accf/aha/acp 2009 competence and training statement: a … · 2017. 1. 4. · blumenthal rs,...

doi:10.1016/j.jacc.2009.05.019 2009;54;1336-1363 J. Am. Coll. Cardiol.

Patrick T. O'Gara, Paul D. Thompson, and James A. Underberg Fonseca, Barry A. Franklin, Patrick E. McBride, George A. Mensah, Geno J. Merli,Michael H. Davidson, Sara B. Fazio, Keith C. Ferdinand, Lawrence J. Fine, Vivian

Balady, Christie M. Ballantyne, Kathy Berra, Henry R. Black, Roger S. Blumenthal,Cardiovascular Nurses Association, C. Noel Bairey Merz, Mark J. Alberts, Gary J.

Association of Black Cardiologists, National Lipid Association, PreventiveMedicine, American Diabetes Association, American Society of Hypertension,

of Cardiovascular and Pulmonary Rehabilitation, American College of PreventiveCardiovascular Disease), American Academy of Neurology, American Association

Committee to Develop a Competence and Training Statement on Prevention ofAmerican College of Physicians Task Force on Competence and Training (Writing

American College of Cardiology Foundation, American Heart Association, Prevention of Cardiovascular Disease

ACCF/AHA/ACP 2009 Competence and Training Statement: A Curriculum on

This information is current as of March 15, 2010

http://content.onlinejacc.org/cgi/content/full/54/14/1336located on the World Wide Web at:

The online version of this article, along with updated information and services, is

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Journal of the American College of Cardiology Vol. 54, No. 14, 2009© 2009 by the American College of Cardiology Foundation and the American Heart Association, Inc. ISSN 0735-1097/09/$36.00P

COMPETENCE AND TRAINING STATEMENT

ACCF/AHA/ACP 2009 Competence and Training Statement:A Curriculum on Prevention of Cardiovascular DiseaseA Report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Competence and Training (Writing Committee toDevelop a Competence and Training Statement on Prevention of Cardiovascular Disease)

Developed in Collaboration With the American Academy of Neurology; American Association ofCardiovascular and Pulmonary Rehabilitation; American College of Preventive Medicine; American DiabetesAssociation; American Society of Hypertension; Association of Black Cardiologists; National Lipid Association;and Preventive Cardiovascular Nurses Association

ublished by Elsevier Inc. doi:10.1016/j.jacc.2009.05.019

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WritingCommitteeMembers

f cardiovascular disease: a repomerican Heart Association/Am

. Noel Bairey Merz, MD, FACC, FAHA, Chair*

ark J. Alberts, MD, FAHA†ary J. Balady, MD, FACC‡hristie M. Ballantyne, MD, FACC*athy Berra, MSN, ANP, FAHA, FAAN§enry R. Black, MD�oger S. Blumenthal, MD, FACC, FAHA*ichael H. Davidson, MD, FACC¶

ara B. Fazio, MD#eith C. Ferdinand, MD, FACC, FAHA**awrence J. Fine, MD, DRPH††***ivian Fonseca, MD‡‡arry A. Franklin, PHD, FAHA§§atrick E. McBride, MD, MPH, FACC, FAHA*eorge A. Mensah, MD, FACC, FACP,

rt of the American College of Cardiology Foundation/erican College of Physicians Task Force on Competence

of Cardiologyhealthpermissi

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eno J. Merli, MD, FACP#atrick T. O’Gara, MD, FACC, FAHA§§aul D. Thompson, MD, FACC¶¶

ames A. Underberg, MD, MS, FACPM, FACP##

American College of Cardiology Foundation Representative; †Amer-can Academy of Neurology Representative; ‡American Association ofardiovascular and Pulmonary Rehabilitation Representative; §Preven-

ive Cardiovascular Nurses Association Representative; �American So-iety of Hypertension Representative; ¶National Lipid Associationepresentative; #American College of Physicians Representative; **As-

ociation of Black Cardiologists Representative; ††National Heart,ung, and Blood Institute Representative; ‡‡American Diabetes Asso-iation Representative; §§American Heart Association Representative;�Centers for Disease Control and Prevention; ¶¶American College ofports Medicine Representative; ##American College of Preventiveedicine Representative; ***The findings and conclusions in this

ompetence and training statement reflect ACCF policy and do notecessarily represent the views of the Centers for Disease Control andrevention or the National Institutes of Health, by whom Drs. Fine and

FAHA� �*** Mensah are employed.

his document was approved by the American College of Cardiology Foundation Boardf Trustees in October 2008, by the American Heart Association Science Advisory andoordinating Committee in November 2008, and by the American College of Physiciansoard of Regents in April 2009.The American College of Cardiology Foundation requests that this document be cited

s follows: Bairey Merz CN, Alberts MJ, Balady GJ, Ballantyne CM, Berra K, Black HR,lumenthal RS, Davidson MH, Fazio SB, Ferdinand KC, Fine LJ, Fonseca V, FranklinA, McBride PE, Mensah GA, Merli GJ, O’Gara PT, Thompson PD, Underberg JA.CCF/AHA/ACP 2009 competence and training statement: a curriculum on prevention

and Training (Writing Committee to Develop a Competence and Training Statement onPrevention of Cardiovascular Disease). J Am Coll Cardiol 2009;54:1336–63.

This article has been copublished in the September 29, 2009, issue of Circulation.Copies: This document is available on the World Wide Web sites of the American

College of Cardiology (www.acc.org) and the American Heart Association (my.americanheart.org). For copies of this document, please contact Elsevier Inc. ReprintDepartment, fax (212) 633-3820, e-mail [email protected].

Permissions: Modification, alteration, enhancement, and/or distribution of thisdocument are not permitted without the express permission of the American College

Foundation. Please contact Elsevier’s permission department [email protected].

n March 15, 2010

http://www.acc.orghttp://my.americanheart.orghttp://my.americanheart.orgmailto:[email protected]:[email protected]://content.onlinejacc.org

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1337JACC Vol. 54, No. 14, 2009 Bairey Merz et al.September 29, 2009:1336–63 Competence and Training for Prevention of CVD

Task ForceMembers

Jonathan L. Halperin, MD, FACC, ChairMark A. Creager, MD, FACC, FAHA†††Gordon L. Fung, MD, PHD, FACC, FAHADavid R. Holmes, JR, MD, FACC‡‡‡Geno J. Merli, MD, FACPIra S. Nash, MD, FACC, FACP

L. Kristin Newby, MD, FACC, FAHAIleana Piña, MD, FACC, FAHAGeorge P. Rodgers, MD, FACC, FAHA‡‡‡Cynthia M. Tracy, MD, FACC‡‡‡Howard H. Weitz, MD, FACC, FACP

†††Former Task Force chair during the writing effort; ‡‡‡Former TaskForce member during the writing effort.

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TABLE OF CONTENTS

reamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1338

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1338

2. Cardiovascular and Vascular Biology . . . . . . . . . . . . . .1339

2.1. Justification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1339

2.2. Minimal Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1339

3. Clinical Epidemiology and Biostatistics . . . . . . . . . . .1339

3.1. Justification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1339


4. Cardiovascular Pharmacology (ComplexMultipharmacologic Understanding) . . . . . . . . . . . . . . .1343

4.1. Justification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1343


5. Genetics and Cardiovascular Disease inIndividuals and Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1344

5.1. Justification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1344


6. Behavioral and Psychosocial Programs(Financial and Socioeconomic Factors) . . . . . . . . . . .1344

6.1. Justification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1344


7. Advanced Risk Assessment(Renal, Inflammatory Diseases) . . . . . . . . . . . . . . . . . . . .1345

7.1. Justification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1345


8. Subclinical Atherosclerosis Assessment(Imaging and Nonimaging). . . . . . . . . . . . . . . . . . . . . . . . . . .1345

8.1. Justification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1345


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9. Adherence and Disease OutcomeInterdisciplinary Programs . . . . . . . . . . . . . . . . . . . . . . . . . .1346

9.1. Justification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1346


0. Nutrition Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1347

10.1. Justification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1347


1. Lipid Management(Management of Dyslipidemia) . . . . . . . . . . . . . . . . . . . . .1347

11.1. Justification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1347


2. Thrombosis Management . . . . . . . . . . . . . . . . . . . . . . . . . . . .1348

12.1. Justification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1348


3. Hypertension Management. . . . . . . . . . . . . . . . . . . . . . . . . .1349

13.1. Justification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1349


4. Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1349

14.1. Justification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1349


5. Obesity Management (Behavioral Programs) . . . . . .1350

15.1. Justification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1350


6. Exercise Physiology, Physical ActivityManagement, and Cardiac Rehabilitation(Secondary Prevention). . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1351

