Current Cardiology Reports (2021) 23: 22
`https://doi.org/10.1007/s11886-021-01450-1
`
`DIABETES AND CARDIOVASCULAR DISEASE (D BRUEMMER, SECTION EDITOR)
`
`Comprehensive Care Models for Cardiometabolic Disease
`
`Cara Reiter-Brennan 1,2 & Omar Dzaye 1,2 & Dorothy Davis 1 & Mike Blaha 1,3 & Robert H. Eckel 4
`
`/ Published online: 24 February 2021
`Accepted: 8 January 2021
`# The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature 2021
`
`Abstract
`Purpose of Review The high burden of cardiovascular disease and the simultaneous obesity pandemic is placing an extraordinary
`strain on the health care system. In the current siloed care model, patients with cardiometabolic disease receive only fractionated
`care from multiple specialists, leading to insufficient treatment, higher costs, and worse outcomes.
`Recent Findings The imminent need for a new care model calls for the creation of a distinct cardiometabolic specialty in
`conjunction with a cardiometabolic outpatient clinic dedicated to the comprehensive cardiometabolic care. The cardiometabolic
`clinic would consist of a diverse range of professionals relevant to comprehensive treatment.
`Summary The outpatient clinic we envision here would facilitate an interdisciplinary collaboration between specialists and
`deliver prevention-focused treatment to patients at risk/established cardiometabolic disease.
`
`Keywords Cardiology . Diabetes . Endocrinology . Metabolism . Prevention
`
`Abbreviations
`ASCVD
`AWV
`BMI
`CDCES
`
`CHD
`CKD
`CVD
`CVOTS
`DASH
`DM
`DSMES
`
`Atherosclerotic cardiovascular disease
`Annual wellness visit
`Body mass index
`Certified diabetes care and education
`specialist
`Coronary heart disease
`Chronic kidney disease
`Cardiovascular disease
`Cardiovascular outcome trials
`Dietary approach to stop hypertension
`Diabetes mellitus
`Diabetes self-management education
`and support
`
`This article is part of the Topical Collection on Diabetes and
`Cardiovascular Disease
`
`Food and Drug Administration
`FDA
`Glucagon-like peptide-1 receptor agonist
`GLP-1 RA
`Heart failure
`HF
`Hemoglobin A1c
`HbA1c
`Intensive care unit
`ICU
`Low-density lipoprotein cholesterol
`LDL-C
`Myocardial infarct
`MI
`Medical nutrition therapy
`MNT
`Non-alcoholic fatty liver disease
`NAFLD
`Sodium-glucose transporter-2
`SGLT-2
`T1DM/T2DM Type 1/type 2 diabetes mellitus
`
`* Robert H. Eckel
`robert.eckel@cuanschutz.edu
`
`Cara Reiter-Brennan
`cara.reiter-brennan@charite.de
`
`Omar Dzaye
`odzaye@jhmi.edu
`
`Dorothy Davis
`ddavis71@jhmi.edu
`
`Mike Blaha
`mblaha1@jhmi.edu
`
`1
`
`Johns Hopkins Ciccarone Center for the Prevention of
`Cardiovascular Disease, Johns Hopkins University School of
`Medicine, Baltimore, MD, USA
`
`2 Department of Radiology and Neuroradiology, Charité,
`Berlin, Germany
`
`3 Welch Center for Prevention, Epidemiology and Clinical Research,
`Johns Hopkins University, Baltimore, MD, USA
`
`4 Division of Endocrinology, Metabolism and Diabetes and Division
`of Cardiology, University of Colorado School of Medicine, 18582
`Stone Gate Dr., Morrison, CO 80465, USA
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`Introduction
`
`The prevalence of patients with chronic metabolic and with
`cardiovascular multi-comorbidities has been increasing
`steadily over the course of the last decades. Cardiovascular
`disease (CVD) is the main cause of morbidity and mortality
`among patients with type 2 diabetes mellitus (T2DM) [1].
