are hospitalized for acute coronary syndrome.
`At discharge, there are several medications to be managed,
`including high-intensity statin, angiotensin-converting en-
`zyme inhibitor or angiotensin receptor blocker, beta blocker,
`and a dual antiplatelet regimen. In follow-up, nonstatin thera-
`pies may need to be added for further low-density lipoprotein
`
`Funding: None.
`Conflicts of Interest: RE has funding from the NIH and ENDECE and has
`served on scientific advisory boards for Merck, Sanofi/Regeneron, Novo
`Nordisk, and Kowa. MB has funding from NIH, FDA, AHA, Amgen, and
`Aetna and served on scientific advisory boards of Amgen, Sanofi/Regeneron,
`Medicure, Novartis, and Novo Nordisk.
`Authorship: Both authors had access to the data and a role in writing the
`manuscript.
`Requests for reprints should be address to Dr. Michael J. Blaha, John
`Hopkins Ciccarone Center for the Prevention of Heart Disease, Division of
`Cardiology, John Hopkins School of Medicine, Baltimore, MD.
`E-mail address: mblaha1@jhmi.edu
`
`0002-9343/© 2019 Elsevier Inc. All rights reserved.
`https://doi.org/10.1016/j.amjmed.2019.02.027
`
`cholesterol (LDL-C) or triglyceride lowering, and anti-
`hypertensive titrations may be needed to achieve stricter
`blood pressure goals.5,6 A cardiologist, who may not have
`been the inpatient attending physician of record, is most com-
`monly the first outpatient visit. Does this physician have time,
`bandwidth, and capacity to manage traditional cardiovascular
`medications yet also consider GLP-1 receptor agonist or
`SGLT2 inhibitor therapy?
`For optimal care of patients with cardiovascular disease in
`2019 and beyond, a critical question before the medical com-
`munity must be answered: is the cardiology practice willing
`and capable of taking on the responsibility of assuming at
`least part of the patient’s cardiometabolic disease?7 This in-
`cludes treating obesity, managing type 2 diabetes mellitus
`(ie, setting HbA1c goals), modifying glucose-lowering medi-
`cations, and when prescribing a GLP-1 receptor agonist or
`SGLT2 inhibitor, assessing for potential adverse effects of
`medications, including nausea and vomiting with injectable
`GLP-RAs and genital mycotic infections or rare diabetic
`ketoacidosis (often with near normal levels of plasma glucose)
`with SGLT2 inhibitors.8
`In 2019, we believe that nearly all cardiology practices are
`poorly suited to assume the role of an endocrinologist or expe-
`rienced primary care physician. Thus, even though the cardiol-
`ogist may understand the importance and have an interest in
`prescribing GLP-1 receptor agonist or SGLT2 inhibitor ther-
`apy, primary attention may be diverted to ongoing issues in-
`cluding angina, heart failure, cardiac arrhythmia, medication-
`related bleeding, and beyond. An alternative follow-up plan
`directed to cardiometabolic disease management, broadly
`interpreted, is desperately needed.
`With no end in sight to the medical issues related to an aging
`and increasingly sedentary and obese population with cardio-
`vascular disease,9 we believe a new internal medicine subspe-
`cialty is more than timely and much needed. Rather than
`shunting patients back and forth among cardiologist, endocri-
`nologist, and primary care physician—with uncertain “owner-
`ship” of different aspects of
`the patient’s care—the
`cardiometabolic specialist will be sufficiently trained in internal
`medicine, preventive cardiology, and endocrinology with a
`practice designed to be the medical home for patients with car-
`diometabolic disease and atherosclerotic cardiovascular disease.
`
`Novo Nordisk Exhibit 2094
`Mylan Pharms. Inc. v. Novo Nordisk A/S
`IPR2023-00724
`Page 00001
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`

`

`Eckel and Blaha
`
`Cardiometabolic Medicine: New IM Specialty?
`
`789
`
`What would be the components of a training program in
`cardiometabolic medicine (Figure)? This specialized train-
`ing experience would be preceded by 2-3 years of focused
`general internal medicine house-staff training. The next 3
`years would be a composite of endocrinology and
`cardiology.