16.1. Justification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1351


7. Prediabetes, Metabolic Syndrome, InsulinResistance, and Diabetes Management . . . . . . . . . .1352

17.1. Justification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1352


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1338 Bairey Merz et al. JACC Vol. 54, No. 14, 2009Competence and Training for Prevention of CVD September 29, 2009:1336–63

8. Chronic Disease Management . . . . . . . . . . . . . . . . . . . . . .1352

18.1. Justification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1352


eferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1353

ppendix 1. Author Relationships With Industrynd Other Entities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1359

ppendix 2. Reviewer Relationships With Industrynd Other Entities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1362

reamble

he American College of Cardiology Foundation (ACCF)/merican Heart Association (AHA)/American College ofhysicians (ACP) Task Force on Clinical Competence was

ormed in 1998 to develop recommendations for attainingnd maintaining the cognitive and technical skills necessaryor the competent performance of a specific cardiovascularervice, procedure, or technology. These documents arevidence-based, and where evidence is not available, expertpinion is utilized to formulate recommendations. Indica-ions and contraindications for specific services or proce-ures are not included in the scope of these documents.ecommendations are intended to guide curriculum devel-pment and assist those who judge the competence ofardiovascular healthcare providers entering practice for therst time and/or those in practice who undergo periodiceview of their expertise or who apply for privileges at a newnstitution. The assessment of competence is complex and

ultidimensional; therefore, isolated recommendationsontained herein may not necessarily be sufficient or appro-riate for judging overall competence. The current docu-ent addresses a curriculum for developing competence in

he prevention of cardiovascular disease (CVD) and isuthored by representatives of the ACCF, AHA, ACP, themerican Academy of Neurology; American Association ofardiovascular and Pulmonary Rehabilitation; Americanollege of Preventive Medicine; American College ofports Medicine; American Diabetes Association (ADA);merican Society of Hypertension; Association of Blackardiologists; Centers for Disease Control and Prevention;ational Heart, Lung, and Blood Institute; National Lipidssociation; and the Preventive Cardiovascular Nurses As-

ociation. The recommendations contained herein recog-ize the broader context of clinical training and the impor-ance of systems of care in improving patient outcomes.rainees should be aware of and responsive to the larger

ontext of systems-based health care and utilize all availableesources to provide optimum care. Similarly, the develop-ent of competence embodies knowledgeable incorporation

f technological advances for the evaluation of health and fcontent.onlinejaDownloaded from

isease based on ongoing familiarity with the emergingcientific and social literature.

The ACCF/AHA/ACP Task Force makes every effort tovoid actual or potential conflicts of interest that may arises a result of an outside relationship or personal interest ofmember of the ACCF/AHA/ACP Writing Committee.pecifically, all members of the writing committee are askedo provide disclosure statements of all such relationshipshat might be perceived as real or potential conflicts ofnterest relevant to the document topic. These statementsre reviewed by the writing committee and updated ashanges occur. The relationships with industry for authorsnd peer reviewers are published in Appendixes 1 and 2 ofhe document.

Jonathan L. Halperin, MD, FACCChair, ACCF/AHA/ACP Task Force

on Competence and Training

. Introduction

he mission of many organizations is providing optimalare to those with or at risk of developing CVD (primarynd secondary prevention). Over the past 2 decades, thereave been dramatic increases in knowledge concerningpecific risk factors in atherosclerosis, hypertension, throm-osis, and other forms of vascular dysfunction. Clinical trialsave proven that strategies aimed at the appropriate detec-ion and modification of risk factors can slow progression oftherosclerosis, diabetes mellitus, and hypertension andeduce the occurrence of clinical cardiovascular events inoth primary and secondary prevention settings. Moreecently, it has been shown that atherosclerosis can betabilized or even modestly reversed. Finally, a new androwing knowledge base of molecular genetics applied tohe study of the cardiovascular system has potential rele-ance to the clinical practice of preventive cardiovascularedicine.Despite the fact that clinical outcomes can be improved

y promotion of favorable life habits and behaviors and byhe proper use of drug treatment, the application of primarynd secondary preventive interventions in clinical practice isot optimal. Prevention of CVD in both the primary andecondary prevention setting, while dominantly the respon-ibility of the primary care provider, is increasingly chal-enged given the ever expanding new knowledge as well ashe ongoing problems related to adherence to recommen-ations. New knowledge in the area of preclinical diseaseetection has presented increasingly challenging scenarios torimary care healthcare providers relative to the decisionsegarding the need for further risk stratification and aggres-ive medical regimens. Furthermore, increasingly complexatients are surviving with CVD, many of whom can benefitrom advanced knowledge and expertise with regard to risk

actor management and rehabilitation that is beyond the



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raditional general primary and cardiology practitioner’scope of practice.

The prevention of cardiovascular morbidity and mortalitys a shared responsibility among all health professionalsnvolved in the care of people at risk of developing CVD.his document is directed at those individuals seeking

xpertise at a leadership level in this field, and includespportunities for formal training and alternative routes toompetence and maintenance of competence in preventionf CVD (Table 1) (1–5), and educational resources forcquisition and maintenance of competence in the preven-ion of CVD (Table 2) (6–43). To address the expandingund of knowledge in the area and to ensure that andequately trained force of preventive cardiovascular leadersill be available to primary care providers, as well as torovide a pool of providers with expertise in runningehabilitation and other programs designed to address thengoing issue of adherence, the formulation of clinicalompetency criteria for the cardiovascular preventive special-st is needed. These competency criteria are expected to addressssues of expert clinical and scientific leadership, specialtyatient care and consultation, and directorship of primary andecondary preventive cardiac programs. Of note and similar tother subspecialty areas of medicine, cardiovascular preventivepecialists will have varying areas of expertise and will notecessarily achieve all of the outlined areas of competencies.hese clinical competency criteria in the area of specialty

reatment and prevention of CVD are needed given the currentetting of a rapidly growing field of knowledge ranging fromolecular and cellular mechanisms to clinical outcomes in

rder to translate this into improved patient care.

C. Noel Bairey Merz, MD, FACC, FAHAChair, ACCF/AHA/ACP Writing Committee toDevelop a Competence and Training Statement

on Prevention of Cardiovascular Disease

. Cardiovascular and Vascular Biology

.1. Justification

ecent advances in cardiac and vascular biology and relatedolecular and cellular mechanisms provide a sound scientific

oundation for the practice of preventive cardiovascular medi-ine. A basic knowledge of the structure and function of therterial wall, its interactions with components of the circulatinglood, and key pathologic processes such as oxidation, inflam-ation, thrombosis, and remodeling is important to the

pplication of strategies for the detection, evaluation, andrevention of atherosclerotic CVD (44,45). Similarly, a basicnderstanding of myocardial cellular and molecular processes isssential for effective application of therapies that addressyocardial salvage, regeneration, and remodeling.

.2. Minimal Knowledge

he expert in the prevention of CVD should demonstrate

nowledge and competence in: e


. The process of atherosclerosis that begins in youth,initially as a fatty streak containing mainly lipid-richmacrophages in the arterial intima (46), and the role ofvarious blood lipoproteins in this process and the factorsthat promote the initiation and progression of the fattystreak to arterial plaque (including endothelial activationand dysfunction, smooth muscle cell migration and prolif-eration, collagen production, and arterial remodeling).

. Disorders of lipid metabolism and major atherogenic riskfactors, and the pathophysiological significance of thebiological composition of the arterial plaque and itsfibrous cap (47,48).

. A substantial understanding of vulnerable plaque and thecrucial role of inflammation, plaque fissuring, erosion,and rupture in the genesis of acute coronary syndromes,should be emphasized. An understanding of the conceptsof plaque pathophysiology remodeling and progressionshould also be understood, as well as an appreciation ofthe systemic nature of atherosclerosis.

. Systemic (endocrine) and local (autocrine/paracrine)neurohormonal derangements that lead to an impairedvasoregulatory and fibrinolytic balance, including thebiological, social, and environmental determinants ofthese derangements as well as the pharmacologic andtherapeutic lifestyle changes established for their control.

. Mechanisms of atherosclerosis-specific targeted interven-tions with the use of combination medications that can beused to slow progression and reverse the process (49).

. Vascular and hemodynamic benefits of smoking cessa-tion, increased physical activity, and a diet low insaturated fats and rich in fruits, vegetables, fiber, andwhole grains, particularly promoted at an early age.

