Cardiovascular Signs and Symptoms

As family physicians, we never know what is waiting for us in the next room. When in medical school, I was often encouraged to consider subspecialty medicine to avoid a career of caring for colds and other self-limited conditions. Again this week, I frequently found myself wishing for a few more patients with “just a cold” to make the schedule go a little more smoothly. In addition to managing chronic diabetes and heart disease, preventive care for patients from 1 week to 94 years of age, and complex social and psychological situations, as usual, I had several patients who came in for new symptoms concerning for cardiovascular disease.

In spite of my training and experience in managing acute cardiovascular care in the outpatient and inpatient settings, I always find it a little stressful to separate the occasional potentially life-threatening condition from the multitudes of worried patients. Early in the week, I saw a 23-year-old woman with new palpitations; after obtaining a thorough history and an electrocardiogram that was normal, I was able to reassure her that she was experiencing occasional premature ventricular contractions and discuss things she could do to reduce her symptoms. The next day, I saw a 62-year-old who had to be hospitalized with unstable angina. Finally, on Thursday, I had a postoperative follow-up visit with an adolescent patient in whom I had diagnosed Marfan syndrome earlier this year after multiple episodes of spontaneous pneumothorax that manifested as chest pain.

Section One of this monograph addresses the evaluation of chest pain in the office setting, including the identification of patients at low risk of coronary artery disease, evaluation of the various emergent and nonemergent causes of chest pain, and selection of appropriate testing to evaluate for coronary artery disease. The next section reviews the causes of palpitations and the necessary history and testing, then discusses ambulatory electrocardiographic monitoring, including the consumer devices that many of our patients use. Section Three explores the evaluation and treatment of syncope and presyncope and includes information about the special populations of children, older adults, athletes, and individuals with postural orthostatic tachycardia syndrome (POTS). The final section examines the various causes of acute and chronic edema, including volume overload, focusing on the differences in management of these conditions.

After reading this edition, you will have the information to confidently identify and evaluate the small number of individuals at high risk of adverse outcomes from the many patients who present in your office with signs or symptoms of possible cardiovascular conditions, including chest pain, palpitations, syncope, and swelling.

Ryan D. Kauffman, MD, FAAFP, CCFP, Associate Medical Editor
Family Medicine Physician
Erie Shores Family Health Team, Leamington, Ontario, Canada

Jenna Greenberg, MD, is a board-certified family physician with 10 years of active clinical experience in inpatient and outpatient medicine. Education is her passion. She has been the assistant residency director at the University of Michigan Family Medicine Residency in Ann Arbor for the past 7 years, regularly precepting residents in the inpatient and outpatient setting. She has also served as the assistant service chief for her family medicine department. These roles have given her a deep understanding of the importance of evidence-based guidelines for clinical care to aid in everyday practice.

Anna Laurie, MD, is a board-certified family medicine physician at the University of Michigan, Ann Arbor, who has 10 years of experience in a busy outpatient practice. She is the director of Population Health and chair of the Quality Improvement Committee. Through these roles, she has unique expertise in providing evidence-based and cost-conscious care. She is a leader in departmental initiatives to implement new clinical care guidelines.

Joshua Greenberg, MD, is a board-certified cardiac electrophysiologist at the Henry Ford Health System, Detroit, Michigan, with 5 years of clinical experience. He has a passion for education and is also the assistant program director for the electrophysiology fellowship program. He is the chair of peer review for the Henry Ford Department of Cardiology. In this role, he ensures the most recent clinical guidelines are followed throughout the department, including in the electrophysiology, general cardiology, and other cardiovascular subspecialties.

Disclosure: It is the policy of the AAFP that all individuals in a position to control CME content disclose any relationships with ineligible companies upon nomination/invitation of participation. Disclosure documents are reviewed for potential relevant financial relationships. If relevant financial relationships are identified, mitigation strategies are agreed to prior to confirmation of participation. Only those participants who had no relevant financial relationships or who agreed to an identified mitigation process prior to their participation were involved in this CME activity. Associate medical editor Michelle Nelson, MD, disclosed stock ownership in Eli Lilly. This relevant financial relationship was mitigated when she sold her shares in May 2024, before her work as FPE associate medical editor began. All other individuals in a position to control content for this activity have indicated they have no relevant financial relationships to disclose.

• Determine which patients presenting to the office with chest pain are at low risk for coronary artery disease.
• Select an appropriate stress test based on a patient’s comorbid conditions.
• Choose appropriate initial testing for a patient presenting with palpitations.
• Determine the optimal ambulatory electrocardiographic monitoring technique to evaluate a patient’s palpitations.
• Select appropriate testing to determine the cause of undifferentiated syncope.
• Counsel patients about the management of syncope.
• Determine the etiology of lower extremity edema.
• Recommend the optimal level of compression for individuals with various etiologies of lower extremity edema.