`Affecting 85.6 million Americans, 219 billion dollars are
`spent on CVD each year [2]. Often, both diseases coexist
`together, with as many as two-thirds of patients with CVD
`being dysglycemic [3]. However, metabolic disorders of pa-
`tients with CVD frequently remain undiagnosed and are un-
`treated, resulting in a higher incidence of cardiovascular death
`[4]. Cardiometabolic disease already places substantial strain
`on the health care system. Individuals with diabetes have 2.3
`higher medical costs when adjusted for age and gender [1]. In
`light of increasing obesity prevalence, the aging population,
`and rising medical expenditures, this will only expand in the
`future.
`However, in our present health care system, the optimal
`management of these complex cardiometabolic patients is
`compromised. In our traditional siloed care model, there is
`no “main” specialist coordinating treatment, as cardiologists
`and endocrinologists often work with little overlap. Other im-
`portant aspects of cardiometabolic therapy such as lifestyle
`intervention and psychological counseling are not adequately
`addressed. As a result, cardiometabolic patients receive
`fragmented care with redundant diagnostic testing and higher
`costs and are at risk of drug-drug interaction and, most impor-
`tantly, adverse CVD events.
`Fortunately, we have witnessed advancements on the front
`of cardiometabolic pharmacology. Novel, evidence-based
`“cardiometabolic drugs” initially approved for the treatment
`of T2DM have proven to treat not only diabetes but also CVD.
`These cardiometabolic drugs further blur the lines between
`traditional specialties, emphasizing the need to rethink current
`siloed care models.
`As a solution to this urgent issue, we propose the de-
`velopment of a distinct cardiometabolic specialty address-
`ing the needs of the cardiometabolic patient. The educa-
`tion of cardiometabolic physicians would start early, with
`core concepts of cardiometabolic disease introduced in
`medical school. After a general internal residency pro-
`gram, physicians could specialize in cardiometabolic
`medicine by completing a 2–3-year cardiometabolic spe-
`cialist training program. Finally, the cardiometabolic phy-
`sician would have the opportunity to work in an outpa-
`tient clinic dedicated to the cardiometabolic patient
`(Fig. 1). In this publication, we formulate a prototype
`for a cardiometabolic clinic distinctly addressing the
`needs of the cardiometabolic patient. This clinic would
`consist of a well-coordinated team of specialists of a car-
`diometabolic physician, cardiometabolic nurses,
`
`Curr Cardiol Rep (2021) 23: 22
`
`dieticians, rehabilitation physicians, certified diabetes care
`and education specialist (CDCES), and psychologists.
`Through a collaborative, interdisciplinary approach to this
`care model, we would hope to optimize treatment of the
`cardiometabolic patient, improve outcomes, and reduce
`medical expenditure.
`
`Recent Trends in Epidemiology
`of Cardiometabolic Disease
`
`Recent trends in CVD-related mortality are concerning.
`While the USA has witnessed a considerable decrease of
`death from CVD in the past decades, this trend seems to
`be dissipating. However, age-adjusted CVD mortality has
`remained at 0.5%/year, while other areas have witnessed
`a continuous decrease in mortality (e.g., cancer decreased
`1.5% annual between 2000 and 2015) [5, 6]. Indeed,
`CVD accounts for 17.3 million deaths a year globally,
`but according to a 2014 study, is expected to cause over
`23.6 million deaths per year by 2030 [7]. Reduced im-
`provement of CVD mortality is most likely to be attrib-
`uted to the alarming increase in obesity prevalence. In
`the USA, 39.4% of adults ≥ 20 years of age are obese
`[8]. By 2030, estimates suggest
`that one in two
`Americans will suffer from obesity [9]. Obese individ-
`uals, particularly those with metabolic syndrome, are at
`higher risk of diabetes and adverse CVD outcomes [10].