. Clinical Epidemiology and Biostatistics

.1. Justification

linical epidemiology is the study of the magnitude, distri-ution, and trends in the factors that affect health, disease,nd their determinants in populations. Within the contextf preventive cardiology, clinical epidemiology providesrucial information in the enumeration of CVD events,ates, trends, and outcomes in defined populations and theirubgroups. It also permits the identification of populationst different levels of risk for CVD events and the existencef health disparities (51). The surveillance components oflinical epidemiology provide clues to new and emergingVD threats and permit assessment of the effectiveness of

nterventions.Recent emphasis on quality, economic end points, andodeling in epidemiologic studies provides an opportunity

or epidemiology to inform clinical practice on the cost-ffectiveness and health impact of alternative preventivetrategies (52–55). In addition, clinical epidemiology servesn important role in informing practitioners about the use of

vidence from clinical trials and the strength and general-



Table 1. Opportunities for Formal Training and Alternative Routes to Competence and Maintenance of Competence in Prevention of Cardiovascular Disease

SectionA

Ways to Achieve Formal TrainingB

Alternate Routes to Achieve CompetenceC

Maintenance of Competence

2. Cardiovascular and Vascular Biology ACCF Self-Assessment programs (ACCSAP,LipidSAP)

CME that focuses on cardiovascular and vascular biology andatherosclerosis is important to receive each year

3. Clinical Epidemiology andBiostatistics

ACCSAPThe AHA 10-Day Seminar on the Epidemiology and

Prevention of CVD

5. Genetics and CardiovascularDisease in Individuals and Families

Participation in an active genetic CVD referral clinicunder the supervision of expert cardiovascularspecialists in the relevant areas

CME that focuses on the genetic aspects of CVD preventionin individuals and families is important to receive eachyear

6. Behavioral and PsychosocialPrograms (Financial andSocioeconomic Factors)

Participation in cardiac rehabilitation program thatincludes psychosocial assessment, management,and referral under the supervision of expertcardiovascular and other specialists in therelevant areas

CME that focuses on behavioral assessment andmanagement of patients with CVD

10. Nutrition Management Clinical experience in a preventive cardiology clinicprogram during formal fellowship training.Clinical experience in nutrition subspecialtyprograms such as weight loss clinics, lipidclinics, and diabetes management programs

11. Lipid Management (Managementof Dyslipidemia)

A comprehensive understanding of the NCEP ATPIII and updates is critical to achievecompetence. The ACCF provides a self-assessment program in lipidology, and theNational Lipid Association has a self-studyprogram that can provide eligibility for Boardcertification by the American Board of ClinicalLipidology

National Lipid Association sponsored self-assessmentprogram, self-study modules, masters class, and advancedmasters summits in lipidology

12. Thrombosis Management ACCF/AHA continuing education programs, theAmerican College of Chest Physician ConsensusConference Guidelines, the Peripheral ArterialDiseases Antiplatelet Consensus Group:Antithrombotic and thrombolytic therapy:American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (1)

Web sites of the PAD Coalition and AHA National society meetings with focus on antithrombotictherapy

13. Hypertension Management American Society of Hypertension Certification as aclinical specialist in hypertension and medicaleducation seminars and didactic sessions withfaculty members with expertise in each of theabove areas

14. Smoking Cessation Formal training in behavioral science and smokingcessation is a critical link to successful office-based or hospital-based smoking cessationprograms. Mentoring by faculty/colleagues withexpertise in behavioral medicine/science is animportant training modality

Medical education seminars, Webcast CMEprograms, Society for Behavioral Medicinepublications and meetings, and CME programsspecifically addressing addiction and smokingcessation

National Cancer Institute Web site: Prevention and Cessationof Cigarette Smoking: Control of Tobacco Use (2)

MedlinePlus: Quitting Smoking (3)AHA Web site: Smoking and Cardiovascular Disease (4)CDC Web site: Smoking & Tobacco Use

Continued on next page

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Table 1. Continued

SectionA

Ways to Achieve Formal TrainingB

Alternate Routes to Achieve CompetenceC

Maintenance of Competence

15. Obesity Management (BehavioralPrograms)

A clinical rotation in both an endocrinology and abariatric surgery–based obesity clinic to learnhow to apply patient-specific behavioralmethods to achieve weight loss should bemandatory, with a suggested involvement in thecare of 5 patients entering a weight lossmanagement program over the course of formaltraining. Attendance at an accredited obesitytraining program for healthcare professionals.

Continued clinical practice as well as yearly CME courses inpreventive cardiology with a focus on overweight/obesitymanagement

16. Exercise Physiology, PhysicalActivity Management, and CardiacRehabilitation (SecondaryPrevention)

Active instruction in a preventivecardiology/cardiac rehabilitation center thatincludes access to a multidisciplinary staff (e.g.,cardiologists with specific expertise/training insecondary prevention, nurse clinicians, exercisephysiologists, registered dieticians, behaviorists,smoking cessation counselors, andpharmacists). A listing of cardiopulmonaryrehabilitation programs in the United States andCanada is available through the AmericanAssociation of Cardiovascular and PulmonaryRehabilitation. Moreover, the American Collegeof Sports Medicine offers certificationexaminations and registry programs for exercisephysiology, as well as a complete listing of theknowledge, skills, and abilities that comprisethe foundations of these relevant certifications(e.g., exercise specialist, registered clinicalexercise physiologist), with specific reference torequirements (e.g., educational degree,minimum hours of practical experience) andrecommended competencies (5).

Direct clinical training with exercise physiologists,smoking cessation counselors, registereddieticians, and lipid specialists in settings otherthan formal cardiac rehabilitation programs

Active involvement with cardiac rehabilitation/secondaryprevention programs and direct involvement in thesupervision and care of cardiac rehabilitation patientseach year. CME that focuses on clinical exercise physiologyapplications, exercise prescription in health and disease,and cardiac rehabilitation/secondary prevention areimportant to receive each year. Organizations with relatedregional and national conference programming include:ACCF; AHA; American College of Sports Medicine; and theAmerican Association of Cardiovascular and PulmonaryRehabilitation

17. Prediabetes, Metabolic Syndrome,Insulin Resistance, and DiabetesManagement

Clinical experience in a preventive cardiovascularmedicine clinic program during formalfellowship training, as well as rotations in aspecialized diabetes clinic. ADA trainingmodules with multiple choice questions anddetailed, evidence-based answers.

ADA clinical practice guidelines are updated annually andpublished as a supplement to Diabetes Care

18. Chronic Disease Management Clinical rotation in a preventive cardiology centerto learn about and apply a patient-specific,systems approach to prevention of CVD inprimary and secondary prevention patients

A indicates use of ACCF/AHA training modules with multiple choice questions and detailed, evidence-based answers during training with mentoring by faculty members with expertise in each of the specified areas; B indicates medical education seminars and didactic sessions with faculty memberswith expertise in each of the above areas; and C indicates CME activities that focus in each of the specified areas. Use American Board of Internal Medicine recertification modules in the relevant area. ACCF indicates American College of Cardiology Foundation; ADA, American Diabetes Association;AHA, American Heart Association; CDC, Centers for Disease Control and Prevention; CME, continuing medical education; CVD, cardiovascular disease; and NCEP ATP, National Cholesterol Education Program Adult Treatment Panel III. 1341JACC

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able 2. Educational Resources for Acquisition and Maintenance of Competence in the Prevention of Cardiovascular Disease

Section Educational Opportunities

. Cardiovascular and Vascular Biology (6)

. Clinical Epidemiology and Biostatistics (7–10)

. Cardiovascular Pharmacology (ComplexMultipharmacologic Understanding)

Micromedex is available in many hospitals for dosing and interactions information

Facts and Comparisons page is useful to check for drug–drug interactions

. Genetics and Cardiovascular Disease in Individualsand Families

(6,11)

National Coalition for Health Professionals Education in Genomics—competencies in genomics

CDC genetics and genomics competencies for public health

Inventory of family history tools and resources

. Behavioral and Psychosocial Programs (Financialand Socioeconomic Factors)

(12–16)

. Advanced Risk Assessment (Renal, InflammatoryDiseases)

(17,18)

. Subclinical Atherosclerosis Assessment (Imagingand Nonimaging)

(17–20)

. Adherence and Disease Outcome InterdisciplinaryPrograms

Patient compliance information for the professional

(21–24)

