Cardiovascular Management in Family Medicine

7/18/2019 Cardiovascular Management in Family Medicine

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CardiovascularManagement in Family

MedicineErwin Sukandi

Cardiology Division

Internal Medicine Department

FAMUS/RSM !alem"ang


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Introduction

Cardiovascular disease is a ma#or cause o$ mor"idityand mortality in our society%

&'e $amily p'ysician s'ould "e pro(cient in t'ediagnosis and management o$ a variety o$

cardiovascular disorders% Family p'ysicians provide compre'ensive and

continuing care to individuals and $amilies) wit'particular attention to "e'avioral and li$estyle

$actors% At times t'e $amily p'ysician may (nd it appropriate

to seek consultation $rom a cardiologist to eit'ermanage or co*manage a patient $or optimal care%


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Competencies

Understand "asic and clinical knowledge o$ cardiacanatomy and pat'op'ysiology o$ commoncardiovascular diseases% +Medical ,nowledge-

!er$orm an appropriate cardiac 'istory and p'ysical

e.amination) document (ndings) develop anappropriate dierential diagnosis) and plan $or

$urt'er evaluation and management% +!atient Care)Medical ,nowledge) Interpersonal and

Communication Skills- Use evidence "ased knowledge regarding primary

and secondary prevention o$ cardiovascular disease%+Medical ,nowledge) !atient Care-


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Competencies

Review current practices regarding t'e care o$patients wit' cardiovascular disease and developplans to improve t'e care% +!atient Care) Medical,nowledge) !ractice*"ased 0earning andImprovement) !ro$essionalism-

1ork wit' p'ysicians) nurses) p'armacists)dieticians) and ot'er 'ealt' care pro$essionals w'o

care $or patients wit' common cardiovasculardiseases% +!atient Care) Medical ,nowledge)!ro$essionalism) Systems*"ased !ractice-


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Attitudes

2 &'e importance o$ p'ysician and patient working as partnersto promote optimal cardiovascular 'ealt'%

2 A compassionate approac' to t'e care o$ patients wit' cardiacdisease%

2 &'e psyc'osocial and economic impact o$ cardiovasculardisease on t'e individual and $amily and use o$ t'e 'ealt' caresystem to assist as needed%

2 Support o$ t'e individual and $amily t'roug' consultation)evaluation) treatment) and re'a"ilitation%

2 &'e importance o$ li$estyle $actors on t'e development ande.acer"ation o$ cardiovascular disease%

2 A multidisciplinary approac' to t'e care o$ individuals wit'cardiovascular disease%


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,nowledge3% 4ormal cardiovascular anatomy and p'ysiology

5% C'anges in cardiovascular p'ysiology wit' ageand pregnancy

6% Risk $actors o$ CAD

i% yperlipidemia

ii% Cigarette smokingiii% 7enetic predisposition

iv% Sedentary li$e style

v% ypertension

vi% Dia"etes mellitusvii% 8"esity

viii%4utrition

i.% ormonal status

.% Emotional stress


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,nowledge9% Cardiovascular 'istory

:% Cardiovascular p'ysical e.amination;% 4oninvasive e.aminationsa% Electrocardiograp'y

"% C'est radiograp'y

c% Stress testing) including treadmill/"icycle or

p'armacologic tec'nied tomograp'y +C&-

i% Magnetic resonance imaging +MRI- and Magneticresonance angiogram +MRA-


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?% Invasive e.aminations

a% Diagnostic cardiac cat'eteri>ation andangiograp'y

"% Diagnostic carotid and perip'eral vascularangiograp'y

c% Intracoronary and perip'eral vascularintervention using appropriate devices

d% Internal monitoring devices

i% Central venous and perip'eral arterialcat'eter

e% Electrop'ysiologic studies

$% Indications and contraindications o$ t'erapeuticinterventions

i% Coronary artery "ypass

ii% Angioplasty tec'ni


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,nowledge

@% Relevant la"oratory interpretation) including

serum en>ymes) isoen>ymes) lipids) and "*typenatriuretic peptide +4!- or pro*4!%

B% Speci(c diseases/conditionsa% Coronary artery disease

i% Sta"le/unsta"le anginaii% Myocardial in$arction) wit' and wit'out

complications3- Cardiogenic s'ock5- Dysr'yt'mias6- !apillary muscle dys$unction and rupture9- =entricular rupture:- Aneurysm

iii% Sudden deat'

"% Syncope) cardiogenic and non*cardiogenic


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,nowledge

c% Dysr'yt'miasi% &ac'yarr'yt'mia

3- Supraventricular

5- =entricular

6- Reentrant

ii% radyarr'yt'miaiii% Ectopy

3- Atrial

5- =entricular

d% ypertensioni% Essential

ii% Secondary

iii% !ulmonary


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,nowledge

e% !ulmonary 'eart disease

i% Cor pulmonale

$% eart $ailure

i% Systolic dys$unction

ii% Diastolic dys$unction

g% =enous &'rom"oem"olic disease +=&E-

'% =alvular 'eart disease

i% R'eumaticii% Congenital

iii% Degenerative

iv% Mitral valve prolapse syndrome


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i% Congenital 'eart diseasei% Common le$t to rig't s'unts +acyanotic-

ii% Common rig't to le$t s'unts +cyanotic-iii% Common o"structive pro"lems

#% Dissecting aneurysmk% Innocent 'eart murmurs

l% !erip'eral vascular diseasei% Aneurysmii% Carotid at'erosclerosisiii% Arterial diseaseiv% Arteriosclerosis o"literans

m% Cardiomyopat'iesi% Congestive +dilated-ii% Restrictiveiii% ypertrop'ic cardiomyopat'yiv% !ostpartum


