Cardiovascular health

This Topic Guide explores part of the RCGP curriculum, Being a General Practitioner. It will help you understand important issues relating to cardiovascular health by illustrating the key learning points with a case scenario and questions. It also contains tips and advice for learning, assessment and continuing professional development, including guidance on the knowledge relevant to this area of general practice.

Each Topic Guide is intended to illustrate important aspects of everyday general practice, rather than provide a comprehensive overview of each clinical topic. It should therefore be considered in conjunction with other Topic Guides and educational resources.

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 life style choices, and limiting unhealthy behaviours 
  • Communicate the risk of cardiovascular disease clearly and effectively in a non-biased 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 potentially be caused by cardiovascular conditions  
  • Monitor and manage the care of patients with long-term cardiovascular conditions such as hypertension, chronic heart failure or atrial fibrillation 
  • 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 Aortic Aneurysm screening programme. 

Emerging issues in cardiovascular health

Cardiovascular disease (CVD) causes more than a quarter of all deaths in the UK; coronary heart disease (CHD) is the UK's single biggest killer, and around 40,000 people die each year in the UK from stroke. There are also considerable variations in mortality throughout the UK: early deaths from CVD (before the age of 75) are most common in the north of England, central Scotland and the south of Wales, and lowest in the south of England. A very significant number of people are living with cardiovascular disease in the UK, affecting equal numbers of men and women. As the population ages and grows and with improving survival rates from cardiovascular events it is likely that the number of people affected by cardiovascular disease will rise. 

GPs are involved in coordinating and commissioning care to provide appropriate acute and chronic disease management for patients at all stages of cardiovascular disease.  You should be able to describe the key government policy documents that influence healthcare provision for cardiovascular problems. 

Other emerging issues in cardiovascular health:

For example: 

  • Defining and measuring overall cardiovascular health 
  • Assessing and communicating lifetime risk for cardiovascular disease 
  • Addressing depression as a risk factor for and associated condition of heart disease and stroke 
  • Examining cognitive impairment due to cardiovascular disease 
  • Improving the cardiovascular surveillance system. 

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 untreated condition including whether acute or chronic
  • The prevalence and incidence across all ages and any changes over time
  • Typical and atypical presentations 
  • Recognition of normal variations throughout life 
  • Risk factors, including lifestyle, socio-economic and cultural factors 
  • Diagnostic features and differential diagnosis 
  • Recognition of ‘alarm’ or ‘red flag’ features 
  • Appropriate and relevant investigations 
  • Interpretation of test results 
  • Management including self-care, initial, emergency and continuing care, chronic disease monitoring 
  • Patient 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: peripheral and central 
  • Palpitations and arrhythmias 
  • Syncope, dizziness and collapse including non-cardiovascular causes 
  • Symptoms and signs of stroke/Transient Ischaemic Attack (TIA). 

Common and important conditions 

  • Acute cardiovascular problems including cardiac arrest, acute coronary syndrome, acute myocardial infarct, acute left ventricular failure, dissecting aneurysms, severe hypertension and life-threatening arrhythmias, cardiogenic shock, acute ischaemia of limbs and gut, TIA and stroke 
  • Arrhythmias including conduction defects such as atrial fibrillation and flutter, heart block, supraventricular tachycardia, ventricular rhythm abnormalities
  • Cardiovascular conditions for which anticoagulation may be relevant such as Atrial Fibrillation (AF), myocardial ischaemia, peripheral vascular disease and TIA/stroke (including heparin, thrombolysis indications, oral anticoagulation)
  • Cardiomyopathies: primary and acquired, including dilated, hypertrophic obstructive 
  • Cerebral disease for which cardiovascular risk factors are important e.g. stroke, vascular dementia (see also Topic Guide 4.17 Neurology) 
  • Circulation disorders including: 
    • arterial problems such as peripheral vascular disease, vasculitis, aneurysms (cerebral, aortic and peripheral); and
    • venous problems such as venous thromboembolism, pulmonary embolism, Raynaud’s disease, varicose veins, venous and arterial 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 (e.g. secondary to cancer treatment with chemotherapy/ 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, rheumatic fever and complications 
  • Complications and malfunction of pacemakers relevant to primary care
  • Pulmonary hypertension: primary and secondary to underlying causes such as fibrotic lung disease and recurrent pulmonary emboli 
  • Risk factors for coronary heart disease and other thromboembolic diseases such as lipid disorders, diabetes, hypertension 
  • Valvular problems such as mitral, tricuspid, pulmonary and aortic stenosis and regurgitation. 

Examinations and procedures 

  • Cardiovascular system examination 
  • Blood pressure monitoring 
  • Pulse oximetry 
  • Use of emergency equipment, including defibrillator, and oxygen delivery
  • Emergency cardio-pulmonary resuscitation

Investigations 

  • Knowledge and application of current risk assessment tools such as CHADSVASC and HASBLED for atrial fibrillation, QRISK/ASSIGN for Coronary Heart Disease
  • Relevant blood investigations such as cardiac enzymes, natriuretic peptides, or D-dimer
  • Secondary care interventions such as coronary angiography and stents, perfusion scanning, and CT scans 
  • Specific cardiac investigations including home and ambulatory BP monitoring, electrocardiogram (ECG), exercise ECG, 24 hour and event monitoring ECGs, echocardiography, venous dopplers and Ankle Brachial Pressure Index (ABPI) measurement

Service issues

  • Cardiovascular health screening, including abdominal aortic aneurysm screening, blood pressure, cholesterol and glucose 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. 

Case discussion

Mr 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 blood pressure is 155/95 with a pulse rate of 85 b.p.m. and regular. His BMI is 32 kg/m². 

