Who Needs to See a Cardiologist/Cardiometabolic Specialist?

If you’ve never seen a cardiologist or cardiometabolic specialist and are wondering if you should, we have compiled a list of common, but often overlooked conditions that, in our opinion, warrant the attention of a cardiologist or cardiometabolic specialist, at least once or periodically. 

• Any patient seen for chest pain in an Emergency Room (ER) or Urgent Care Clinic (UCC):  Cardiologist or Cardiometabolic specialist

• • Chest pain represents the most common reason for ED visit (5-10%)
  • 50% are discharged with “nonspecific” chest pain
  • We feel these patients represent a “high risk” cardiometaboilc patient, despite the “low risk” ER or UCC workup for an acute emergent issue. 
  • • 3% are readmitted for serious cardiovascular event in 6 months
    • 20-25% have underlying cardiovascular disease
  • In the absence of further risk stratification, many of these patients are at risk of returning to the ER or UCC with recurrent complaints. 

• Current smoker: Cardiometabolic specialist or Cardiologist.

• • Smoking represents a serious “uncontrolled” risk factor and contributes to ASCVD risk to a greater degree than just about any other risk factor.

• Prior heavy smoker: Cardiometabolic specialist or Cardiologist.

• • Prior heavy smoking accelerates plaque inflammation and promotes premature atherosclerosis

• Anybody with smoking induced lung disease: Cardiologist, CM.

• • It’s not uncommon for the smoker to first be seen by a pulmonologist without consideration of a referral to a cardiologist or cardiometabolic specialist.
  • If the smoking were severe enough to cause lung disease, it’s highly probable that there is already advanced atherosclerosis.

• Prior CABG (coronary artery bypass graft) or PCI (percutaneous coronary intervention or “stent”): Cardiologist at least annually.

• • This is called "secondary prevention."
  • Coronary atherosclerosis is a systemic disease.
  • Coronary revascularization does not represent a “one and done” treatment option.
  • CAD requires lifelong treatment.
  • Treatments change and they are updated frequently. Cardiovascular specialists, while not perfect, are more likely to offer the latest treatments than generalists.

• PAD (peripheral artery disease): Cardiologist: 

• • This is an often forgotten form of ASCVD. 
  • It’s not uncommon that a patient is referred to a vascular surgeon for PAD, without a referral to a cardiologist. 
  • PAD, like CAD, represents a systemic disease of atherosclerosis. 
  • Vascular surgeons are not medical doctors. They are surgeons. Like cardiothoracic surgeons, they may be able to help with revascularization (stents and bypasses) but it would be rare to find a vascular surgeon that adequately treats the disease - lifelong. 
  • They may monitor plaque build up with imaging, but the vast majority of them are ill equipped with the knowledge or time to treat the actual disease. 
  • Every one of these patients needs to be seen by a cardiovascular specialist. 

• Elevated BNP (Brain Natriuretic Peptide) - even once: Cardiologist. 

• • This is a blood test biomarker for heart failure. 
  • There may be an obvious primary culprit for an elevated BNP, or it may be multifactorial. But a cardiologist is best equipped to sort this out.

• Reduced EF (Ejection Fraction): Cardiologist. 

• • This is called HFrEF or systolic heart failure - heart failure due to a weak pump. 
  • Even if the heart function recovered, it can relapse, just like cancer. 
  • This needs to be monitored by a cardiologist at least annually, when stable. 
  • But much much more frequently when newly diagnosed or not yet maximally treated (like every 1-3 weeks).

• Moderate valvular regurgitation or worse: Cardiologist. 

• • Oftentimes valvular diseases do not need intervention or definitive treatment until severe.
  • Valve diseases are graded as trace, mild, moderate, severe, very severe. 
  • Once moderate, it can obviously progress to severe. 
  • It can also at times be underestimated. This is why all moderate valvular lesions need to be evaluated and monitored by a cardiologist.

• Aortic stenosis - of any degree: Cardiologist. 

• • Aortic stenosis of any magnitude needs to be further evaluated by a cardiologist to look for other associated diseases and to determine frequency of monitoring. 

• Metabolic Syndrome: Cardiometabolic specialist. 

• • Represents a high risk cardiometabolic syndrome where the ASCVD risk is greater than the sum of its parts. 
  • A cardiometabolic specialist is best equipped to address the overall picture.

• Stage III CKD (Chronic Kidney Disease) or worse: Cardiometabolic specialist. 

• • The most common cause of death and demise in those with stage III CKD is an ASCVD event and is therefore considered an “ASCVD risk equivalent”

• Hypertension on medication: Cardiometabolic specialist

• Hypertensive pregnancy disorder: Cardiometabolic specialist.

• • Eclampsia
  • Preeclampsia
  • Gestational hypertension

• Gestational hypertension: Cardiometabolic specialist.

• Polycystic Ovarian Syndrome: Cardiometabolic specialist.

• Fatty Liver Disease (NAFLD/NASH): Cardiometabolic specialist.

• • Nonalcoholic Fatty Liver Disease (NAFLD): Fat in the liver without liver damage
  • NonAlcoholic SteatoHepatitis (NASH): Fat in the liver with signs of inflammation and cellular damage