The role of the GP in cardiovascular health
As a GP, your role is to:
- manage the risk factors for cardiovascular disease as an essential part of health promotion activity in primary care. You should be able to describe the key research findings that influence management of cardiovascular risk and disease. A large part of our work in primary care involves working with patients to engage them in making healthy lifestyle choices and limiting unhealthy behaviours
- communicate the risk of cardiovascular disease clearly and effectively in an unbiased manner, and use disease registers and data-recording templates effectively for opportunistic and planned monitoring
- manage cardiovascular emergencies in primary care
- accurately diagnose and manage symptoms that may be caused by cardiovascular conditions
- be aware of the impact that cardiovascular disease may have on disability and fitness to work, as well as the legal obligations relating to driving. You should also be able to recognise the cultural significance attached to heart disease
- be aware of the potential psychological and social impact of cardiovascular conditions
- advise on cardiovascular screening, such as the UK-wide abdominal aortic aneurysm (AAA) screening programme1
Knowledge and skills guide
For each problem or disease, consider the following areas within the general context of primary care:
- the natural history of the condition, including whether acute or chronic
- the incidence and prevalence, including in different demographic groups
- typical and atypical presentations
- recognition of normal variations throughout life
- risk factors, including lifestyle, socio-economic and genetic factors
- diagnostic features and differential diagnosis
- recognition of ‘alarm’ or ‘red flag’ features
- appropriate and relevant investigations
- interpretation of test results
- management, including initial and continuing care, chronic disease monitoring and emergency care
- patient and carer information and education, including self-care prognosis.
Symptoms and signs
- Cardiac murmurs
- Chest pain (including factors suggestive of cardiac origin)
- Circulatory symptoms of ischaemia, thrombosis, chronic arterial and venous insufficiency
- Dyspnoea
- Oedema
- Palpitations and arrhythmias
- Syncope, dizziness, and collapse, including non-cardiovascular causes
- Symptoms and signs of stroke or transient ischaemic attack (TIA)
Common and important conditions
- Acute cardiovascular problems including cardiac arrest, acute coronary syndrome (ACS), acute myocardial infarct, acute left ventricular failure, dissecting aneurysms, malignant hypertension and life-threatening arrhythmias, cardiogenic shock, acute ischaemia of limbs and bowel, TIA and stroke
- Arrhythmias including conduction defects such as atrial fibrillation (AF) and flutter, heart block, supraventricular tachycardia, ventricular rhythm abnormalities
- Cardiovascular conditions for which anticoagulation may be relevant, such as AF, myocardial ischaemia, peripheral vascular disease, and TIA or stroke (including heparin, thrombolysis indications, oral anticoagulation)
- Cardiomyopathies: primary and acquired, including dilated and hypertrophic obstructive
- Cerebral disease for which cardiovascular risk factors are important, for example, stroke, vascular dementia
- Circulation disorders, including:
- arterial problems such as peripheral vascular disease, vasculitis, aneurysms (cerebral, aortic and peripheral), arterial ulcers
- venous problems such as venous thromboembolism, pulmonary embolism, Raynaud’s disease, varicose veins, venous ulcers
- Congenital heart disease such as coarctation of the aorta, ventricular septal defect (VSD), atrial septal defect (ASD), patent ductus arteriosus (PDA), and presentation of these both in children and adults
- Coronary heart disease, including complications such as mural thrombus, ventricular aneurysm and rhythm disturbance
- Drug-induced heart disease (for example, secondary to cancer treatment with chemotherapy or radiotherapy, recreational drugs)
- Heart failure: acute and chronic, including left ventricular dysfunction, right heart failure and cor pulmonale
- Hypertension: essential (and its classification into stages), secondary and malignant
- Infections such as viral myocarditis, infective endocarditis, pericarditis and rheumatic fever, and their complications
- Complications and malfunction of pacemakers relevant to primary care
- Pulmonary hypertension and its causes (for example, fibrotic lung disease and recurrent pulmonary emboli)
- Risk factors for coronary heart disease and other thromboembolic diseases such as lipid disorders, diabetes and hypertension
- Valvular problems such as mitral, tricuspid, pulmonary and aortic stenosis, and regurgitation.
Examinations and procedures
- Cardiovascular system examination, including methods for monitoring blood pressure and pulse oximetry
- Use of emergency equipment, including defibrillator and oxygen delivery
- Emergency cardiopulmonary resuscitation
Investigations
- Knowledge and application of current risk assessment tools, such as CHA2DS2VASc and ORBIT for AF and QRISK for cardiovascular risk
- Relevant blood investigations such as cardiac enzymes, natriuretic peptides or D-dimer
- Investigations including home and ambulatory blood pressure (BP) monitoring, electrocardiogram (ECG), exercise ECG, 24-hour and event monitoring ECGs, echocardiography, venous dopplers and ankle brachial pressure index (ABPI) measurement.
