ACCF/AHA/ACP 2009 Competence and Training Statement: A Curriculum on Prevention of Cardiovascular Disease
2009; Lippincott Williams & Wilkins; Volume: 120; Issue: 13 Linguagem: Inglês
10.1161/circulationaha.109.192640
ISSN1524-4539
AutoresC. Noel Bairey Merz, Mark J. Alberts, Gary Balady, Christie M. Ballantyne, Kathy Berra, Henry R. Black, Roger S. Blumenthal, Michael H. Davidson, Sara B. Fazio, Keith C. Ferdinand, Lawrence J. Fine, Vivian Fonseca, Barry A. Franklin, Patrick E. McBride, George A. Mensah, Geno J. Merli, Patrick T. O’Gara, Paul M. Thompson, James Underberg,
Tópico(s)Cardiac Imaging and Diagnostics
ResumoHomeCirculationVol. 120, No. 13ACCF/AHA/ACP 2009 Competence and Training Statement: A Curriculum on Prevention of Cardiovascular Disease Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBACCF/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 to Develop a Competence and Training Statement on Prevention of Cardiovascular Disease): Developed in Collaboration With the American Academy of Neurology; American Association of Cardiovascular and Pulmonary Rehabilitation; American College of Preventive Medicine; American College of Sports Medicine; American Diabetes Association; American Society of Hypertension; Association of Black Cardiologists; Centers for Disease Control and Prevention; National Heart, Lung, and Blood Institute; National Lipid Association; and Preventive Cardiovascular Nurses Association WRITING COMMITTEE MEMBERS C. Noel Bairey Merz, MD, FACC, FAHA, Chair, Mark J. Alberts, MD, FAHA, Gary J. Balady, MD, FACC, Christie M. Ballantyne, MD, FACC, Kathy Berra, MSN, ANP, FAHA, FAAN, Henry R. Black, MD, Roger S. Blumenthal, MD, FACC, FAHA, Michael H. Davidson, MD, FACC, Sara B. Fazio, MD, Keith C. Ferdinand, MD, FACC, FAHA, Lawrence J. Fine, MD, DrPH, Vivian Fonseca, MD, Barry A. Franklin, PhD, FAHA, Patrick E. McBride, MD, MPH, FACC, FAHA, George A. Mensah, MD, FACC, FACP, FAHA, Geno J. Merli, MD, FACP, Patrick T. O'Gara, MD, FACC, FAHA, Paul D. Thompson, MD, FACC and James A. Underberg, MD, MS, FACPM, FACP WRITING COMMITTEE MEMBERS , C. Noel Bairey MerzC. Noel Bairey Merz , Mark J. AlbertsMark J. Alberts , Gary J. BaladyGary J. Balady , Christie M. BallantyneChristie M. Ballantyne , Kathy BerraKathy Berra , Henry R. BlackHenry R. Black , Roger S. BlumenthalRoger S. Blumenthal , Michael H. DavidsonMichael H. Davidson , Sara B. FazioSara B. Fazio , Keith C. FerdinandKeith C. Ferdinand , Lawrence J. FineLawrence J. Fine , Vivian FonsecaVivian Fonseca , Barry A. FranklinBarry A. Franklin , Patrick E. McBridePatrick E. McBride , George A. MensahGeorge A. Mensah , Geno J. MerliGeno J. Merli , Patrick T. O'GaraPatrick T. O'Gara , Paul D. ThompsonPaul D. Thompson and James A. UnderbergJames A. Underberg Originally published21 Sep 2009https://doi.org/10.1161/CIRCULATIONAHA.109.192640Circulation. 2009;120:e100–e126Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: September 21, 2009: Previous Version 1 Preamble…e1011. Introduction…e1022. Cardiovascular and Vascular Biology…e102 2.1. Justification…e102 2.2. Minimal Knowledge…e1053. Clinical Epidemiology and Biostatistics…e106 3.1. Justification…e106 3.2. Minimal Knowledge…e1064. Cardiovascular Pharmacology (Complex Multipharmacologic Understanding)…e106 4.1. Justification…e106 4.2. Minimal Knowledge…e1075. Genetics and Cardiovascular Disease in Individuals and Families…e107 5.1. Justification…e107 5.2. Minimal Knowledge…e1076. Behavioral and Psychosocial Programs (Financial and Socioeconomic Factors)…e107 6.1. Justification…e107 6.2. Minimal Knowledge…e1087. Advanced Risk Assessment (Renal, Inflammatory Diseases)…e108 7.1. Justification…e108 7.2. Minimal Knowledge…e1088. Subclinical Atherosclerosis Assessment (Imaging and Nonimaging)…e108 8.1. Justification…e108 8.2. Minimal Knowledge…e1099. Adherence and Disease Outcome Interdisciplinary Programs…e109 9.1. Justification…e109 9.2. Minimal Knowledge…e11010. Nutrition Management…e110 10.1. Justification…e110 10.2. Minimal Knowledge…e11011. Lipid Management (Management of Dyslipidemia)…e110 11.1. Justification…e110 11.2. Minimal Knowledge…e11112. Thrombosis Management…e111 12.1. Justification…e111 12.2. Minimal Knowledge…e11113. Hypertension Management…e111 13.1. Justification…e111 13.2. Minimal Knowledge…e11214. Smoking Cessation…e112 14.1. Justification…e112 14.2. Minimal Knowledge…e11215. Obesity Management (Behavioral Programs)…e112 15.1. Justification…e112 15.2. Minimal Knowledge…e11316. Exercise Physiology, Physical Activity Management, and Cardiac Rehabilitation (Secondary Prevention)…e113 16.1. Justification…e113 16.2. Minimal Knowledge…e11417. Prediabetes, Metabolic Syndrome, Insulin Resistance, and Diabetes Management…e114 17.1. Justification…e114 17.2. Minimal Knowledge…e11418. Chronic Disease Management…e115 18.1. Justification…e115 18.2. Minimal