`Obesity is a main driver of diabetes. Among US adults,
`10.5% are diagnosed with diabetes while another 37.6%
`are pre-diabetic [11]. Data from National Health and
`Nutrition Examination Survey (NHANES) suggest that
`in the last three decades, blood glucose health has dete-
`riorated in obese individuals, leading to a worsening of
`CVD [12]. Individuals with diabetes are associated with
`a two times higher risk of coronary heart disease (CHD)
`and 2.3 times higher for ischemic stroke [13]. Estimates
`suggest that 10% of vascular deaths are attributed to
`diabetes and two-thirds of patients with T2DM die from
`CVD [13, 14]. Indeed, diabetes is often unrecognized in
`patients with CVD. In a study of left ventricular dysfunc-
`tion, 11% of patients with HF had undiagnosed T2DM
`[15]. Finally, apart from cardiovascular comorbidities,
`CKD is one of the most relevant co-diagnosis of diabe-
`tes. In the developed world, diabetes is the primary cause
`of CKD and patients with diabetes and CKD have a
`markedly elevated risk of CVD [16, 17]. Albuminuria
`is associated with an atherogenic lipoprotein profile of
`elevated TGs, low HDL-C, and a shift in LDL-C, with
`a higher proportion of small, high-density lipoproteins
`[18, 19]. However, current guidelines are inconstant in
`assessment of cardiovascular risk of patients with CKD,
`prohibiting adequate preventive CVD treatment.
`
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`Fig. 1 The cardiometabolic clinic
`
`Advances in Cardiometabolic Drugs and Their
`Limited Use in Clinical Care
`
`Fortunately, we have witnessed a paradigm shift in the devel-
`opment of pharmaceutical drugs targeting T2DM as well as
`CVD. Cardiovascular outcome trials (CVOTs) demonstrated
`the cardiovascular benefits of SGLT-2 inhibitors and GLP1-
`RAs for patients with T2DM (and in some cases without
`T2DM). The Food and Drug Administration (FDA) has now
`approved the use of antidiabetic agents to lower risk of a
`composite of major adverse cardiac events (liraglutide [20],
`canagliflozin [21(cid:129)(cid:129)], semaglutide [22], dulaglutide [23(cid:129)]), car-
`diovascular death (empagliflozin [24]), and HF (dapagliflozin
`[25]). This recommendation is echoed in recent professional
`guidelines. SGLT-2 inhibitors were shown to be particularly
`beneficial for patients with HF and chronic kidney disease
`(CKD) and should be subscribed to patients with T2DM and
`CKD or HF [21, 26]. If obesity is a central concern, GLP-1
`RAs are recommended, as they are currently the most potent
`anti-diabetic drug for weight loss [27].
`However, despite guideline recommendation and FDA ap-
`proval, these evidence-based therapies are underused. A co-
`hort study investigating contemporary use of guideline recom-
`mended medication among patients with atherosclerotic
`
`cardiovascular disease (ASCVD) and diabetes found that only
`9.0% of individuals received SGLT-2 inhibitors and 7.9%
`were subscribed GLP-1 RAs [28]. Indeed, investigators ob-
`served optimal pharmaceutical therapy in only 6.9% of cases
`[28]. These agents are a vital opportunity to improve care and
`reduce cardiovascular events in these patients. We believe that
`training physicians to appropriately treat cardiometabolic pa-
`tients would lower barriers of subscription of these agents.
`
`Current Siloed Care Models
`
`While the pharmaceutical sector has developed “cardiometa-
`bolic” agents, physician education and clinical care is still
`divided into isolated cardiology and endocrinology programs,
`with little overlap between disciples. Some argue that primary
`care physicians should be adept in managing care for patients
`with ASCVD and diabetes. In reality, primary care providers
`battle time constraints and face competing demands during
`routine primary care visits with little bandwidth to compre-
`hensively treat the cardiometabolic patient [29(cid:129)]. We are also
`facing a severe shortage of primary care physicians. Only one-
`quarter of medical students plan on pursing primary care [30].