`The endocrine component would be metabolism-centric with
`an extensive experience in conditions such as obesity, metabolic
`syndrome, types 1 and 2 diabetes mellitus, lipid and lipoprotein
`disorders, hypertension, and lifestyle. Part of this training would
`include obesity pharmacology, frequent interactions with meta-
`bolic surgeons, advanced training in basal/bolus insulin admin-
`istration, insulin pumps, and glucose sensors. This would be
`distinct from the classic board-certifiable training program in
`endocrinology, metabolism, and diabetes because there would
`be no additional education in disorders of the thyroid,
`hypothalamic-pituitary-adrenal axis, reproductive endocrinol-
`ogy, or metabolic bone disease, including parathyroid disorders.
`The cardiology component of cardiometabolic medicine
`training would be focused on primary and secondary prevention
`of atherosclerotic cardiovascular disease. This would include in-
`patient cardiology consults, outpatient preventive cardiology
`clinic, electrocardiogram and echocardiography interpretation,
`stress testing, cardiac rehabilitation, and interpretation of
`noncontrast and contrasted coronary computed tomography.
`To stay focused on cardiometabolic disease, there would be
`no requirement for training in critical care medicine, interven-
`tional cardiology, electrophysiology, advanced heart failure,
`and cardiac transplantation. For more expertise in severe hyper-
`tension, at least 2 months of elective time should be spent in a
`multispecialty resistant hypertension clinic, with at least a 1
`month spent learning vascular medicine.
`
`Finally, a substantial component of cardiometabolic medi-
`cine training would be advanced concepts in lifestyle. This ex-
`perience would go far beyond inquiring about diet, exercise,
`tobacco, alcohol, and illicit drug use. The cardiometabolic
`physician would gain expertise in smoking cessation including
`cessation pharmacology, novel tobacco products, advanced
`concepts in nutrition and diet, and use of mobile health tech-
`nology to promote general physical activity and individualized
`exercise goals.
`Who would choose such a specialty? For starters, the 2 au-
`thors of this Commentary would have chosen such a specialty.
`We believe that many internal medicine residents are inter-
`ested in obesity and diabetes, yet may not be interested in thy-
`roid, bone health, or endocrinologic cancer syndromes.
`Likewise, many residents are interested in atherosclerotic car-
`diovascular disease, yet do not envision training spent pre-
`dominantly in the hospital setting seeing patients who are
`critically ill with heart failure or performing electrophysiology
`procedures. Currently, such potential cardiometabolic special-
`ists pursue cardiology, perhaps begrudgingly spending more
`than 6 months of training in the catheterization or electrophys-
`iology lab, only later pursuing additional sub-subspecialty
`training in preventive cardiology.
`In the end, the cardiometabolic medicine physician would be
`a new type of board-certified specialist poised to address issues
`related to the major global health problem of the 21st century.
`Over time, the practicing cardiometabolic physician’s practice
`would grow to include nurse educators, a dietician, certified di-
`abetes educator, a mobile technology hub, and an adjoining fa-
`cility for cardiac rehabilitation and supervised exercise.
`What are the next steps forward? The American Board of In-
`ternal Medicine (ABIM) could conduct a needs assessment
`
`Cardiology
`
`IntervenƟonal
`
`EP
`
`Advanced HF
`
`Cardiometabolic
`Medicine
`Obesity
`Lifestyle
`T2DM
`Smoking
`HTN
`Rehab
`Lipids
`CVD TesƟng
`
`Pain
`
`Screening
`
`Thyroid
`
`ReproducƟve
`
`Bone
`
`Endocrinology
`
`Musculoskeletal
`
`Internal
`Medicine
`
`Proposed Training Plan (3 years)
`
`Endocrinology component
`• Obesity
`(cid:129) Diabetes
`(cid:129)
`Lipids and Lipoprotein disorders
`Cardiology component
`(cid:129)
`InpaƟent cardiology
`(cid:129) Cardiology consults
`(cid:129) EKG
`(cid:129) ECHO
`(cid:129) Stress tesƟng
`(cid:129) Cardiac CT
`(cid:129) Cardiac RehabilitaƟon
`(cid:129) Vascular Medicine
`Internal Medicine component
`(cid:129)
`Lifestyle
`(cid:129) Smoking CessaƟon
`(cid:129) Hypertension
`
`Figure Conceptual Approach to Cardiometabolic Medicine. The left panel of the figure illustrates the
`proposed overlap among cardiology, endocrinology, and internal medicine. The right panel details a
`proposed 3-year training plan for a Cardiometabolic Medicine specialist. CVD = cardiovascular disease;
`EP = electrophysiology; HF = heart failure; HTN = hypertension; T2DM = type 2 diabetes mellitus.
