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American Academy Of Physical Medicine And Rehabilitation

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. An interest in prevention and the impact of medical, psychosocial and economic factors on patients and their families lies is of utmost importance.

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:

A. Awareness of the importance of physician and patient working as partners to promote optimal cardiovascular health. B. A compassionate approach to the care of patients with cardiac disease, especially those with chronic disease. C. Recognition of the psychosocial and economic impact of cardiovascular disease on the individual and family D. Support of individual and family through consultation, evaluation, treatment and rehabilitation.

Knowledge

A. Normal cardiovascular anatomy and physiology B. Changes in cardiovascular physiology with age and pregnancy C. Risk factors

1. Coronary artery disease

a. Hyperlipidemia

b. Cigarette smoking

c. Genetic predisposition

d. Sedentary life style

e. Hypertension

f. Emotional stress

g. Diabetes

h. Excess weight

i. Nutrition

j. Hormonal status

2. Acute rheumatic fever D. Cardiovascular history E. Cardiac@centered physical examination F. 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 G. 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

a. Central venous and

peripheral arterial

b. Bedside hemodynamic

monitoring using balloon

flotation catheter

5. Electrophysiologic studies

6. Indications and contraindications

of therapeutic interventions

a. Coronary artery bypass

b. Angioplasty: percutaneous,

including balloon, atherectomy

and laser

volume 53, number 2

c. Pacemaker insertion

d. Valve replacement/

repair, percutaneous

balloon valvotomy

e. Electrophysiologic

ablation H. Relevant laboratory interpretation, including serum enzymes, isoenzymes and lipids I. Specific diseases/conditions

1. Coronary artery disease

a. Stable/unstable angina

b. Myocardial infarction,

with and without

complications.

1. Cardiogenic shock

2. Arrhythmias

3. Papillary muscle

dysfunction and

rupture

4. Ventricular rupture

5. Aneurysm

c. Sudden death

2. Types of syncope

3. Arrhythmias

a. Tachyarrhythmia

1. Supraventricular

2. Ventricular

3. Reentrant

b. Bradyarrhythmia

4. Hypertension

a. Essential

b. Secondary

c. Pulmonary

5. Pulmonary heart disease

a. Cor pulmonale

6. Congestive heart failure

a. Systolic dysfunction

b. Diastolic dysfunction

7. Thromboembolic disease

8. Valvular heart disease

a. Rheumatic

b. Congenital

c. Degenerative

d. Mitral valve prolapse

syndrome

9. Congenital heart disease

a. Common left to right

shunts (acyanotic)

b. Common right to left

shunt (cyanotic)

c. Common obstructive

problems

10. Dissecting aneurysm

11. Innocent heart murmurs

12. Peripheral vascular disease

a. Aneurysm

b. Carotid atherosclerosis

c. Arterial disease

d. Arteriosclerosis obliterans

(ASO)

13. Cardiomyopathies

a. Congestive (dilated)

b. Restrictive

c. Hypertrophic

cardiomyopathy

d. Postpartum

14. Pericardial disease

15. Infection-related

a. Viral myocarditis

b. Subacute bacterial

endocarditis

c. Kowaski syndrome

16. Other cardiac disorders

a. Immunologic

1. Acute rheumatic

fever

2. Autoimmune

disorders

b. Psychogenic

c. Traumatic

d. Nutritional

e. Tumor (emphasis on left

atrial myxoma)

f. Thyroid dysfunction

g. Marfan syndrome

h. Drug-related, such as

cocaine, steroids and

chemotheraputic agents

17. Evaluation of cardiac

patient for noncardiac

surgery

a. Cardiac risk

b. Preoperative and post-operative

management

18. Antibiotic prophylaxis for

valvular disease

a. Prevention of rheumatic

carditis and its

recurrence

b. Prevention of infective

endocarditis, valvular

heart disease and necessity

for use of shunts J. 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.

Those skills not usually offered on a routine basis in family practice programs and considered advanced skills requiring additional training are identified by(**).

A. 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

6. Right heart flotation

catheters and interpretation

of results** B. Therapeutic

1. Cardiopulmonary resuscitation

(CPR), both basic

and advanced

2. Treating arrhythmias and

conduction disturbances

3. Use of intracardiac temporary

pacemakers

4. Use of external temporary

pacemakers

5. Elective cardioversion**

6. Management of acute

myocardial infarction and

postinfarction care

a. Use of thrombolytics

b. Use of anticoagulants

c. Use of anticoagulants

d. Complications of

myocardial infarction

7. Congestive heart failure

8. Hypertensive emergencies

9. Supervision and management

of rehabilitation

10. Psychologic issues

a. Sexual

b. Depression

c. Family dynamics

11. Management of patients

after an intervention

a. Coronary bypass surgery

b. Valve surgery

c. Congenital heart disease

surgery

d. 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 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 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

1. Gazes PC. Clinical cardiology. M ed. Philadelphia, Pa.: Lea & Febiger, 1990. 2. Wagner GS, Marriott HJ. Marriott's Practical electrocardiography. 9th ed. Williams & Wilkins, 1994. 3. Heger JW, Niemann JT, Criley JM. Cardiology for the house officer. 3d ed. Williams & Wilkins, 1993. 4. Schlant RC, Alexander RW, eds. The heart, arteries and veins. New York, N.Y.: McGraw-Hill, 1994. 5. Braunwald E, ed. Heart disease: a textbook of cardiovascular medicine. 4th ed. Philadelphia, Pa.: Saunders, 1992.

COPYRIGHT 1996 American Academy of Family Physicians
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