`While it may seem intuitive for cardiologists to lead the
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`Curr Cardiol Rep (2021) 23: 22
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`management of cardiometabolic patients, traditional cardiolo-
`gy training does not prepare physicians for glycemic manage-
`ment, prescribing weight loss drugs or adequate lifestyle
`counseling. Cardiologists may feel uncomfortable monitoring
`side effects of novel cardiometabolic drugs like SGLT-2 in-
`hibitors and GLP1-RAs, in addition to the complex manage-
`ment of ASCVD drugs like PCSK9 inhibitors, beta blockers,
`renin-angiotensin-aldosterone system inhibitors, or anticoag-
`ulant regimes. As a result of this fractionated care, fewer than
`20% of patients with diabetes reach all three guideline recom-
`mended targets for HbA1c, blood pressure, and low-density
`lipoprotein-cholesterol [31]. Ultimately, this issue calls for
`professional experts and related health care team in cardiomet-
`abolic disease to provide comprehensive, guideline-
`recommended treatment of these complex patients.
`
`Education in Cardiometabolic Medicine
`
`Medical School
`
`The foundations of cardiometabolic medicine should be laid
`in medical school, and students who are interested can choose
`further training as a cardiometabolic specialist during residen-
`cy. Current medical education teaches disease as single enti-
`ties, rather than emphasizing that chronic conditions often
`occur simultaneously and multimorbid patients are the norm.
`Teaching ASCVD and T1DM/T2DM in one holistic cardio-
`metabolic course instead of in separate system blocks would
`allow students to better grasp the interdisciplinary nature of
`disease entities and prepare students for multimorbid patients.
`Education in cardiometabolic medicine in medical school
`would incorporate lessons on lifestyle counseling and behav-
`ioral medicine: an area underdeveloped in current curricula.
`
`The Cardiometabolic Specialist
`
`Following medical school and 2–3 years of general internal
`medicine house-staff training, we envision a cardiometabolic
`training program consisting of a composite of cardiology, en-
`docrinology, and other specialties relevant to the cardiometa-
`bolic patient.
`Primary and secondary ASCVD prevention would be the
`focus of the cardiology component of this program. Training
`in electrophysiology, interventional cardiology, advanced HF,
`or cardiac transplantation would however not be part of this
`curriculum. Rotations in hypertension clinics and vascular
`medicine would allow for training for treatment of severe
`hypertension. Physicians would be able to correctly diagnose
`resistant hypertension by excluding pseudoresistance and
`screening for secondary hypertension, as well as assessing
`organ damage. Compared to traditional endocrinology spe-
`cialist training, more emphasis would be placed on lessons
`
`on the complex pharmacological treatment of resistant hyper-
`tension and life-style intervention. In addition, some experi-
`ence in hepatology would further broaden the experience of
`cardiometabolic medicine that relates non-alcohol fatty liver
`disease (NAFLD) and non-alcoholic steatohepatitis (NASH)
`to ASCVD [32]. The endocrinology aspects of this speciali-
`zation program would focus on obesity, metabolic syndrome,
`T1DM and T2DM, lipid and lipoprotein disorders, endocrine
`causes of hypertension, and lifestyle. Physicians would be
`trained in advanced glucose management by covering the ad-
`ministration of basal/bolus insulin, insulin infusion pumps,
`and glucose sensors. Other traditional topics regarding dis-
`eases of thyroid, hypothalamic-pituitary-adrenal axis, repro-
`ductive endocrinology, or metabolic bone disease, including
`parathyroid disorders would not be covered during the cardio-
`metabolic training program.
`In addition to endocrinology and cardiology training, the
`curriculum would allow enough time for training in lifestyle
`counseling. Physicians would be adept in smoking cessation
`therapy, exercise physiology, and nutrition counseling.