`
`Novo Nordisk Exhibit 2094
`Mylan Pharms. Inc. v. Novo Nordisk A/S
`IPR2023-00724
`Page 00002
`
`

`

`790
`
`The American Journal of Medicine, Vol 132, No 7, July 2019
`
`References
`
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`Schwartzbard AZ. The changing landscape of diabetes therapy for cardio-
`vascular risk reduction: JACC state-of-the-art review. J Am Coll Cardiol
`2018;72:1856-69.
`3. Zweck E, Roden M. GLP-1 receptor agonists and cardiovascular disease:
`drug-specific or class effects?Lancet Diabetes Endocrinol 2019;7:89-90.
`4. Scheen AJ. cardiovascular effects of new oral glucose-lowering agents:
`DPP-4 and SGLT-2 inhibitors. Circ Res 2018;122:1439-59.
`5. Arps K, Pallazola VA, Cardoso R, et al. Clinician’s guide to the updated
`abcs of cardiovascular disease prevention: a review part 1. Am J Med
`2019 Jan 30. [Epub ahead of print].
`6. Arps K, Pallazola VA, Cardoso R, et al. Clinician’s guide to the updated
`abcs of cardiovascular disease prevention: a review part 2. Am J Med
`2019 Jun;132:e569-80.
`7. Das SR, Everett BM, Birtcher KK, et al. 2018 ACC expert consensus de-
`cision pathway on novel therapies for cardiovascular risk reduction in pa-
`tients with type 2 diabetes and atherosclerotic cardiovascular disease: a
`report of the american college of cardiology task force on expert consensus
`decision pathways. J Am Coll Cardiol 2018;72:3200-23.
`8. Scheen AJ. SGLT2 inhibitors: benefit/risk balance. Curr Diab Rep
`2016;16:92.
`9. Global Burden of Metabolic Risk Factors for Chronic Diseases
`Collaboration. Cardiovascular disease, chronic kidney disease, and diabe-
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`
`and surveys documenting interest in a new specialty. Health
`systems might perform analyses of how cardiometabolic spe-
`cialists might improve the flow of patients through the system,
`improve adherence to lifestyle and pharmacology therapy, and
`improve risk-factor control metrics. Internists, endocrinolo-
`gists, and cardiologists could come together to hash out the
`outlines of a training program with a proposed curriculum.
`The subspecialty may start as a fast-track pathway within
`both endocrinology and cardiology, later differentiating into
`a stand-alone 3-year program.
`Barriers to implementation would be familiar. Turf wars be-
`tween specialists could occur, and the training program must
`find a clear academic “home” within either cardiology or en-
`docrinology (perhaps most likely cardiology). However, we
`believe the increasingly complicated treatment landscape
`will bring together the many stakeholders.
`It’s time to move forward and not wait until we wish we had.
`The answer should not be to add more training, but to sharpen
`and focus existing education concepts to produce the product
`we know we need.
`As Albert Einstein said, “In the middle of difficulty lies
`opportunity.”
`
`Robert H. Eckel, MDa
`Michael J. Blaha, MD, MPHb
`
`aDivision of Endocrinology,
`Metabolism and Diabetes,
`University of Colorado Anschutz Medical Campus,
`Aurora
`bJohns Hopkins Ciccarone Center
`for the Prevention of Heart Disease,
`Division of Cardiology,
`Johns Hopkins School of Medicine,
`Baltimore, Md
`
`Novo Nordisk Exhibit 2094
`Mylan Pharms. Inc. v. Novo Nordisk A/S
`IPR2023-00724
`Page 00003
`
`