0. Nutrition Management (25–27)

1. Lipid Management (Management of Dyslipidemia) American Board of Clinical Lipidology

National Lipid Association Self-Assessment Program

(28)

2. Thrombosis Management See PAD Coalition and AHA for resources

(9,29–32)

3. Hypertension Management (33–35)

Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiologyand Prevention

4. Smoking Cessation (2,36–38)

Links to MEDLINE and access to multiple governmental and professional Web sites for smoking cessationsupport and literature

AHA Web site: Smoking and Cardiovascular Disease: includes educational resources for smokingcessation

5. Obesity Management (Behavioral Programs) (39–41)

6. Exercise Physiology, Physical ActivityManagement, and Cardiac Rehabilitation(Secondary Prevention)

American College of Sports Medicine Annual Meetings and Regional Conferences

American Association of Cardiovascular and Pulmonary Rehabilitation Annual Meeting and resourcematerials

AHA Annual Scientific Sessions

AHA Guidelines and Statements on Exercise

7. Prediabetes, Metabolic Syndrome, InsulinResistance, and Diabetes Management

American Diabetes Association (ADA) clinical practice guidelines

ADA Professional Practice Resources

(42)

Diabetes (Personal Health Decisions) PHD risk assessment tool

ADA for healthcare professionalsAmerican Association of Clinical Endocrinologists

8. Chronic Disease Management (43)

HA indicates American Heart Association.

by on March 15, 2010 content.onlinejacc.orgDownloaded from

http://www.thomsonhc.com/hcs/librarian/PFPUI/rl1qVr81sXLxSyhttp://online.factsandcomparisons.com/index.aspxhttp://www.nchpeg.org/core/Corecomps2005.pdfhttp://www.cdc.gov/genomics/training/competencies/forum.htmhttp://www.cdc.gov/genomics/public/famhix/links.htmhttp://www.americanheart.org/presenter.jhtml?identifier=815http://www.lipidboard.orghttp://www.lipid.org/sap/http://PADCoalition.orghttp://heart.orghttp://www.americanheart.org/presenter.jhtml?identifier=3055921http://www.americanheart.org/presenter.jhtml?identifier=3055921http://www.nlm.nih.gov/medlineplus/smokingcessation.htmlhttp://www.nlm.nih.gov/medlineplus/smokingcessation.htmlhttp://www.americanheart.org/smokingcessationhttp://www.americanheart.org/smokingcessationhttp://www.acsm.orghttp://www.aacvpr.orghttp://www.aacvpr.orghttp://www.americanheart.orghttp://www.americanheart.orghttp://care.diabetesjournals.org/content/vol30/suppl_1/http://professional.diabetes.org/ProfessionalResources_Search.aspxhttp://www.diabetes.orghttp://www.diabetes.orghttp://www.diabetes.orghttp://content.onlinejacc.org

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zability of that evidence. In this endeavor, the related fieldf biostatistics provides important principles for appropriateesign of clinical trials, interpretation of trial results, and theffective use of screening, diagnostic, and prognostic tools inhe practice of preventive cardiology (56).


he expert in the prevention of CVD should demonstratenowledge and competence in:

. Terms used to describe the central tendency of popula-tion distributions (e.g., mean, median, and mode), andthe terms used to describe the magnitude of dispersionaround these measures (e.g., standard deviation, standarderror, and percentiles) (51–56). Familiarity with terms thatdescribe the frequency and burden of CVD as well as theimportance of age adjustment.

. Terms used to characterize screening and diagnostic testsincluding sensitivity, specificity, accuracy, and predictivevalues (positive and negative) (56,57).

. Experimental study designs (randomized, nonrandom-ized, and noninferiority clinical trials) and nonexperi-mental designs (cohort, case-control, nested case-control,cross-sectional studies), as well as the principle of hypoth-esis testing that underlies these studies, and the numberneeded to treat and the number needed to harm.

. Common analyses encountered in the medical literaturesuch as the t test, chi-square test, multiple regression,Kaplan-Meier survival analysis, and the Cox propor-tional hazards analysis is necessary, including the types oferrors that can be committed when inferences are madeabout data in studies.

. Traditional risk factors (8–10) and nontraditional riskfactors, such as calculation of non–high-density lipopro-tein cholesterol (non–HDL-C) in persons with triglyc-eride levels above 200 mg/dL.

. Inflammatory biomarkers, including high-sensitivityC-reactive protein, serum amyloid A, interleukin-6,lipoprotein-associated phospholipase A2, monocyte che-moattractant protein-1, soluble CD40 ligand, and my-eloperoxidase and their possible utility in risk assessment(58,59).

. The concepts of relative and absolute risk; short-term,long-term, and lifetime risk; and the population burdenof CVD attributable to specific risk factors, including theFramingham Risk Assessment score in clinical practiceand knowledge of its limitations (60).

. Cost-benefit analyses of CVD interventions.

. Cardiovascular Pharmacology (Complexultipharmacologic Understanding)

.1. Justification

nowledge of cardiovascular pharmacology and the basicrinciples of pharmacokinetics, pharmacodynamics, and

harmacogenomics is critical to the targeted application of


rug therapy for individual patients. A basic knowledge ofrug interactions, anticipated side effects, and dosing regi-ens in a heterogeneous mix of complex patients is neces-

ary to integrate new research and new approaches for CVDrevention and treatment. The challenges posed by age,ender, reproductive hormones, and medical comorbidities,ncluding the coexistence of disorders known to contributeo cardiac and vascular endothelial dysfunction, must beecognized. Interactions between medication and nutritione.g., grapefruit), over-the-counter supplements (e.g., anti-xidant vitamins), nutriceuticals (e.g., stanol/sterol esters),nd dietary alcohol intake are increasingly reported and ofractical relevance. Knowledge that pharmacologic thera-ies may have differing impact based on underlying exis-ence of disease and endogenous hormone status, includingormonal therapies, is important. A basic understanding ofharmacology will also be important as new therapies foryocardial salvage, regeneration, and remodeling become

vailable.



. Pharmacological approaches to lipids, hypertension,thrombosis, diabetes and insulin resistance, cigarettesmoking cessation, and obesity (10). The important roleof statins and other lipid-lowering medications, anti-platelet therapies, renin-angiotensin-aldosterone systemagents, and antihypertensive medications should be con-sidered (49).

. Use of multiple drug combinations (coexistent condi-tions and risk factor clustering) (61) and drug–druginteractions (62), including the ever-increasing complex-ity of pharmacological regimens and potential and real-ization of drug–drug interactions.

. Preventive cardiovascular strategies for comorbiditiessuch as renal disease, autoimmune inflammatory disor-ders, diabetes mellitus, and cancer, which raise the riskfor CVD due to the comorbidity itself as well as thetreatment regimens used to treat these comorbidities.

. Pharmacologic dosing adjustment in consideration ofissues of aging (63), gender (64), ethnicity, and comor-bidities, for example, renal disease and liver disease andethnicity. Aggressive preventive cardiovascular regimensare optimally tolerated when body weight– and renalfunction–adjusted, including the elderly, women, andsmaller-sized men. Knowledge of ethnic groups thathave higher rates of toxicity to certain medications is alsoimportant.

. Pharmacological interactions with over-the-counter sup-plements, nutriceuticals (soluble fiber, psyllium seed,stanol/sterol esters), and common dietary ingredients,such as grapefruit, which can interact with many com-mon medications, including most statins, increasing

blood levels of the medication when taken concurrently



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(65). A majority of patients are taking over-the-countersupplements that may interact with their medication,such as the antioxidant vitamins that adversely interact toreduce the antiatherosclerotic niacin benefit.

. Pharmacogenomics, including the prospective role ofpatient testing for genetic polymorphisms that raise/lower the likelihood of adverse pharmacological sideeffects, or lack of metabolism/efficacy with a particularclass of medications.

. Genetics and Cardiovascular Disease inndividuals and Families

.1. Justification

enes and gene–environment interactions play importantoles in the causation, pathogenesis, and prognosis of CVD6,66). Thus, knowledge of the spectrum of inheritedusceptibilities to CVD and elucidation of the patterns ofnheritance for specific genetic abnormalities may providemprovements in early detection, risk stratification, andrevention of CVD in individual patients and their familyembers (6,66–68). Additionally, advances in pharmaco-

enomics provide an opportunity for improving diseasereatment and response (69,70).