[Example 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 Competence           
                      Questions                   

Fitness to practise
This concerns the development of professional values, behaviours and personal resilience and preparation for career-long development and revalidation. It includes having insight into when your own performance, conduct or health might put patients at risk, as well as taking action to protect patients. 

 

 

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 well am I balancing work and life?  

Maintaining an ethical approach
This addresses the importance of practising ethically, with integrity and a respect for diversity. 

 

 

How might cardiovascular disease prevention vary in different cultures and sexes? 

Should overweight smokers be offered open access to treatment if they do not lose weight or stop smoking? 

Communication and consultation
This is about communication with patients, the use of recognised consultation techniques, establishing patient partnerships, managing challenging consultations, third-party consulting and the use of interpreters. 

 

 

 

 
How would I go about explaining cardiovascular risk to this patient? 

How could I influence a change in Mr Black’s lifestyle? 

How would I explore this patient’s ideas, concerns and expectations? 

 

Data gathering and interpretation
This is about interpreting the patient's narrative, clinical record and biographical data. It also concerns the use of investigations. 

 

 

What additional information do I need? 

If I have access to same day ECG, how confident am I at interpreting it? 

Would blood tests be useful? Which ones?  
Clinical Examination and Procedural Skills 
This is about the adoption of an appropriate and proficient approach to clinical examination and procedural skills.  
How well can I assess and manage a patient presenting with acute breathlessness due to LVF? 

Making decisions
This is about having a conscious, structured approach to decision-making; within the consultation and in wider areas of practice. 

 

 

What is my differential diagnosis? 

What drug treatment might I suggest for Mr Black? 

How does the prevalence of cardiovascular disease vary within the UK population?  

Clinical management
This concerns the recognition and management of common medical conditions encountered in generalist medical care. It includes safe prescribing and medicines management approaches. 

 

 

What are the national guidelines for diagnosis and longer-term treatment in this case? 

What would be the key features of my safety-netting conversation with Mr Black? 

What advice would I give him about smoking cessation? 

Managing medical complexity  
This is about aspects of care beyond managing straightforward problems. It includes multi-professional management of co-morbidity and poly-pharmacy, as well as uncertainty and risk. It also covers appropriate referral, planning and organising complex care, promoting recovery and rehabilitation. 

 

 

How would I manage his 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 DVLA guidance on fitness to drive? 

Working with colleagues and in teams  

 

 

 

This is about working effectively with other professionals to ensure good patient care. It includes sharing information with colleagues, effective service navigation, use of team skill mix, applying leadership, management and team-working skills in real-life practice, and demonstrating flexibility with regard to career development. 

How might other members of the practice team be involved in the care of this patient? 

What rapid access clinics are available locally? 
Improving performance, learning and teaching
This is about maintaining performance and effective CPD for oneself and others. This includes self-directed adult learning, leading clinical care and service development, quality improvement and research activity. 
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? 
Organisational management and leadership
This is about the understanding of organisations and systems, the appropriate use of administration systems, effective record keeping and utilisation of IT for the benefit of patient care. It also includes structured care planning, using new technologies to access and deliver care and developing relevant business and financial management skills. 
How do I record cardiovascular risk on my IT system? 

What Read code might I use for this patient?  

What computerised resources might I use in the consultation with Mr Black?  

Practising holistically, safeguarding and promoting health
This is about the physical, psychological, socioeconomic and cultural dimensions of health. It includes considering feelings as well as thoughts, encouraging health improvement, preventative medicine, self-management and care planning with patients and carers. 

 

 

 

 

How do I take my patients’ occupations into account when assessing, managing and advising them? 

What are his 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 Mr Black's cardiovascular problems on his friends and dependants? 

How would I address the cultural significance of the heart as a seat of emotions? 
Community orientation
This is about involvement in the health of the local population. It includes understanding the need to build community engagement and resilience, family and community-based interventions, as well as the global and multi-cultural aspects of delivering evidence-based, sustainable healthcare. 
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 specialty trainees to develop problem-solving skills. Supervised practice will also give trainees confidence.  

In particular, the GP specialty trainee 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 acute coronary syndrome (ACS), MI, stroke and aortic aneurysms. This could be in a variety of secondary care placements including cardiology, emergency medicine or general medicine. Some GP specialty training programmes have placements of varying lengths with cardiologists; here, you may also get the opportunity to become familiar with the invasive management of cardiovascular problems: angioplasty, coronary artery bypass grafts, transplantation, other forms of vascular surgery (carotid endarterectomy, 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 trainees 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, MRI/CT, carotid dopplers, angiography and echocardiography).   

Self-directed learning 

You can find e-Learning module(s) relevant to this Topic Guide at e-Learning for Healthcare

Many postgraduate deaneries provide courses on cardiovascular problems. Other providers include universities and the Royal College of General Practitioners. There is a growing e-Learning resource to help you consolidate and build on the knowledge you have gained in the workplace. This includes NHS Evidence Search which provides access to information on a wide variety of topics including chest pain, stroke, hypertension, chronic kidney disease, deep vein thrombosis etc. 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 specialty trainee 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 that 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 
  • Adverse drug effects of anti-hypertensives 
  • Genetics of familial hypercholesterolaemia

Clinical Skills Assessment (CSA) 

  • Man is concerned that he may have heart disease having experienced chest pain when he exercises at the gym 
  • Woman with well-controlled heart failure has increasing exertional dyspnoea over the past fortnight 
  • 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) 

  • Learning log reflecting on having to explain a pacemaker to a patient who has not understood the consultant’s explanation 
  • 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 
  • CEPS about performing CPR on a collapsed patient. 

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