`Behavioral intervention training would provide trainees with
`skills to enhance therapy adherence, physician-patient com-
`munication, and motivational interviewing. A substantial
`component of training would be spent on the most relevant
`topics of obesity medicine, focusing particularly on NAFLD
`and NASH. Rotations through obesity clinics would provide
`physicians with training in obesity pharmacology, as well as
`when and how to refer patients to bariatric surgery and post-
`operative management.
`
`The Cardiometabolic Clinic
`
`The Cardiometabolic Team
`
`Finally, we envision the establishment of a cardiometabolic
`outpatient clinic with a multidisciplinary team consisting of a
`cardiometabolic physician, behavioral psychologists, nutri-
`tionists, certified diabetes care and education specialists
`(CDCES), and specialized rehabilitation physicians. These
`professionals as well as three cardiometabolic nurses would
`form a cohesive, interdisciplinary team. The cardiometabolic
`clinic would be managed by two administrative personnel. In
`a well-groomed high-volume clinic, this is the minimum num-
`ber of staff required but can be expanded as needed. As the
`clinic would provide clinical training, students and residents
`would be a welcomed part of the team.
`
`Practicalities
`
`The cardiometabolic nurse would triage new patients and pro-
`vide an initial assessment to decide which type of professional
`the patient requires. Triaging would incorporate
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`cardiovascular risk assessment when indicated through cardi-
`ac imaging, as well as initial bloodwork. After consultation
`with the cardiometabolic physician, a personalized treatment
`plan for the patient would be created. Through this type of
`holistic assessment of patients, high-risk individuals can be
`quickly identified. We envision the cardiometabolic clinic as
`a continuous care model, where patients return for regular
`check-ups and counseling sessions after initial referral.
`The success of treating complex cardiometabolic patients
`relies on the successful collaboration between team members
`of the cardiometabolic clinic. Other medical specialties report
`a multidisciplinary approach as the most efficient strategy to
`handling complex patients [33]. This approach would be fos-
`tered by daily team meetings discussing therapeutic plans and
`new research evidence regarding cardiometabolic disease.
`Results from a meta-analysis suggest that poor coordination
`of and information transfer within a medical team reduced
`patient satisfaction in outpatient clinical settings [34]. In a
`survey of chronically ill US adults, 30% reported missing
`medical records or duplication of tests during outpatient treat-
`ment [35]. A well-coordinated cardiometabolic outpatient
`clinic would reduce such errors, improving outcome and pa-
`tient satisfaction.
`
`Subspecialties Working at the Clinic
`
`Cardiometabolic Specialist
`
`The cardiometabolic physician’s work would primarily con-
`sist of a composite of endocrinology and cardiology, with a
`focus on primary and secondary prevention of CVD.
`At the beginning of treatment, cardiovascular imaging
`(echocardiography, stress testing, and coronary computed to-
`mography) to assess ASCVD would be individualized and at
`times used to make nuanced decisions about cardiovascular
`risk. The cardiometabolic clinic would also offer transthoracic
`echocardiography to quickly and easily assess patients with
`suspect structural heart disease. Transesophageal echocardi-
`ography, magnetic resonance imaging, and nuclear imaging
`are beyond the scope of the cardiometabolic physician.
`Additionally, the cardiometabolic physician would manage
`lipids and have experience in treating complex patients with
`severe hypertriglyceridemia, statin intolerance or genetic lipid
`and lipoprotein disorders such as familial hypercholesterol-
`emia. Patients would also be treated for hypertension includ-
`ing resistant. The ramification of causes of resistant hyperten-
`sion demands a systematic and multidisciplinary approach in
`diagnosis and treatment [36]. This would be facilitated by the
`well-coordinated integrative team of the cardiometabolic clin-
`ic. A routine part of the cardiometabolic physician’s work
`would be assessment of CKD and the associated cardiovascu-
`l a r ri s k t h r o u g h a l b u m i n u r i a m e a s u r e m e n t . T h e
`
`cardiometabolic physician possessing endocrinology and car-
`diology expertise could competently manage CKD as well as
`any cardiovascular comorbidities according to most recent
`evidence. Physicians would be adept in glycemic manage-
`ment of patients, from coordinating prescriptions of metfor-
`min, GLP-1 RAs, SGLT-2 inhibitors, thiazolidinediones, and
`other drug classes for the treatment of diabetes to complex
`insulin administration schemes and new diabetes technolo-
`gies. The cardiometabolic specialist would also be in charge
`of obesity management by prescribing and individualized ap-
`proach to lifestyle management, weight loss medications, and
`when and how to refer patients to metabolic surgeons and be
`knowledgeable in managing post-bariatric surgery patients.