Knowledge…e115References…e116Appendix 1. Author Relationships With Industry and Other Entities…e121Appendix 2. Reviewer Relationships With Industry and Other Entities…e124PreambleThe American College of Cardiology Foundation (ACCF)/American Heart Association (AHA)/American College of Physicians (ACP) Task Force on Clinical Competence was formed in 1998 to develop recommendations for attaining and maintaining the cognitive and technical skills necessary for the competent performance of a specific cardiovascular service, procedure, or technology. These documents are evidence-based, and where evidence is not available, expert opinion is utilized to formulate recommendations. Indications and contraindications for specific services or procedures are not included in the scope of these documents. Recommendations are intended to guide curriculum development and assist those who judge the competence of cardiovascular healthcare providers entering practice for the first time and/or those in practice who undergo periodic review of their expertise or who apply for privileges at a new institution. The assessment of competence is complex and multidimensional; therefore, isolated recommendations contained herein may not necessarily be sufficient or appropriate for judging overall competence. The current document addresses a curriculum for developing competence in the prevention of cardiovascular disease (CVD) and is authored by representatives of the ACCF, AHA, ACP, the American Academy of Neurology; American Association of Cardiovascular and Pulmonary Rehabilitation; American College of Preventive Medicine; American College of Sports Medicine; American Diabetes Association (ADA); American Society of Hypertension; Association of Black Cardiologists; Centers for Disease Control and Prevention; National Heart, Lung, and Blood Institute; National Lipid Association; and the Preventive Cardiovascular Nurses Association. The recommendations contained herein recognize the broader context of clinical training and the importance of systems of care in improving patient outcomes. Trainees should be aware of and responsive to the larger context of systems-based health care and utilize all available resources to provide optimum care. Similarly, the development of competence embodies knowledgeable incorporation of technological advances for the evaluation of health and disease based on ongoing familiarity with the emerging scientific and social literature.The ACCF/AHA/ACP Task Force makes every effort to avoid actual or potential conflicts of interest that may arise as a result of an outside relationship or personal interest of a member of the ACCF/AHA/ACP Writing Committee. Specifically, all members of the writing committee are asked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts of interest relevant to the document topic. These statements are reviewed by the writing committee and updated as changes occur. The relationships with industry for authors and peer reviewers are published in Appendixes 1 and 2 of the document.Jonathan L. Halperin, MD, FACC Chair, ACCF/AHA/ACP Task Force on Competence and Training1. IntroductionThe mission of many organizations is providing optimal care to those with or at risk of developing CVD (primary and secondary prevention). Over the past 2 decades, there have been dramatic increases in knowledge concerning specific risk factors in atherosclerosis, hypertension, thrombosis, and other forms of vascular dysfunction. Clinical trials have proven that strategies aimed at the appropriate detection and modification of risk factors can slow progression of atherosclerosis, diabetes mellitus, and hypertension and reduce the occurrence of clinical cardiovascular events in both primary and secondary prevention settings. More recently, it has been shown that atherosclerosis can be stabilized or even modestly reversed. Finally, a new and growing knowledge base of molecular genetics applied to the study of the cardiovascular system has potential relevance to the clinical practice of preventive cardiovascular medicine.Despite the fact that clinical outcomes can be improved by promotion of favorable life habits and behaviors and by the proper use of drug treatment, the application of primary and secondary preventive interventions in clinical practice is not optimal. Prevention of CVD in both the primary and secondary prevention setting, while dominantly the responsibility of the primary care provider, is increasingly challenged given the ever expanding new knowledge as well as the ongoing problems related to adherence to recommendations. New knowledge in the area of preclinical disease detection has presented increasingly challenging scenarios to primary care healthcare providers relative to the decisions regarding the need for further risk stratification and aggressive medical regimens. Furthermore, increasingly