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n% !ericardial diseaseo% In$ection*related

i% =iral myocarditisii% Su"acute "acterial endocarditisiii% ,awasakis disease

p% 8t'er cardiac disordersi% Immunologic

3- Acute r'eumatic $ever5- Autoimmune disorders

ii% !syc'ogeniciii% &raumaticiv% 4utritional

v% My.omavi% &'yroid dys$unctionvii% Mar$an syndromeviii%Drug*related suc' as cocaine) steroids and

c'emot'erapeutic agents


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,nowledge


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Skills

In t'e appropriate setting) t'e resident s'oulddemonstrate t'e a"ility to per$orm orappropriately re$er

3% Diagnostic proceduresa% !er$ormance o$ 'istory taking and p'ysical

e.amination

"% Mec'anics and interpretation o$ EC7

c% Interpretation o$ c'est radiograp'sd% &readmill/"icycle stress test monitoring and

interpretation

e% Am"ulatory EC7 monitoring and interpretation


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Skills

5% &'erapeutic procedures

a% Risk management

"% Cardiopulmonary resuscitation +C!R-) "ot' "asic li$esupport +0S- and advanced cardiac li$e support +AC0S-

c% &reating dysr'yt'mias and conduction distur"ances

d% Use o$ e.ternal temporary pacemakers

e% Management o$ acute myocardial in$arction)

postin$arction care) and complications$% Congestive 'eart $ailure

g% ypertensive emergencies


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'% Supervision and management o$ cardiovascularre'a"ilitation

i% !syc'osocial issues

i% Se.ual $unctioningii% Depression

iii% Family dynamics

#% Management o$ patients a$ter an intervention

i% 0i$estyle ad#ustments

ii% Coronary artery "ypass surgery

iii% =alve surgery

iv% Congenital 'eart disease surgery

v% Cat'eter*related interventional procedures


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!revention

&'ere is a range o$ 'ig'ly prevalentcardiovascular diseases and well*known risk $actors) in addition to age)

se. and genetic $actors) w'ic'inuence an individualscardiovascular risk pro(le% roadly)

t'ree areas o$ prevention can "edistinguis'ed%


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!revention1. Prevention in the total population. Life style

factors, such as smoking, physical exercise, diet, and

use o$ alco'ol 'ave impact on t'e cardiovascularrisk%

2. Prevention in high-risk groups. There is a rangeof chronic clinical conditions that increase t'e risk $orcardiovascular events) w'ic' mainly aect adultsaged :: years or over) suc' as 'ypertension+G39/B mmg) prevalence at least 5:/3patients in t'is age group-% Also) dia"etes+prevalence at least :/3 patients in t'is age

group- is a condition t'at predisposes $orcardiovascular diseases%3. Prevention after cardiovascular events. Acute

cardiovascular events such as myocardial in$arctionand stroke) determine mortality and) i$ t'e patient

survives)


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Eective life style and pharmaceuticalinterventions

Stop smoking A review +5 studies- s'owed t'at smokingcessation interventions in patients wit' coronary 'eart disease

were associated wit' reduced overall mortality +RRH%;9-+Critc'ley 56-%

Physical exercise A review +:3 studies- s'owed t'at e.ercise*only re'a"ilitation in patients wit' coronary 'eart disease led to areduction o$ cardiac mortality +RRH%;B- +ollie 5-%

Diet A review +5? studies- s'owed t'at reduced $at intake led to

protection $rom C=D events +rate ratio %@9- "ut not $rommortality% &'e degree o$ protection $rom cardiovascular eventsappeared similar in 'ig' and low risk groups) "ut was statisticallysigni(cant only in t'e $ormer +ooper 53-%

Alcohol 0owered levels o$ alco'ol consumptions were associatedwit' lowered risk o$ C=D events +RRH%;?- +Corrao 5-% +4ote

t'at t'is was not an intervention study%- Antihypertensive drugs +ACE in'i"itors) calcium antagonists)

diuretics) "eta*"lockers- A review +5B eJcacy trials- on dierentdrugs s'owed relative risk reductions o$ 3@*55K $or C=D eventsagainst place"o +lood !ressure 0owering etc% 56-%

Statins A review +:@ studies- s'owed t'at statins wereassociated wit' a reduced relative risk $or ID deat' or non*$atal


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=ERL I7 RIS,

Su"#ects wit' any o$ t'e $ollowing

Documented C=D "y invasive or non*invasive testing +suc'as coronary angiograp'y) nuclear imaging) stressec'ocardiograp'y) carotid plaation +!CI)CA7-) and ot'er arterial revasculari>ation procedures)isc'aemic stroke) perip'eral artery disease +!AD-%

Dia"etes mellitus +type 3 or type 5- wit' one or more C=risk $actors and/or target organ damage +suc' as

microal"uminuria 66 mg/59 '-% Severe c'ronic kidney disease +C,D- +7FR )6 m0/min/3%?6

m5-%

A calculated SC8RE N3K%


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I7 RIS,

Su"#ects wit' any o$ t'e $ollowing

Markedly elevated single risk $actors suc' as$amilial dyslipidaemias and severe'ypertension%

Dia"etes mellitus +type 3 or type 5- "ut wit'outC= risk $actors or target organ damage%

Moderate c'ronic kidney disease +7FR 6:B

m0/min/3%?6 m5-% A calculated SC8RE o$ N:K and )3K $or 3*

year risk o$ $atal C=D%


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M8DERA&E RIS,

Su"#ects are considered to "e at moderate risk w'ent'eir SC8RE is N3 and ):K at 3 years% Many middle*aged su"#ects "elong to t'is category% &'is risk is $urt'er

modulated "y $actors mentioned a"ove%

081 RIS,

&'e low*risk category applies to individuals wit' a SC8RE

O3K and $ree o$


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Cardiovascular Management in Family Medicine

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