`
`The Cardiometabolic Nurse
`
`We envision the cardiometabolic nurse to work side by side
`with the cardiometabolic physician. Evidence suggests that
`diabetes and CVD care quality was comparable between phy-
`sicians and advanced care providers (nurse practitioners or
`physician assistants) delivered in a primary care setting [37].
`The cardiometabolic nurse would conduct an initial compre-
`hensive health assessment, including cardiac and metabolic
`history, screening for risk factors, taking blood tests, and re-
`ferring patients to cardiac imaging tests. After discussion with
`the cardiometabolic specialist, the cardiometabolic nurse
`would contact patients to discuss lab and imaging results
`and help direct patients to follow-up appointments and when
`necessary to other subspecialists. With respect to the continu-
`ity of care model, nurses would contact patients regularly to
`inquire about treatment progress and remind patients of ap-
`pointments. As the cardiometabolic clinic would grow, clerks
`would take over scheduling routine appointments while car-
`diometabolic nurses would ensure continuity of care by
`discussing lifestyle goals and progress with patients and de-
`cide if follow-up appointments or referrals are necessary.
`Preventive care in the form of intensive lifestyle intervention
`should form an essential part of the new model of care under-
`pinning the cardiometabolic clinic. In lifestyle counseling ses-
`sions, nurses will discuss exercise and diet as well as smoking
`cessation plans with patients. For some patients, these lifestyle
`counseling sessions will suffice. If more intensive lifestyle
`interventions are needed, the cardiometabolic nurse can refer
`patients to the behavioral psychologist, nutritionist, or exer-
`cise physiologist. An excellent lifestyle counseling program is
`vital for the successful treatment of cardiometabolic disease
`and will distinguish this clinic from other programs. An esti-
`mated 40% of deaths in USA are attributed to poor lifestyle
`choices, but physicians only provide lifestyle counseling in
`34% of cases [38, 39]. The importance of physicians to effec-
`tive lifestyle assessment of patients with cardiovascular dis-
`ease has been previously emphasized [40].
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`Behavioral Psychologist
`
`Some patients may require regular sessions with a behavioral
`psychologist. CVD outcomes are highly linked to psycholog-
`ical factors. For example, depression is a known risk factor for
`CHD and HF and a relevant comorbidity of diabetes [41, 42].
`Behavioral change therapy would also address nonadherence
`to prescribed medication. Only half of patients without CHD
`and one-third with CHD adhere to their drugs prescribed [43].
`Using techniques such as cognitive behavioral therapy tech-
`niques and motivational interviewing, behavioral change psy-
`chologists would facilitate lasting transformation in patient’s
`exercise and eating habits and expedite smoking cessation.
`Evidence suggests that structured behavioral support by a psy-
`chological specialist is more effective for smoking cessation
`therapy than counseling by nurse practitioners or pharmacist
`[44]. Smoking cessation medication acts synergistically with
`behavioral consultation and should be subscribed to patients
`[45].
`
`Nutritionists
`
`Nutritionists are an important part of lifestyle management
`and need to be available to counsel patients regarding die-
`tary interventions to optimize cardiometabolic health.