complex patients are surviving with CVD, many of whom can benefit from advanced knowledge and expertise with regard to risk factor management and rehabilitation that is beyond the traditional general primary and cardiology practitioner's scope of practice.The prevention of cardiovascular morbidity and mortality is a shared responsibility among all health professionals involved in the care of people at risk of developing CVD. This document is directed at those individuals seeking expertise at a leadership level in this field, and includes opportunities for formal training and alternative routes to competence and maintenance of competence in prevention of CVD (Table 1)1–5 and educational resources for acquisition and maintenance of competence in the prevention of CVD (Table 2).6–43 To address the expanding fund of knowledge in the area and to ensure that an adequately trained force of preventive cardiovascular leaders will be available to primary care providers, as well as to provide a pool of providers with expertise in running rehabilitation and other programs designed to address the ongoing issue of adherence, the formulation of clinical competency criteria for the cardiovascular preventive specialist is needed. These competency criteria are expected to address issues of expert clinical and scientific leadership, specialty patient care and consultation, and directorship of primary and secondary preventive cardiac programs. Of note and similar to other subspecialty areas of medicine, cardiovascular preventive specialists will have varying areas of expertise and will not necessarily achieve all of the outlined areas of competencies. These clinical competency criteria in the area of specialty treatment and prevention of CVD are needed given the current setting of a rapidly growing field of knowledge ranging from molecular and cellular mechanisms to clinical outcomes in order to translate this into improved patient care. Table 1. Opportunities for Formal Training and Alternative Routes to Competence and Maintenance of Competence in Prevention of Cardiovascular DiseaseSectionA Ways to Achieve Formal TrainingB Alternate Routes to Achieve CompetenceC Maintenance of Competence2. Cardiovascular and Vascular BiologyACCF Self-Assessment programs (ACCSAP, LipidSAP)CME that focuses on cardiovascular and vascular biology and atherosclerosis is important to receive each year3. Clinical Epidemiology and BiostatisticsACCSAPThe AHA 10-Day Seminar on the Epidemiology and Prevention of CVD5. Genetics and Cardiovascular Disease in Individuals and FamiliesParticipation in an active genetic CVD referral clinic under the supervision of expert cardiovascular specialists in the relevant areasCME that focuses on the genetic aspects of CVD prevention in individuals and families is important to receive each year6. Behavioral and Psychosocial Programs (Financial and Socioeconomic Factors)Participation in cardiac rehabilitation program that includes psychosocial assessment, management, and referral under the supervision of expert cardiovascular and other specialists in the relevant areasCME that focuses on behavioral assessment and management of patients with CVD10. Nutrition ManagementClinical experience in a preventive cardiology clinic program during formal fellowship training. Clinical experience in nutrition subspecialty programs such as weight loss clinics, lipid clinics, and diabetes management programs11. Lipid Management (Management of Dyslipidemia)A comprehensive understanding of the NCEP ATP III and updates is critical to achieve competence. The ACCF provides a self-assessment program in lipidology, and the National Lipid Association has a self-study program that can provide eligibility for Board certification by the American Board of Clinical LipidologyNational Lipid Association sponsored self-assessment program, self-study modules, masters class, and advanced masters summits in lipidology12. Thrombosis ManagementACCF/AHA continuing education programs, the American College of Chest Physician Consensus Conference Guidelines, the Peripheral Arterial Diseases Antiplatelet Consensus Group: Antithrombotic and thrombolytic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines1Web sites of the PAD Coalition and AHANational society meetings with focus on antithrombotic therapy13. Hypertension ManagementAmerican Society of Hypertension Certification as a clinical specialist in hypertension and medical education seminars and didactic sessions with faculty members with expertise in each of the above areas14. Smoking CessationFormal training in behavioral science and smoking cessation is a critical link to successful office-based or hospital-based smoking cessation programs. Mentoring by faculty/colleagues with expertise in behavioral medicine/science is an important training modalityMedical education