A wide spectrum of CVD with inherited genetic suscep-ibilities is now known, and the advances made over the last5 years in understanding the genetic basis of these disor-ers provide a rationale for ensuring competence in geneticsor experts in the prevention of CVD (71–73). The limita-ions of current genetic information in patient care and theaps between knowledge of an apparently inherited suscep-ibility and the availability of, or access to, correspondingffective treatments must be explicitly acknowledged (74).inally, the benefits, risks, and costs associated with knowl-dge of a patient’s genetic susceptibility to CVD and thethical implications of referral for genetic testing andounseling must be recognized (75,76).



. Basic skills in eliciting a comprehensive family historyduring the patient encounter and familiarity withclinical tools and/or questionnaires for collecting ge-netic information.

. Differences between genotype and phenotype and theconcepts of dominance, recessiveness, X-linked inheri-tance, genetic heterogeneity, and penetrance.

. Basic principles of clinical genetics including the types offamily studies, linkage analyses, genetic association stud-ies, and familiarity with recent advances in genome-wideassociation.

. Chromosomal deletions, duplications, and rearrange-ments as a cause of clinical syndromes associated with

genetic disorders. o


. Mendelian disorders and syndromes associated with con-genital heart disease (e.g., DiGeorge, Noonan, and Wil-liams syndromes) and those involving connective tissue(e.g., Marfan syndrome, Ehlers-Danlos syndrome).

. Genetic basis of specific cardiovascular disorders such ascardiomyopathies, arrhythmias, and lipoprotein disor-ders and their potential role in diagnostic evaluation andtreatment.

. Teratogens including warfarin, hydantoin, retinoic acid,valproic acid, rubella, and alcohol.

. The indications for, as well as benefits, risks, and ethicalimplications of, referral for genetic testing and counsel-ing, and the limitations of available testing kits.

. Behavioral and Psychosocial ProgramsFinancial and Socioeconomic Factors)

.1. Justification

sychosocial factors add a significant dimension to CVDevelopment and outcomes (13,14,77–80). Psychosocialactors influence the pathophysiology of disease, access toealthcare services, and adherence to treatment (81,82).he best treatments are of no use to a patient if he or she

annot access the healthcare system, has inadequate services,r obtains health care too late to change the outcome15,16,83–85).

Prospective cohort studies provide evidence for a role forepression, stress, psychosocial work characteristics, socialsolation and support, and possibly hostility as factors in thetiology of CVD and prognosis after CVD diagnosis13,14,77–80). Over 30% of all patients with diagnosedardiovascular or cerebrovascular disease have either clinicalepression, anxiety, or other psychologically adverse condi-ions (13,14). Depression is common overall, and risk isncreased following a CVD event (14,78,80). Depression is

risk factor for coronary heart disease (CHD), recurrentHD events, and heart failure (HF), and is associated withoor outcomes in CVD, postcoronary bypass, and HF.ocioeconomic factors such as education, occupation, in-ome, and insurance status have a significant impact on riskactor development, CVD, and mortality (77,86–90).

All physicians and other healthcare providers should beble to diagnose anxiety and depression, and this should beoutine after a CVD event or stroke (14). While psycho-ogical and medical interventions to treat depression andnxiety have not been shown to reduce future cardiac eventso date, further research is underway to determine ifutcomes after CVD events benefit from treatment14,16,83,84,91). Cardiac rehabilitation programs that in-orporate psychosocial screening and intervention can im-rove treatment outcomes, the quality of life, and adherence

f patients with psychological disorders (15,92).



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. Psychosocial factors in the development of CVD and onCVD outcomes, particularly as barriers to treatmentimplementation.

. The diagnosis of anxiety and depression disorders, recog-nition of suicidality, and the appropriate use of referrals.

. Use of pharmacotherapies in the treatment of depressionincluding patient selection, side effects, monitoring forefficacy, and impact on risk factors.

. Recognition of safe treatments for anxiety and depres-sion in patients with CVD.

. Recognition of when referral for psychiatric or psycho-logic care is needed and appropriate.

. Cardiac rehabilitation for the assessment and manage-ment of psychosocial conditions related to CVD.

. The role of healthcare systems and financing on psycho-social risks and outcomes for CVD, including the role ofsocial workers and case managers in identifying andfacilitating social services.

. Advanced Risk AssessmentRenal, Inflammatory Diseases)

.1. Justification

he assessment of both traditional and nontraditional riskactors underlies the primary and secondary prevention ofVD. Novel biomarkers are emerging as prognostic tools

or CVD risk assessment. Persons with chronic kidneyisease are considered to be a CHD risk equivalent by someuidelines (93,94). The doses of many cardiovascular med-cations need to be adjusted in persons with chronic kidneyisease, especially as glomerular filtration rate declines andhronic kidney disease worsens.

Adults with inflammatory diseases such as lupus, psoria-is, or rheumatoid arthritis seem to be prone to acceleratedtherothrombotic vascular disease (95,96). Healthcare pro-iders need to be more aggressive in trying to motivate patientsith chronic kidney disease or inflammatory disorders toptimize their lifestyle habits and to achieve optimal levels oflood pressure and lipids. A number of ongoing studies arerying to assess the role of chronically high levels of inflamma-ion in the development of CVD. Persons with lupus may alsoeed to be screened for a prothrombotic state.Recent studies have also shown that acute myocardial

nfarction (MI) rates and cardiovascular risk factors arencreased in persons with human immunodeficiency virusHIV) infection as compared with non-HIV patients97,98). Certain classes of antiretroviral drugs, especiallyrotease inhibitors, appear to promote dyslipidemia anday independently increase risk via inflammatory pathways

99). Strategies to reduce risk for atherosclerotic vascular econtent.onlinejaDownloaded from

isease should be incorporated into the standard care ofIV infection.There is considerable ongoing research dealing with the

rognostic role of biomarkers in persons with renal, inflam-atory, or chronic infectious disease in both the primary

nd secondary prevention settings. In future years, we willave a better understanding of when measurement ofiomarkers such as C-reactive protein, B-natriuretic pep-ide, and urinary microalbumin should change standardlinical management and the intensity of risk factor modi-cation (100–102).



. Measurement of urinary albumin creatinine ratio inchanging pharmacologic management.

. Inquiry regarding erectile difficulties on at least a yearlybasis as a marker for early atherosclerotic vascular diseaseand generalized endothelial dysfunction.

. Measurement of systolic blood pressures in each brachialartery and one of the pedal arteries in each foot tocalculate an ankle-brachial index, and the therapeuticimplications for diagnosis of peripheral vascular disease,a CHD risk equivalent.

. Individuals with certain infectious diseases, chronic in-flammatory conditions, and other collagen vascular dis-eases, as they are often at increased risk for atheroscle-rotic vascular disease and need to undergo comprehensiverisk factor modification (97).

. Aggressive management of all risk factors, as appropri-ate, in patients with a history of chest wall irradiation, asthey are prone to premature atherosclerotic disease.

. Subclinical Atherosclerosis AssessmentImaging and Nonimaging)

.1. Justification

he preclinical detection of atherosclerosis is an area ofrowing interest. The concept is to detect lesions in theerebral, coronary, or peripheral vasculature before symp-oms of end-organ ischemia occur (transient ischemic at-ack/stroke, angina/MI, claudication/limb ischemia), or be-ore rupture and bleeding (aortic aneurysm) (19,20,103).wo recent studies from the MESA (Multi-Ethnic Studyf Atherosclerosis) trial have clearly documented the prog-ostic power of elevated coronary calcium scores (104,105).uch patients could be targeted for intensive risk factorontrol, other medical interventions, and endovascular orurgical treatments if indicated.

While the concept of preclinical detection is appealing foreveral reasons, controversy exists about the usefulness andfficacy of some screening programs and paradigms. Thereventive cardiovascular specialist should have the knowl-

dge base and skills to 1) advise patients about the useful-



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ess of such screening, including costs; 2) interpret theesults of a screening test in terms of formulating a carelan; and 3) provide guidance about the need for subsequentesting and therapy.

Some screening approaches entail financial as well asotential medical risks, particularly if a positive test leads tourther investigations and in some cases medical, surgical, orndovascular interventions. Thus, it is important to haveome guidance about what competencies are needed in thesereas.



. General epidemiology and risk factors for asymptomaticdisease in various vascular beds. Knowledge of these factorsand associations will be helpful to the clinician in determin-ing which patients are at higher versus lower risk to haveasymptomatic disease in various vascular beds.

. While controversial as to efficacy, the potential screeningmodalities for asymptomatic disease in the various vas-cular beds (Table 3) (18,20,106–118).