`There is a growing consensus that a cardioprotective diet
`consists of a diverse inclusion of healthful, nutrient-dense
`foods and is one of the most effective methods to prevent
`and treat CVD, obesity, and diabetes [46]. Dietary patterns
`such as the DASH (dietary approach to stop hypertension)
`diet and Mediterranean style diets can reduce ASCVD risk,
`improve blood lipids and blood pressure, and reduce in-
`flammation [47, 48]. Evidence suggests that response to
`diet needs to be personalized, rather than focusing on a
`specific macro- and micro-nutrient distribution for each
`patient with diabetes. Thus, dietary counseling should take
`comorbidities, current eating patterns, preferences, and so-
`ciocultural factors into consideration. Patients with diabe-
`tes in particular profit from sessions with nutritionists, as
`choosing the right foods is often the most challenging part
`of treatment. Diabetes-specific medical nutrition therapy
`(MNT) is highly effective and awarded A-level recommen-
`dation by the ADA Standards of Medical Care 2020 [49].
`Conveyed by a registered dietician, MNT is associated
`with a HbA1C decrease up from 0.3 to 2% in individuals
`with T2DM and 1.0–1.9% in patients with T1DM [50].
`
`Certified Diabetes Care and Education Specialist
`
`Certified Diabetes Care and Education Specialist (CDCES)
`will form an integral part of the cardiometabolic team. The
`primary goal of diabetes education is to provide knowledge
`and skills to facilitate self-care behavior and help patients
`
`Curr Cardiol Rep (2021) 23: 22
`
`make informed self-management decisions. This type of life-
`style management known as diabetes self-management edu-
`cation and support (DSMES) is associated with lower HbA1c
`[51], lower all-cause mortality risk [52], and improved quality
`of life [53]. Despite ample evidence of the benefits of DSMES
`and B-level guideline recommendation, this service is
`underutilized. Only 6.8% of privately insured and 5%
`Medicare beneficiaries with diabetes take part in diabetes ed-
`ucation, even though covered by most insurances [54, 55].
`Through integration of CDCES in cardiometabolic clinic,
`we hope to make diabetes self-management and education a
`consistent part of standardized diabetes care.
`
`Specialized Rehabilitation Physicians
`
`Patients with previous cardiac events would be able to visit a
`cardiac rehabilitation specialist. Especially since hospitaliza-
`tion for serious cardiovascular events has shortened, outpa-
`tient rehabilitation is becoming more important. However, of
`eligible patients with previous MI, only 14–35% participated
`in cardiac rehabilitation programs but use is higher when pa-
`tients are referred to rehabilitation facilities [56]. The integra-
`tion of rehabilitation facilities into the cardiometabolic clinic
`and adding it to the standardized cardiometabolic treatment
`program would increase use of rehabilitation and improve
`outcomes.
`
`Pharmacist
`
`Incorporating clinical pharmacists in primary care settings
`significantly increased the percentage of patients with con-
`trolled hypertension and reduced medical expenditures [57].
`Interdisciplinary, team-based interventions, such as facilitated
`in the cardiometabolic clinic, are particularly effective in im-
`proving outcome. Results suggest that involving pharmacists
`or nurses in team-based care is the most potent strategy to
`successfully control blood pressure [58]. Apart from manag-
`ing complex medication plans, pharmacists would assist with
`time-consuming tasks, like drafting appeal letters for non-
`formulary medications such as the PSCK9 inhibitor drugs.
`Finally, pharmacists can improve medication adherence by
`reducing drug expenditure, one of the major causes for non-
`adherence [59]. Pharmacists employed in cardiac out-patient
`clinics facilitated cost-saving interventions like discount pro-
`grams and copay interventions, resulting in a yearly 852$ cost
`avoidance per patient [60].
`
`Patient Referral
`
`Primary care physicians, endocrinologists, and cardiolo-
`gists who are overwhelmed or with too little expertise in
`certain areas of cardiometabolic medicine would refer
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`patients. Additionally, the cardiometabolic clinic would
`manage follow-up care after cardiometabolic surgery (bar-
`iatric, vascular, or cardiothoracic) as part of patient’s re-
`habilitation program. Patient referral could also be initiat-
`ed by nurse practitioners, who could educate patients on
`benefits of the cardiometabolic clinic.
