Cardiovascular Medicine

This document has been endorsed by the American Academy of Family Physicians and was developed in cooperation with the American College of Cardiology, the Association of Departments of Family Medicine, the Association of Family Practice Residency Directors and the Society of Teachers of Family Medicine.

Cardiovascular disease causes major morbidity and mortality in our society. The family physician should be proficient in the diagnosis and management of a variety of cardiovascular disorders. Family physicians emphasize comprehensive and continuing care to individuals and families, with particular attention to behavioral and lifestyle factors.

The depth of experience for each resident depends on the expected practice needs of the resident, especially in terms of practice location, available facilities and accessibility of consultants. At times the family physician may find it appropriate to seek consultation from a cardiologist to either manage or co-manage a patient for optimal care.

Attitudes

The resident should develop attitudes that encompass:

Awareness of the importance of physician and patient working as partners to promote optimal cardiovascular health.
A compassionate approach to the care of patients with cardiac disease.
Recognition of the psychosocial and economic impact of cardiovascular disease on the individual and family.
Support of individual and family through consultation, evaluation, treatment and rehabilitation.
Recognition of the importance of lifestyle factors on the development and exacerbation of cardiovascular disease.

Knowledge

Normal cardiovascular anatomy and physiology
Changes in cardiovascular physiology with age and pregnancy
Risk factors
1. Coronary artery disease
  1. Hyperlipidemia
  2. Cigarette smoking
  3. Genetic predisposition
  4. Sedentary life style
  5. Hypertension
  6. Diabetes mellitus
  7. Obesity
  8. Nutrition
  9. Hormonal status
  10. Emotional stress
2. Valvular heart disease
Cardiovascular history
Cardiovascular physical examination
Noninvasive examinations
1. Electrocardiography
2. Chest radiography
3. Stress testing, including treadmill/bicycle or pharmacologic techniques
4. Echocardiography/Doppler imaging, both rest and stress, using treadmill/bicycle or pharmacologic techniques
5. Radioisotope imaging, both rest and stress, using treadmill/bicycle or pharmacologic techniques
6. ECG monitoring, in-hospital and ambulatory
7. Vascular Doppler and ultrasound examinations
Invasive examination
1. Diagnostic cardiac catheterization and angiography
2. Diagnostic carotid and peripheral vascular angiography
3. Intracoronary and peripheral vascular intervention using appropriate devices
4. Internal monitoring devices
  1. Central venous and peripheral arterial catheter
  2. Bedside hemodynamic monitoring using balloon flotation catheter
5. Electrophysiologic studies
6. Indications and contraindications of therapeutic interventions
  1. Coronary artery bypass
  2. Angioplasty techniques and stent placement
  3. Pacemaker insertion
  4. Valve replacement/repair, percutaneous balloon valvotomy
  5. Electrophysiologic ablation
Relevant laboratory interpretation, including serum enzymes, isoenzymes and lipids
Specific diseases/conditions
1. Coronary artery disease
  1. Stable/unstable angina
  2. Myocardial infarction, with and without complications
    1. Cardiogenic shock
    2. Dysrhythmias
    3. Papillary muscle dysfunction and rupture
    4. Ventricular rupture
    5. Aneurysm
  3. Sudden death
2. Syncope
3. Dysrhythmias
  1. Tachyarrhythmia
    1. Supraventricular
    2. Ventricular
    3. Reentrant
  2. Bradyarrhythmia
  3. Ectopy
    1. Atrial
    2. Ventricular
4. Hypertension
  1. Essential
  2. Secondary
  3. Pulmonary
5. Pulmonary heart disease
  1. Cor pulmonale
6. Congestive heart failure
  1. Systolic dysfunction
  2. Diastolic dysfunction
7. Thromboembolic disease
8. Valvular heart disease
  1. rheumatic
  2. congenital
  3. degenerative
  4. Mitral valve prolapse syndrome
9. Congenital heart disease
  1. Common left to right shunts (acyanotic)
  2. Common right to left shunts (cyanotic)
  3. Common obstructive problems
10. Dissecting aneurysm
11. Innocent heart murmurs
12. Peripheral vascular disease
  1. Aneurysm
  2. Carotid atherosclerosis
  3. Arterial disease
  4. Arteriosclerosis obliterans
13. Cardiomyopathies
  1. Congestive (dilated)
  2. Restrictive
  3. Hypertrophic cardiomyopathy
  4. postpartum
14. Pericardial disease
15. Infection-related
  1. Viral myocarditis
  2. Subacute bacterial endocarditis
  3. Kawasaki’s disease
16. Other cardiac disorders
  1. Immunologic
    1. Acute rheumatic fever
    2. Autoimmune disorders
  2. Psychogenic
  3. Traumatic
  4. Nutritional
  5. Myxoma
  6. Thyroid dysfunction
  7. Marfan syndrome
  8. Drug-related such as cocaine, steroids and chemotherapeutic agents
17. Evaluation of cardiac patient for noncardiac surgery
  1. Cardiac risk including preoperative assessment tools
  2. Preoperative and postoperative management
18. Antibiotic prophylaxis for valvular disease
Cardiovascular pharmacology