. Technical limitations and overall sensitivity, specificity,accuracy, and risks of various screening tests (106,111,113,118,119). Radiation exposure from coronary com-puted tomography angiogram may increase the risk ofbreast cancer, but the amount of ionizing radiationassociated with the test is considerably less than thatassociated with a stress radionuclide examination (120).Knowledge of these factors is important for the clinicianto weigh the results and risks of such screening tests anddetermine the need for further testing depending on theoverall clinical scenario.

. The need for further testing in patients with evidence ofasymptomatic disease (Table 3). This would include theclinical indications for further testing, the methods usedfor subsequent testing, and their limitations (false posi-tives, false negatives, overall accuracy) (103,108,118).

. How to treat patients with the presence of asymptomaticdisease in various vascular beds, the risks and benefits ofthese various treatments and interventions, and patienteducation and knowledge of sources for such educationalinformation (i.e., Web sites, nonprofit organizations).

. How to order and/or interpret the above screening tests,understand the test results, explain their meaning to thepatient, and plan further testing and treatment, perhaps

able 3. Testing Modalities

Vascular Bed Initial Testing

arotid Auscultation, carotid duplex ultrasound

oronary CAS, CTA

orta Palpation, abdominal ultrasound

oncerebral peripheral arteries Ankle-brachial index

AS indicates coronary artery calcium score; CTA, computed tomography angiogram; MRA, magnetic re


in consultation with other medical specialists in relatedareas of vascular medicine.

. Adherence and Disease Outcomenterdisciplinary Programs

.1. Justification

dherence is a measure of how consistently a patientollows the specific requirements of an intervention. Knowl-dge about how to achieve a superior level of adherence isrucial. While the true rate of patient adherence is difficulto measure without using sophisticated tools that in them-elves may influence patient behaviors, research generallyndicates that long-term adherence to behavioral and med-cal intervention may be as low as 50% (121). Nevertheless,n some settings and in some patients much higher rates ofdherence occur, suggesting that low rates of adherenceesult from specific causal factors such as the cost ofedications, depression, or low health literacy, and that

dherence is amenable to change. Some personal factorsuch as personality traits do not consistently influencedherence while others such as self-efficacy do. Societal,ealthcare system, and provider factors likely influencedherence rates (122–124). Successful prevention oftenequires lifelong actions by the patient, and therefore, a highevel of long-term adherence is very important in effectiverevention (125).Disease outcome or management programs usually con-

ist of at least 2 program elements: a patient monitoringomponent and a system to respond proactively to changesn the patient’s symptoms or physical status. Effectiveisease management programs should reduce or delay thedverse consequences of chronic CVD events, such asreventing or reducing the number of HF hospitalizationsn patients with HF, and reduce the episodic nature ofealth care based on the treatment of acute episodes (21).he long-term efficacy of most disease programs is uncer-

ain. Since many patients have several chronic illnesses oromplex prevention problems, the concepts underlying dis-ase outcome interdisciplinary programs may in the futuree applied to a wider set of prevention problems. Bothdherence and disease outcome management programs areased on the integration of biologically derived scientificoncepts with behavioral and social science concepts.

Follow-Up Tests

, CTA, carotid angiography, if indicated

ss test with or without imaging, if indicated; coronary angiography, if indicated

, MRA

dmill exercise test, PVRs, duplex ultrasound, CTA, MRA

MRA

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CTA

Trea

sonance angiography; and PVRs, pulse volume recordings.



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. How to measure adherence through a variety of ap-proaches such as history and medication reconciliation.

. How to determine the causal factors underlying nonad-herence, including the important patient factors such ashealth literacy, depression, comorbid conditions, trust inthe healthcare provider, adverse effects, and economicfactors.

. Patient-level interventions to improve adherence such asreducing the cost of medications, treating depression,and use of aids like weekly pill boxes.

. Important provider factors such as interest in adherenceand skill in identifying barriers to adherence, combinedwith understanding important healthcare system andsocietal factors such as ease of maintaining the interven-tion or medication, cost, systematic reminders, andnumber and frequency of patient contacts.

. Components of a successful disease outcome programsuch as prompt evaluation and detection of new symp-toms and adjustment of medications in response tochanges in symptoms; frequency and duration of patientinteractions with the disease management program; andmode of collecting information on patient status, includ-ing self-reports and automated devices.

. Disease management programs, the role of feedback tothe patient and provider beyond adjustment of therapeu-tic regimen, and the expected roles of the patient andtheir family, the provider, and other health personnel ina disease management program.

. Common theoretical models for adherence and diseasemanagement such as: Stages of Change (22), Wagner’sChronic Care Model (23), and Self Efficacy (24).

. Motivational interviewing and other patient empower-ment techniques.

0. Nutrition Management

0.1. Justification

any of the conditions and disease states that affecttherosclerotic risk can be prevented or at least modified byietary interventions. These conditions and diseases includebesity and excess body weight, hypertension, lipid abnor-alities, and diabetes. Even when conditions such as

ypertension and hyperlipidemia are established and requireharmacologic therapy, dietary manipulations can reducehe dosage of medication required to achieve therapeuticoals. Similarly, some nutritional supplements (e.g., red riceeast [126] and omega-3 fatty acids [127]) contain phar-acologically active substances that can be used therapeu-

ically in selected patients. In contrast, some dietary andutritional supplements may contain substances such as

ympathomimetics that increase cardiac arrhythmias. Con- t


equently, healthcare providers practicing preventive cardi-logy must be required to have an understanding of nutri-ion and the principles of nutrition so that they are able torovide expert advice to patients and to reinforce expertdvice given by nutritional professionals. In addition, cred-bility as a preventive specialist with patients is enhancedhen the preventive cardiologist is conversant in the basicsf diets and nutritional therapy.

0.2. Minimal Knowledge


. Obesity, its role in producing insulin resistance and themetabolic syndrome, the healthcare provider’s role inhelping patients maintain body weight, the basic classi-fications of body weight, the contribution of overweightto hypertension and hyperlipidemia, the basic conceptsof caloric balance, the caloric content of the major foodgroups, the role of exercise in helping to maintain bodyweight, and the action of the available prescriptionweight loss drugs and their possible cardiovascular sideeffects, including that recommendations may differ ac-cording to age (pediatric versus adult versus very elderly).

. Surgical approaches to morbid obesity and the possiblemedical complications of this surgery.

. Composition of diets used to assist in blood pressurecontrol such as reduced sodium, calorie reduction forweight loss, moderation of alcohol consumption, in-creased potassium intake, and consumption of an overallhealthy diet (128).

. Composition of therapeutic diets used to manage hyper-cholesterolemia and hypertriglyceridemia and especiallythe effect of saturated fats, transfatty acids, and lowdietary fat and cholesterol on serum lipids (129). Inaddition, the preventive cardiology specialist should beconversant in discussing the origin of dietary fats withregard to therapeutic potential (27,129).

. Composition of diets used in patients with impairedglucose tolerance and diabetes (130).

. Use of over-the-counter and nonprescription agents inlipid management including the risks and benefits ofplant stanols and sterols (131), fish oils (127), and dietaryfiber (127,132).

. Potential cardiac dangers of too-rapid weight loss (133).

. The limited role of dietary antioxidants in preventingatherosclerotic disease (126,134).

. The role of alcohol intake in causing and preventingcardiac disease (135,136).

1. Lipid ManagementManagement of Dyslipidemia)

1.1. Justification

he management of dyslipidemia has emerged as a key

herapeutic strategy to reduce both primary and secondary



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ardiovascular events. Despite a plethora of large outcome trials137–139) supporting the evidence for lipid-altering treat-ents to improve outcomes and national guidelines that have

stablished specific goals of treatment, there remains a signif-cant treatment gap in the achievement of low-density lipopro-ein cholesterol (LDL-C), non–HDL-C, and HDL-C targets140,141). The National Cholesterol Education Programdult Treatment Panel III (NCEP ATP III) Guidelines (142)pdated in 2004 (143) mandate an LDL-C goal for high-riskatients of less than 100 mg/dL with an optional goal of lesshan 70 mg/dL for patients with CVD plus diabetes or otherultiple risk factors. The AHA Secondary Prevention Guide-

ines also advocate an LDL-C goal and non–HDL-C goal ofess than 70 mg/dL and less than 100 mg/dL, respectively (10).et, recent surveys demonstrate that less than one third ofatients with CVD with additional risk factors are achievinghese recommended targets (140). In addition, patients withow HDL-C and/or elevated triglycerides remain at elevatedesidual risk even at recommended LDL-C goals (144–146).