seminars, Webcast CME programs, Society for Behavioral Medicine publications and meetings, and CME programs specifically addressing addiction and smoking cessationNational Cancer Institute Web site: Prevention and Cessation of Cigarette Smoking: Control of Tobacco Use2MedlinePlus: Quitting Smoking3AHA Web site: Smoking and Cardiovascular Disease4CDC Web site: Smoking & Tobacco Use(Continued)Table 1. ContinuedSectionA Ways to Achieve Formal TrainingB Alternate Routes to Achieve CompetenceC Maintenance of CompetenceA 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 members with 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.15. Obesity Management (Behavioral Programs)A clinical rotation in both an endocrinology and a bariatric surgery–based obesity clinic to learn how to apply patient-specific behavioral methods to achieve weight loss should be mandatory, with a suggested involvement in the care of 5 patients entering a weight loss management program over the course of formal training. Attendance at an accredited obesity training program for healthcare professionalsContinued clinical practice as well as yearly CME courses in preventive cardiology with a focus on overweight/obesity management16. Exercise Physiology, Physical Activity Management, and Cardiac Rehabilitation (Secondary Prevention)Active instruction in a preventive cardiology/cardiac rehabilitation center that includes access to a multidisciplinary staff (e.g., cardiologists with specific expertise/training in secondary prevention, nurse clinicians, exercise physiologists, registered dieticians, behaviorists, smoking cessation counselors,and pharmacists). A listing of cardiopulmonary rehabilitation programs in the United States and Canada is available through the American Association of Cardiovascular and Pulmonary Rehabilitation. Moreover, the American College of Sports Medicine offers certification examinations and registry programs for exercise physiology, as well as a complete listing of the knowledge, skills, and abilities that comprise the foundations of these relevant certifications (e.g., exercise specialist, registered clinical exercise physiologist), with specific reference to requirements (e.g., educational degree, minimum hours of practical experience) and recommended competencies.5Direct clinical training with exercise physiologists, smoking cessation counselors, registered dieticians, and lipid specialists in settings other than formal cardiac rehabilitation programsActive involvement with cardiac rehabilitation/secondary prevention programs and direct involvement in the supervision and care of cardiac rehabilitation patients each year. CME that focuses on clinical exercise physiology applications, exercise prescription in health and disease, and cardiac rehabilitation/secondary prevention are important to receive each year. Organizations with related regional and national conference programming include: ACCF; AHA; American College of Sports Medicine; and the American Association of Cardiovascular and Pulmonary Rehabilitation17. Prediabetes, Metabolic Syndrome, Insulin Resistance, and Diabetes ManagementClinical experience in a preventive cardiovascular medicine clinic program during formal fellowship training, as well as rotations in a specialized diabetes clinic. ADA training modules with multiple choice questions and detailed, evidence-based answersADA clinical practice guidelines are updated annually and published as a supplement to Diabetes Care18. Chronic Disease ManagementClinical rotation in a preventive cardiology center to learn about and apply a patient-specific, systems approach to prevention of CVD in primary and secondary prevention patientsTable 2. Educational Resources for Acquisition and Maintenance of Competence in the Prevention of Cardiovascular DiseaseSectionEducational OpportunitiesAHA indicates American Heart Association.2. Cardiovascular and Vascular Biology63. Clinical Epidemiology and Biostatistics7–104. Cardiovascular Pharmacology (Complex Multipharmacologic Understanding)Micromedex is available in many hospitals for dosing and interactions informationFacts and Comparisons page is useful to check for drug–drug interactions5. Genetics and Cardiovascular Disease in Individuals and Families6,11National Coalition for Health Professionals Education in Genomics—competencies in genomicsCDC genetics and genomics competencies for public healthInventory of family history tools and resources6. Behavioral and Psychosocial Programs (Financial and Socioeconomic Factors)12–167. Advanced Risk Assessment (Renal, Inflammatory Diseases)17,188. Subclinical Atherosclerosis Assessment (Imaging and Nonimaging)17–209. Adherence and Disease Outcome Interdisciplinary ProgramsPatient compliance information for the professional21–2410. Nutrition Management25–2711. Lipid Management (Management of