Skills

These skills require variable exposure and experience, which must be individually determined by the program director in cooperation with those who teach the various skills. From their determination, the level of required competence for each resident can be decided.

Diagnostic
1. Performance of history taking and physical examination
2. Mechanics and interpretation of ECG
3. Interpretation of chest radiographs
4. Treadmill/bicycle stress test monitoring and interpretation
5. Ambulatory ECG monitoring and interpretation
Therapeutic
1. Risk management
2. Cardiopulmonary resuscitation (CPR), both basic life support (BLS) and advanced cardiac life support (ACLS)
3. Treating dysrhythmias and conduction disturbances
4. Use of external temporary pacemakers
5. Management of acute myocardial infarction, postinfarction care, and complications
6. Congestive heart failure
7. Hypertensive emergencies/urgencies
8. Supervision and management of rehabilitation
9. Psychosocial issues
  1. Sexual functioning
  2. Depression
  3. Family dynamics
10. Management of patients after an intervention
  1. Lifestyle adjustments
  2. Coronary bypass surgery
  3. Valve surgery
  4. Congenital heart disease surgery
  5. Catheter interventional procedures

Implementation

Core cognitive ability and skill may be obtained in block rotations or cardiology experiences in intensive care and cardiac care units. Residents will obtain substantial additional cardiology experience throughout the three years of their experience in the family practice center, on their family practice service and internal medicine rotations. It would be a reasonable goal during this time to accomplish proficiency in ECG interpretation and cardiopulmonary resuscitation.

Family practice residents electing additional training in cardiology, particularly residents who are planning to practice in communities without readily available consultation resources, may require skills for which additional training experience in a structured cardiology education program is strongly recommended. This program should include concentrated experience in the use of intracardiac temporary pacemakers and the performance of elective cardioversion and the use of right heart flotation catheters. Longitudinal experience in the center for family medicine and on the family practice hospital service should add experiences in ECG interpretation, stress testing, coronary care and continued follow-up of patients with cardiovascular problems.

Resources

Wagner GS, Marriott, HJ. Marriott's Practical Electrocardiography 9th ed. Williams & Wilkins, 1994.
Heger JW, Niemann JT, Criley JM. Cardiology for the House Officer 4th ed. Williams & Wilkins, 1998.
Schlant RC, Alexander RW, eds. The Heart, Arteries and Veins 9th ed. New York: McGraw-Hill, 1998.
Braunwald E, ed. Heart Disease: A Textbook of Cardiovascular Medicine 6th ed. Philadelphia: Saunders, 2001.

Web Resources

Cardiovascular medicine websites: http://www.clinicalevidence.org
American College of Cardiology: http://www.acc.org
Centers for Disease Control and Prevention: http://www.cdc.gov/health/cardiov.htm

Published 7/80
Revised 7/88
Revised 7/95
Revised and Retitled 9/95
Revised for review: 1-25-01