. Basic lipid metabolism, including both exogenous andendogenous lipoprotein synthesis.

. Synthetic process in which chylomicrons, very low-density lipoprotein, LDL-C, and HDL-C are devel-oped, and the genetic disorders that are associated withdyslipidemia.

. The diagnosis of familial hypercholesterolemia, familialcombined hyperlipidemia, and familial hypoalphali-poproteinemia, which are associated with a significantlyincreased risk of premature atherosclerosis.

. Familiarity with NCEP guidelines, including the recentupdates that recommend optional LDL-C targets forvery high-risk patients.

. Matching the intensity of treatment to the risk of thepatient. This is the cornerstone of national guidelines,and the preventive cardiovascular specialist should befamiliar with the clinical trials that provided the evidencefor more aggressive LDL-C reduction.

. Ability to instruct a patient on appropriate therapeuticlifestyle changes, which includes an understanding of alow saturated fat and dietary cholesterol food manage-ment program and, if necessary, the incorporation ofviscous soluble fiber and plant stanols/sterols to furtherlower LDL-C levels, and the importance of reducingtrans fats, cholesterol, and simple carbohydrates in pa-tients with high triglycerides and abdominal obesity.

. Mechanism of action of statins, the expected efficacy ofeach dose of statin and, therefore, the ability to achievethe NCEP ATP III goals, plus the mechanism of actionof niacin, ezetimibe, fibrates, bile acid sequestrants, and

omega-3 fatty acids and their expected effects on


LDL-C, HDL-C, and triglycerides and risks and ben-efits of combination therapy.

. Potential side effects of treatment to counsel patients andavoidance of drug interactions, which is imperative toimprove the safety and compliance of long-termtreatment.

2. Thrombosis Management

2.1. Justification

therothrombosis is a progressive process that includestherosclerotic plaque formation, disruption, and thrombo-is. These processes constitute the pathophysiology thatnderlies acute coronary syndrome, ischemic stroke orransient ischemic attack, and peripheral arterial diseasePAD). U.S. prevalence data lists 7.2 million people affectedy MI, 6.5 million with angina pectoris, 5.5 million withtroke (147), and 8 to 12 million people affected by PAD148). The NCEP ATP III considered PAD to be a CHDisk equivalent (142). The recently published REACHReduction of Atherothrombosis for Continued Health)egistry showed that among patients with symptomatictherothrombosis, 16% had symptomatic polyvascular dis-ase (149). Approximately 56% of stroke patients 60 years ofge and older have coexisting coronary artery diseaseCAD), and evidence suggests the 20% to 40% of patientsith ischemic stroke or transient ischemic attack concur-

ently have silent CAD (150,151).



. The core set of risk factors, which includes hypertension,diabetes, hypercholesterolemia, tobacco use, and obesity,that contribute to the bulk of the risk for atherothrom-bosis (149), and novel parameters such as lipoprotein(a),apolipoprotein A-I and apolipoprotein B-100, fibrino-gen, homocysteine, and high-sensitivity C-reactive pro-tein (10,152).

. Management of unstable angina and non–ST-segmentelevation MI is extensive with multiple antithrombotictherapy combinations, and implement systems for anti-thrombotic therapy recommended in the ACC/AHAguidelines for unstable angina and non–ST-segmentelevation MI (153).

. Antithrombotic therapy options for preventing recurrentstroke and other cardiovascular events in patients withnoncardioembolic ischemic stroke (32).

. Risk factor identification and early assessment of PAD(149,152,154), and use of antithrombotic agents toprevent atherothrombotic events in this patient population(155–158), including their indications and contraindica-tions, mechanism of action, efficacy, side effects, drug

interactions, and costs (159).



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3. Hypertension Management

3.1. Justification

ypertension is a major contributor to the global diseaseurden and is one of the leading preventable causes ofremature death worldwide (160). In the United States, aisproportionate burden of hypertension and its associatedomplications, including CHD, HF, stroke, and end-stageenal disease and CVD mortality, affect African Americansalso referred to as U.S. blacks) (161). Preventive cardiovas-ular specialists should have knowledge of hypertension andechanisms of elevated blood pressure, and an understand-

ng of the therapeutic lifestyle changes and pharmacologicnterventions that are crucial for controlling hypertension inlinical practice. A basic knowledge of the potential mech-nisms of elevated blood pressure and associated risk factorss necessary to understand the ongoing research into newpproaches for prevention, identification, and therapy. Aasic understanding of the use of therapeutic lifestylehanges and appropriate drug therapies for patients withompelling indications is necessary to reduce cardiovascularorbidity and mortality.



. Major risk factors for hypertension as described by theSeventh Report of the Joint National Committee (35),and the impact of hypertension on CVD morbidity andmortality specifically related to MI, HF, stroke, and renalfailure, and the diagnostic categories and treatment goals.

. Therapeutic lifestyle and pharmacologic interventions inhypertension and CVD including weight reduction,adopting Dietary Approaches to Stop Hypertension(DASH) eating plan, sodium reduction, physical activity,moderation of alcohol consumption, and medicationregimens.

. Indications for and interpretation of ambulatory bloodpressure and home blood pressure monitoring.

. Definition and approach to white coat hypertension andmasked hypertension.

. Evaluation and treatment of identifiable causes of hyper-tension (secondary hypertension), including chronic kid-ney disease, coarctation of the aorta, glucocorticoidexcess states, pheochromocytoma, primary aldosteron-ism, renovascular hypertension, sleep apnea, thyroid/parathyroid disease, and drug induced or drug related.

. Definition, differential diagnosis, and treatment of resis-tant hypertension.

. The findings of clinical trials in hypertension withevidence supporting compelling indications and contra-

indications for antihypertensive drug classes.


4. Smoking Cessation

4.1. Justification

moking remains the most important risk factor for CVDn the world (162,163). It is estimated that 40% of all heartisease is related to smoking (164,165). The biochemicalnd physiological consequences of smoking on CVD areell defined (164,166,167). Compelling evidence existsemonstrating that smoking cessation is associated withignificant reversal of risk for CAD, stroke, and cancer-elated deaths (162). In addition, there are multiple societalonsequences from cigarette smoking, including enormousconomic costs. In the United States alone, it is estimatedhat smoking costs $167 billion each year (162). Since 1965,moking in the United States has declined by 47% amongeople over the age of 18 years. However, it is estimatedhat more than 23% of adult men and 19% of adult womenontinue to smoke, and this number is rising in the young162). In addition, exposure to secondhand smoke placesignificantly more persons at risk for heart disease andtroke (168,169).

Clinical competency in smoking cessation treatment isritical for those whose expertise encompasses primary andecondary prevention of CVD and stroke. Clinical competencyncludes skills in patient education, counseling, and behavioralhange, and knowledge of important pharmacotherapies, in-luding risks and benefits. Clinical competency relies on thedentification of smoking status in all patients, prompt andefinitive advice to quit, and the implementation of smokingessation counseling and pharmacotherapies. Systematicollow-up of all smokers at subsequent visits and the involve-ent of healthcare professionals with smoking cessation ex-

ertise improves lifetime smoking cessation.



. Short- and long-term pathophysiological consequencesrelated to tobacco use, which include pulmonary andcardiovascular diseases (36,166,167,170–176).

. Pathophysiology of smoking addiction and be knowl-edgeable of the methods of assessing the physiologiclevels of nicotine addiction (e.g., Fagerstrom Question-naire) (176).

. Use of behavioral skills that facilitate smoking cessation,including interpersonal communication skills, behavioralchange techniques such as self-monitoring and self-care,stress management counseling, patient contracting andgoal setting, self-efficacy, motivational interviewing, andrelapse prevention (170,174,176–178).

. Use of the 5 As (Ask, Advise, Assess, Assist, and

Arrange) treatment intervention during office visits.



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Each visit should include preparation, relapse preven-tion, and counseling (170,174,176).

. Use of pharmacologic therapies to support smokingcessation based on age, pregnancy status, medical history,and comorbidities of the patient (167,170,171,175,179–183).

5. Obesity ManagementBehavioral Programs)

5.1. Justification

besity is a disease that is reaching epidemic proportions,ot only in the United States, but also elsewhere throughouthe world. At the present time, more than 60% of the U.S.dult population is classified as either overweight or obese39,184). In addition, childhood obesity is growing in anlarming fashion. Overweight and obesity are particularlyrevalent in certain minority groups and in individuals of

ower socioeconomic status. Overweight is defined as a bodyass index of 25 to 29.9 kg/m2, and obesity as a body mass

ndex greater than 30 kg/m2 (40). Higher body weight isssociated with an increased risk of hypertension, hyperlip-demia, stroke, CAD, insulin resistance, and type 2 diabetes

ellitus. Moderate weight loss has been shown to decreasehe severity of these comorbidities, and data from observa-ional studies suggest a concomitant decrease in mortality41,185).