Dyslipidemia)American Board of Clinical LipidologyNational Lipid Association Self-Assessment Program2812. Thrombosis ManagementSee PAD Coalition and AHA for resources9,29–3213. Hypertension Management33–35Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and Prevention14. Smoking Cessation2, 36–38Links to MEDLINE and access to multiple governmental and professional Web sites for smoking cessation support and literatureAHA Web site: Smoking and Cardiovascular Disease: includes educational resources for smoking cessation15. Obesity Management (Behavioral Programs)39–4116. Exercise Physiology, Physical Activity Management, and Cardiac Rehabilitation (Secondary Prevention)American College of Sports Medicine Annual Meetings and Regional ConferencesAmerican Association of Cardiovascular and Pulmonary Rehabilitation Annual Meeting and resource materialsAHA Annual Scientific SessionsAHA Guidelines and Statements on Exercise17. Prediabetes, Metabolic Syndrome, Insulin Resistance, and Diabetes ManagementAmerican Diabetes Association (ADA) clinical practice guidelinesADA Professional Practice Resources42Diabetes (Personal Health Decisions) PHD risk assessment toolADA for healthcare professionalsAmerican Association of Clinical Endocrinologists18. Chronic Disease Management43C. Noel Bairey Merz, MD, FACC, FAHA Chair, ACCF/AHA/ACP Writing Committee to Develop a Competence and Training Statement on Prevention of Cardiovascular Disease2. Cardiovascular and Vascular Biology2.1. JustificationRecent advances in cardiac and vascular biology and related molecular and cellular mechanisms provide a sound scientific foundation for the practice of preventive cardiovascular medicine. A basic knowledge of the structure and function of the arterial wall, its interactions with components of the circulating blood, and key pathologic processes such as oxidation, inflammation, thrombosis, and remodeling is important to the application of strategies for the detection, evaluation, and prevention of atherosclerotic CVD.44,45 Similarly, a basic understanding of myocardial cellular and molecular processes is essential for effective application of therapies that address myocardial salvage, regeneration, and remodeling.2.2. Minimal KnowledgeThe expert in the prevention of CVD should demonstrate knowledge and competence in: The process of atherosclerosis that begins in youth, initially as a fatty streak containing mainly lipid-rich macro-phages in the arterial intima,46 and the role of various blood lipoproteins in this process and the factors that promote the initiation and progression of the fatty streak to arterial plaque (including endothelial activation and dysfunction, smooth muscle cell migration and proliferation, collagen production, and arterial remodeling).Disorders of lipid metabolism and major atherogenic risk factors, and the pathophysiological significance of the biological composition of the arterial plaque and its fibrous cap.47,48A substantial understanding of vulnerable plaque and the crucial role of inflammation, plaque fissuring, erosion, and rupture in the genesis of acute coronary syndromes, should be emphasized. An understanding of the concepts of plaque pathophysiology remodeling and progression should also be understood, as well as an appreciation of the systemic nature of atherosclerosis.Systemic (endocrine) and local (autocrine/paracrine) neurohormonal derangements that lead to an impaired vasoregulatory and fibrinolytic balance, including the biological, social, and environmental determinants of these derangements as well as the pharmacologic and therapeutic lifestyle changes established for their control.Mechanisms of atherosclerosis-specific targeted interventions with the use of combination medications that can be used to slow progression and reverse the process.49Vascular and hemodynamic benefits of smoking cessation, increased physical activity, and a diet low in saturated fats and rich in fruits, vegetables, fiber, and whole grains, particularly promoted at an early age.3. Clinical Epidemiology and Biostatistics3.1. JustificationClinical epidemiology is the study of the magnitude, distribution, and trends in the factors that affect health, disease, and their determinants in populations. Within the context of preventive cardiology, clinical epidemiology provides crucial information in the enumeration of CVD events, rates, trends, and outcomes in defined populations and their subgroups. It also permits the identification of populations at different levels of risk for CVD events and the existence of health disparities.51 The surveillance components of clinical epidemiology provide clues to new and emerging CVD threats and permit assessment of the effectiveness of interventions.Recent emphasis on quality, economic end points, and modeling in epidemiologic studies provides an opportunity for