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Cardiovascular Management in Family Medicine
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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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TERMA!AS"
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