- Additional investigations and interventions such as coronary angiography and stents, perfusion scanning, and computed tomography (CT) scans.
Service issues
- Cardiovascular health screening, including AAA screening, BP, cholesterol and HbA1c checks
- Local service provision for cardiovascular healthcare
- Disease registers and data-recording templates for opportunistic and planned monitoring of cardiovascular problems to ensure continuity of care between different healthcare providers
- Effective and appropriate acute and chronic disease management, including medication, prevention, rehabilitation and palliative care for those with end-stage cardiac failure
- Recognition of the social determinants of health in relation to cardiovascular disease
- Current population trends in the prevalence of risk factors and cardiovascular disease in the community
- Cardiovascular rehabilitation after a stroke or cardiac event
- Appropriate support services nationally and locally (for example, smoking cessation and weight loss)
- Safe prescribing, including indications for and monitoring of commonly used drugs such as antihypertensive drugs, anticoagulants and statins
- Management of polypharmacy, which is common in patients with cardiovascular problems
- Referral pathways to investigate inherited cardiac conditions
Case discussion
David Black is a 58-year-old bus driver who presents to your clinic with a history of central chest pain radiating to the left arm. This occurs on exertion and is relieved by rest. It started about one month ago and has not got any worse.
He has no history of hypertension, diabetes or hyperlipidaemia that you are aware of, but he rarely visits the practice. He smokes. There is no family history of ischaemic heart disease, but his mother developed diabetes from the age of 65.
On examination, he is comfortable. His BP is 155/95 with a pulse rate of 85 beats per minute (bpm) and regular. His BMI is 32 kg/m².
(Source: Adapted from C. Heneghan in Cardiovascular Disease in Primary Care – a guide for GPs, RCGP Publications, 2010.)
Questions
These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your educational supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.
| Core capabilities | Questions |
|---|---|
Fitness to practise This is about professionalism and the actions expected to protect people from harm. This includes the awareness of when an individual’s performance, conduct or health, or that of others, might put patients, themselves or their colleagues at risk. | How important is it for me to model healthy living for my patients? What actions can I take to help promote an organisational culture in which the health of the members is valued and supported? How might my own feelings towards someone who smokes and is overweight impact on the care I give to a patient who develops cardiovascular disease? |
An ethical approach This is about practicing ethically with integrity and a respect for equality and diversity. | How might cardiovascular disease prevention vary in different cultures and population groups? Should overweight smokers be offered open access to treatment if they do not lose weight or stop smoking? |
Communicating and consulting This is about communication with patients, the use of recognised consultation techniques, establishing and maintaining patient partnerships, managing challenging consultations, third-party consulting, the use of interpreters and consulting modalities across the range of in-person and remote methods. | How would I explain cardiovascular risk to this patient? How could I influence a change in David’s lifestyle? How would I explore this patient’s ideas, concerns and expectations? |
Data gathering and interpretation This is about the gathering, interpretation and use of data for clinical judgement, including information gathered from the history, clinical records, examination and investigations. | What additional information do I need? If I have access to same-day ECG, how confident am I in interpreting it? Would blood tests be useful? Which ones? |
Clinical examination and procedural skills This is about clinical examination and procedural skills. By the end of training, the GP registrar must have demonstrated competence in general and systemic examinations of all the clinical curriculum areas, including the five mandatory examinations and a range of skills relevant to general practice. | How well can I assess and manage a patient presenting with acute breathlessness due to left ventricular failure (LVF)? |
Decision-making and diagnosis This is about having a conscious, organised approach to making diagnosis and decisions that are tailored to the particular circumstances in which they are required. | What is my differential diagnosis? What drug treatment might I suggest for David? How does the prevalence of cardiovascular disease vary within the UK population? |
Clinical management This is about the recognition and a generalist’s management of patients’ problems. | What are the national guidelines for diagnosis and long-term treatment in this case? What would be the key features of my safety-netting conversation with David? What advice would I give him about smoking cessation? |
Medical complexity This is about aspects of care beyond the acute problem, including the management of comorbidity, uncertainty, risk and health promotion. | How would I manage David’s multiple risk factors at this initial consultation? What can I do to help manage the risk in this patient? What are the criteria for referral to secondary care and what would I include in my referral letter? Am I familiar with the Driver and Vehicle Licensing Agency (DVLA) guidance on fitness to drive? |
Team working This is about working effectively with others to ensure good patient care and includes sharing information with colleagues and using the skills of a multiprofessional team. | How might other members of the practice team be involved in the care of this patient? What rapid access clinics are available locally? |
Performance, learning and teaching This is about maintaining the performance and effective CPD of oneself and others. The evidence for these activities should be shared in a timely manner within the portfolio. | How do I keep up to date with developments in cardiovascular health? What learning opportunities does this case present for me? What quality improvement could I consider for patients with ischaemic heart disease at my practice? |