epidemiology to inform clinical practice on the cost-effectiveness and health impact of alternative preventive strategies.52–55 In addition, clinical epidemiology serves an important role in informing practitioners about the use of evidence from clinical trials and the strength and generalizability of that evidence. In this endeavor, the related field of biostatistics provides important principles for appropriate design of clinical trials, interpretation of trial results, and the effective use of screening, diagnostic, and prognostic tools in the practice of preventive cardiology.563.2. Minimal KnowledgeThe expert in the prevention of CVD should demonstrate knowledge and competence in: Terms used to describe the central tendency of population distributions (e.g., mean, median, and mode), and the terms used to describe the magnitude of dispersion around these measures (e.g., standard deviation, standard error, and percentiles).51–56 Familiarity with terms that describe the frequency and burden of CVD as well as the importance of age adjustment.Terms used to characterize screening and diagnostic tests, including sensitivity, specificity, accuracy, and predictive values (positive and negative).56,57Experimental study designs (randomized, nonrandomized, and noninferiority clinical trials) and nonexperimental designs (cohort, case-control, nested case-control, cross-sectional studies), as well as the principle of hypothesis testing that underlies these studies, and the number needed to treat and the number needed to harm.Common analyses encountered in the medical literature, such as the t test, chi-square test, multiple regression, Kaplan-Meier survival analysis, and the Cox proportional hazards analysis is necessary, including the types of errors that can be committed when inferences are made about data in studies.Traditional risk factors8–10 and nontraditional risk factors, such as calculation of non–high-density lipoprotein cholesterol (non–HDL-C) in persons with triglyceride levels above 200 mg/dL.Inflammatory biomarkers, including high-sensitivity C-reactive protein, serum amyloid A, interleukin-6, lipoprotein-associated phospholipase A2, monocyte chemoattractant protein-1, soluble CD40 ligand, and myeloperoxidase and their possible utility in risk assessment.58,59The concepts of relative and absolute risk; short-term, long-term, and lifetime risk; and the population burden of CVD attributable to specific risk factors, including the Framingham Risk Assessment score in clinical practice and knowledge of its limitations.60Cost-benefit analyses of CVD interventions.4. Cardiovascular Pharmacology (Complex Multipharmacologic Understanding)4.1. JustificationKnowledge of cardiovascular pharmacology and the basic principles of pharmacokinetics, pharmacodynamics, and pharmacogenomics is critical to the targeted application of drug therapy for individual patients. A basic knowledge of drug interactions, anticipated side effects, and dosing regimens in a heterogeneous mix of complex patients is necessary to integrate new research and new approaches for CVD prevention and treatment. The challenges posed by age, gender, reproductive hormones, and medical comorbidities, including the coexistence of disorders known to contribute to cardiac and vascular endothelial dysfunction, must be recognized. Interactions between medication and nutrition (e.g., grapefruit), over-the-counter supplements (e.g., antioxidant vitamins), nutriceuticals (e.g., stanol/sterol esters), and dietary alcohol intake are increasingly reported and of practical relevance. Knowledge that pharmacologic therapies may have differing impact based on underlying existence of disease and endogenous hormone status, including hormonal therapies, is important. A basic understanding of pharmacology will also be important as new therapies for myocardial salvage, regeneration, and remodeling become available.4.2. Minimal KnowledgeThe expert in the prevention of CVD should demonstrate knowledge and competence in: Pharmacological approaches to lipids, hypertension, thrombosis, diabetes and insulin resistance, cigarette smoking cessation, and obesity.10 The important role of statins and other lipid-lowering medications, antiplatelet therapies, renin-angiotensin-aldosterone system agents, and antihypertensive medications should be considered.49Use of multiple drug combinations (coexistent conditions and risk factor clustering)61 and drug–drug interactions,62 including the ever-increasing complexity of pharmacological regimens and potential and realization of drug–drug interactions.Preventive cardiovascular strategies for comorbidities such as renal disease, autoimmune inflammatory disorders, diabetes mellitus, and cancer, which raise the risk for CVD due to the comorbidity itself as well as th
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