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