`
`Example of Patients Benefitting
`from the Cardiometabolic Clinic
`
`Type 1 Diabetes
`
`The cardiometabolic clinic would be particularly benefi-
`cial for patients with T1DM. Limited data, primarily in
`the form of observational studies, exist on assessment
`and sustenance of cardiovascular health in T1DM pa-
`tients. Data from randomized controlled trials and cohort
`studies chiefly refer to T2DM patients or make no dis-
`tinction between types [61]. As a result, the underlying
`pathogenesis of the relationship between CVD and
`T1DM is not well understood and CVD treatment of
`T1DM patients has mainly been adapted from observa-
`tional data sets or CVOTs in T2DM. Through the imple-
`mentation of a dedicated cardiometabolic clinic, physi-
`cians working there would see more T1DM patients with
`CVD or at high risk and thereby gain more expertise in
`effectively treating this disease constellation.
`
`Boundaries
`
`The cardiometabolic clinic will focus on primary and second-
`ary prevention of ASCVD and diabetes and will not offer
`some advanced treatments offered in typical cardiology and
`endocrinology clinics. Electrophysiology is not part of physi-
`cian training, and therefore treatment of cardiac arrythmias
`will not take place in this clinic. Similarly, interventional car-
`diology as well as expertise regarding advanced HF or cardiac
`transplantation will not be offered. We envision an outpatient
`clinic, and therefore this setting would not be suitable for
`intensive care patients. For example, patients with advanced
`HF and possible complications such as pulmonary edema with
`acute respiratory failure or pneumonia would require hospital-
`ization with likely admission to the intensive care unit (ICU).
`Similarly, patients with cardiogenic shock requiring intensive
`hemodynamic monitoring and ventilatory support in the form
`of intubation and mechanical ventilation would not be treated
`in the cardiometabolic clinic. Physicians will not treat endo-
`crinological disease not connected to cardiometabolic dis-
`eases, such as thyroid disease, hypothalamic/pituitary disease,
`or metabolic bone disease. Diagnosis and treatment of disor-
`ders of the reproductive axis would also not be implemented
`in this setting. Despite the increasing prevalence of T2DM
`among children and the micro- and macro-vascular complica-
`tions associated with early onset, pediatric endocrinologists
`would for now be better suited to treat this subgroup [63].
`However, cardiometabolic physicians would be available for
`consultations for children with cardiometabolic disease.
`
`Complex Patients
`
`Multi-morbid, complex patients with multiple risk factors
`especially require an interdisciplinary treatment approach
`and would benefit from the cardiometabolic clinic. For
`example, a traditional cardiologist would perhaps be un-
`sure of optimal therapeutic strategy for a 56-year-old
`obese (BMI 34 kg/m2) woman with T2DM patient taking
`four medications to treat diabetes (excluding insulin). Her
`levels of glycemia and lipids are equally worrisome, with
`HbA1c of 8.5% and triglycerides of 350 mg/dL, respec-
`tively. Her blood pressure is 150/88 and the echocardio-
`gram reveals HF with preserved ejection fraction. This
`patient suffers from multiple comorbidities which require
`coordinated care by a cardiologist, endocrinologist, and
`obesity specialist. In the cardiometabolic clinic, even pa-
`tients like this complex patient would receive comprehen-
`sive care. The clinic would also provide high-quality care
`for high-risk, under-represented populations demanding
`more intensive consideration such as patients with immu-
`nodeficiency syndromes, cancer survivors, and mentally
`handicapped individuals [62].
`
`Cardiometabolic Clinic Within the Health
`System
`
`Value-Based-Care
`
`The value-based care model reimburses physicians and health
`care organization by positive health outcomes. Health care
`systems in the USA and in much of the rest of the world are
`dominated by the “fee-for-service”