Overweight and obesity are felt to result from an imbal-nce between energy intake and expenditure. Less than 20%f American adults regularly engage in moderate physicalctivity. The AHA identified an “epidemiological triad” inrevention Conference VII (November 2004), which in-ludes host factors (genetic makeup, age/gender, attitudes,nd behavior), vectors for increased energy consumption orecreased energy expenditure (i.e., automobile travel instead ofalking or biking, large portion sizes, and high-fat andigh-calorie foods), and environmental factors (i.e., cost ofoods, government policy, as well as sociocultural forces).hey suggest that all components need to be addressed inrder for successful prevention to occur (186).A variety of behavioral options exist to manage over-

eight and obesity effectively. These include dietary ther-py, physical activity, and behavioral techniques. To beuccessful in achieving long-term weight maintenance,owever, these methods have to be individually applied toach patient in the context of regular and consistent medicalupervision. Reduction of initial body weight by only 5% to0% has been shown to result in significant cardiovascularisk factor reduction (187), as well as a variety of otherealth benefits. Presently, training on overweight/obesity inpecialty and subspecialty medical education is woefully

nadequate.




1. Assessment of the overweight/obese patient involvescalculation of body fatness, which can be estimated bybody mass index, waist circumference, overall cardio-vascular risk status, as well as the patient’s motivation tolose weight, including the methods for measurement ofthese. Importance of documenting previous history ofweight loss attempts, social supports available, thepatient’s attitude toward and ability to perform physicalactivity, as well as financial considerations that mayimpact his or her attempts at weight loss.

2. Initial goal of weight loss therapy is to reduce bodyweight by 7% to 10% over a 6-month period of time,after which the rate typically declines. Knowledge thatreassessment should occur to determine if furtherweight loss is desirable and that efforts at maintainingweight loss must be put into place.

3. Caloric content and caloric balance of the major foodgroups, the physiologic and pathologic effects of excessbody weight, and the principles of weight loss via reducedcaloric intake and increased caloric expenditure.

4. Combination of individually planned dietary, exercise,and behavioral techniques, and when to use a low-calorie diet versus a very-low-calorie dietary strategy(188), as well as an understanding of exercise physiol-ogy and guidelines for activity prescription, includingaerobic exercise and strength training (189).

5. Behavioral therapy, with the use of other healthcareprofessionals, to include management/problem-solvingtechniques for stress, enhancing social support, cogni-tive restructuring, and promoting the ability to self-monitor, as well as setting realistic goals.

6. Recognition that maintenance of weight loss is oftenmore difficult than the initial loss; thus, the practitionermust be skilled at understanding the utility of a mul-tifaceted program that consists of ongoing dietarymanagement, physical activity, as well as behavioralmanagement.

7. Challenges of treating special populations, such aschildren/adolescents, the elderly, and smokers.

8. Guidelines for pursing pharmacologic or surgical meansof weight loss therapy if behavioral programs are notsuccessful.

9. Pharmacology, use, and side effects of weight lossmedications, both prescription and nonprescription.

0. Counseling of patients regarding the nutritional andmedical risks associated with rapid weight loss (par-ticularly that mediated by surgical intervention) thatmay impact CVD, including iron and B12 deficiencyanemia, folate deficiency, as well as the potential forother deficiencies, including vitamin D and other

fat-soluble vitamins. Knowledge that physical fitness



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6. Exercise Physiology, Physical Activityanagement, and Cardiac Rehabilitation

Secondary Prevention)

6.1. Justification

mportant goals of exercise-based cardiac rehabilitation areo stabilize existing atherosclerotic plaques, improve endo-helial function and lessen arterial inflammation by modu-ating lipid/lipoprotein levels and blood pressure, andchieve smoking cessation, if appropriate (190,191). Addi-ional objectives are to: increase functional capacity, de-rease symptoms, reduce body weight and fat stores, pro-ote psychosocial well-being, and improve the ability of the

atient to return to work (192,193). Recent meta-analysesndicate that exercise-based cardiac rehabilitation improveshe cardiovascular risk factor profile and reduces all-causend cardiovascular mortality, and that these benefits persistn the current era of cardiovascular therapeutics (194).

In the past, only post-MI patients were consideredandidates for exercise-based cardiac rehabilitation. How-ver, the proven benefits and safety of this intervention havexpanded to include patients with angina, diabetes oretabolic syndrome, cardiomyopathy, pacemakers, heart

alve replacement, concomitant pulmonary disease, cardiacransplant, and HF, as well as patients who have undergoneercutaneous coronary intervention or coronary artery by-ass graft surgery (191,192,195), yet these diagnoses are notll covered by health insurance.

Moderate-to-vigorous physical activity and improved car-iorespiratory fitness reduce cardiovascular-associated mor-idity and mortality by multiple mechanisms (189,195),ncluding antiatherosclerotic, anti-ischemic, antiarrhythmic,nd antithrombotic effects. Each 1 metabolic equivalentMET) (1 MET � 3.5 mL O2/kg/min) increase in exerciseapacity appears to confer an 8% to 17% reduction inortality (196). Alternatively, an approximate 1,000-kcal/eek increase in activity confers the equivalent survivalenefit that would accrue by increasing cardiorespiratorytness by 1 MET (197). Exercise testing may be helpful inuantifying aerobic capacity and in establishing a safe andffective exercise prescription (198,199).



1. Prescription of exercise in primary prevention populations.2. Evaluation, appropriate interventions, and expected

outcomes for each of the core components of contem-porary cardiac rehabilitation/secondary prevention pro-grams, including exercise training, risk factor modifica-tion, medical surveillance/emergency support, and

psychosocial (e.g., stress management)/vocational


counseling (200), as well as alternative delivery sources(e.g., site-supervised versus home-based [telephone,Internet, completion of exercise logs] programs) (191).

3. ACC/AHA current guidelines for secondary preven-tion for patients with coronary and other atheroscleroticvascular disease, including smoking cessation, bloodpressure control, lipid management, physical activity,weight management, diabetes management, antiplateletagents/anticoagulants, renin-angiotensin-aldosteronesystem blockers, beta blockers, and influenza vaccina-tion (10).

4. Multidisciplinary team approach to implementing aneffective cardiac rehabilitation/secondary preventionprogram (200,201).

5. Traits, emotional states, and life situations that havebeen linked to CVD; for example, depression, anxiety,anger/hostility, social isolation, vital exhaustion, andchronic life stresses.

6. Stages of behavior change and the concept of motiva-tional interviewing to enable patients to favorably mod-ify long-standing, deleterious lifestyle habits.

7. Administration and interpretation of exercise tests asper the ACC/AHA 2000 Clinical Competence State-ment on Stress Testing (199), with specific reference tothe following variables: indications and contraindica-tions; test end points; peak or maximal oxygen uptake;hemodynamics; rating of perceived exertion; recogni-tion of supraventricular and ventricular arrhythmias;and interpretation of ST-segment displacement(5,196,198,199). Competence includes the knowledgeand skills required for certification in AHA Basic andAdvanced Life Support.

8. Use of exercise test results for activity counseling andexercise prescription (5,196,198).

9. Inverse relationship between physical activity and/orcardiorespiratory fitness, expressed as mL O2/kg/min orMETs, and cardiovascular and all-cause mortality inpersons with and without known CAD (189,196,197).

0. Safety, benefits, rationale for and contraindications toendurance training and resistance exercise in primaryand secondary prevention programs (5,196,198,202).

1. Basic terminology and fundamentals of exercise physi-ology, with specific reference to the interpretation ofclinical exercise testing and the prescription of exercisein health and disease (5,196,198).

2. Spectrum of cardiovascular conditions among patientswho require physical activity counseling and/or mightbenefit from exercise training, including pathophysiol-ogy, signs and symptoms of stable and unstable disease,and medical and surgical treatments for the followingconditions: CAD, including recent MI, postpercutane-ous coronary intervention and postcoronary artery by-pass grafting; cardiomyopathy and HF; valvular heartdisease; peripheral arterial disease; hypertension; car-

diac arrhythmia; and cardiac transplantation.

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