Organisation, management and leadership This is about understanding how primary care is organised within the NHS, how teams are managed and the development of clinical leadership skills. | How do I record cardiovascular risk on my information technology (IT) system? What SNOMED CT (Systemized Nomenclature of Medicine – Clinical Terms) code might I use for this patient? What computerised resources might I use in the consultation with David? How could I use the IT system and electronic health records to develop a search to identify patients with a particular condition, and use this to improve quality of care? |
Holistic practice, health promotion and safeguarding This is about the ability of the doctor to operate in physical, psychological, socio-economic and cultural dimensions. The doctor is able to take into account the patient’s feelings and opinions. The doctor encourages health improvement, self-management, preventative medicine and shared care planning with patients and their carers. The doctor has the skills and knowledge to consider and take appropriate safeguarding actions. | How do I take my patients’ occupations into account when assessing, managing and advising them? What are David’s home circumstances? What would I advise him about having sex? What about driving and fitness to fly? What patient information resources are available? What are the social and psychological impacts of David’s cardiovascular problems on his friends and dependants? How would I address the cultural significance of the heart as a seat of emotions? |
Community health and environmental sustainability This is about the management of the health and social care of the practice population and local community. It incorporates an understanding of the interconnectedness of health of populations and the planet. | What community resources are available for cardiovascular disease prevention in my area? Are there any important characteristics of the local community that might impact on patient care, particularly the epidemiological, social, economic and ethnic features? |
How to learn this area of practice
Work-based learning
General practice is an excellent place for you to learn how to manage cardiovascular problems. Patients will present with a wide range of symptoms and at varying stages in the natural history of their illness. Critical professional discussions with your trainer will help GP registrars to develop problem-solving skills. Supervised practice will also give GP registrars confidence.
In particular, the GP registrar should be able to learn about risk factor management and gain experience in the management of cardiovascular problems as they present (acute and chronic), including emergencies. Primary care is also the best place to learn about cardiovascular chronic disease management (including angina, heart failure, hypertension, post-myocardial infarction (MI), peripheral vascular disease and stroke).
The acute hospital setting is a good place to learn about management of cardiovascular emergencies including ACS, MI, stroke and aortic aneurysms. This could be in a variety of secondary care placements, including cardiology, emergency medicine and general medicine. Some GP specialty training programmes have placements of varying lengths with cardiologists. In these you may also get the opportunity to become familiar with the invasive management of cardiovascular problems, including angioplasty, coronary artery bypass grafts, transplantation and other forms of vascular surgery (such as carotid endarterectomy and vascular bypass), many of which you are likely to have to discuss with your patients in primary care during your career.
Cardiovascular care is increasingly delivered via specialist community clinics where GP registrars may have the opportunity to observe the investigation and management of common cardiovascular problems and familiarise themselves with local care pathways. Outpatient or clinic settings are ideal places for seeing concentrated groups of patients with cardiovascular problems. They also provide you with opportunities to learn about secondary care investigation of cardiovascular problems (exercise tests, radionucleotide scans, magnetic resonance imaging (MRI) and CT scans, carotid dopplers, angiography and echocardiography).
Self-directed learning
You can find eLearning module(s) relevant to this topic guide at elearning for healthcare.
Many postgraduate deaneries provide courses on cardiovascular problems. Other providers include universities and the RCGP. There is a growing eLearning resource to help you consolidate and build on the knowledge you have gained in the workplace.
You can learn about patients’ experiences of living with cardiovascular problems, from early symptoms to diagnosis and management, through the wide range of multimedia clips at Healthtalk.
Learning with other healthcare professionals
Chronic disease management in primary care is a multidisciplinary activity. As a GP registrar it is important for you to attend nurse-led cardiovascular disease annual review assessments in practice and gain an understanding of the follow-up of hypertensive patients in the practice’s clinics, which are often led and delivered by a practice nurse. It is also important to understand the role of district nurses in the assessment and management of leg ulcers or ankle oedema by attending their clinics or home visits. You should also take the opportunity to observe cardiovascular rehabilitation programmes led by physiotherapists.
Examples of how this area of practice may be tested in the MRCGP
Applied Knowledge Test (AKT)
- Interpreting ECG tracings
- Medical management of hypertension
- Cardiovascular risk assessment
Simulated Consultation Assessment (SCA)
- A man is concerned that he may have heart disease, having experienced chest pain when he exercises at the gym
- A woman with well-controlled heart failure has increasing exertional dyspnoea over the past fortnight
- A father is concerned about sudden death in young athletes and requests a routine ECG for his 12-year-old son, who has joined a running club
Workplace-based Assessment (WPBA)
- Having to explain their need for a pacemaker to a patient who has not understood the nature of their condition
- Log entry about the logistics and value of the practice coronary heart disease clinic
- Consultation Observation Tool (COT) about advice for a man requesting a calcium score after a private medical examination when you are unsure about the evidence for this
- Clinical examination and procedural skills (CEPS) to demonstrate how to perform a focused cardiovascular examination in primary care