Cardiovascular Medicine


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Cardiovascular Medicine

  1. 1. AAFP Reprint No. 262 Recommended Curriculum Guidelines for Family Practice Residents Cardiovascular Medicine This document has been endorsed by the American Academy of Family Physicians and was developed in cooperation with the American College of Cardiology, the Association of Departments of Family Medicine, the Association of Family Practice Residency Directors and the Society of Teachers of Family Medicine. 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, with particular attention to behavioral and lifestyle factors. 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. Patient Care Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to: A. Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families a. Recognition of the psychosocial and economic impact of cardiovascular disease on the individual and family b. Psychosocial issues i. Sexual functioning ii. Depression iii. Family dynamics B. Take a supportive and compassionate approach to the care of the patient with cardiac disease, especially in the case of someone with chronic disease C. Take an accurate and effective cardiac history D. Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment E. Develop and carry out patient management plans (including management and recognition of the prevalent and treatable diseases under “Medical Knowledge”) taking into consideration the severity and need for immediate expert assistance and referral.
  2. 2. a. Management of patients after an intervention i. Lifestyle adjustments ii. Coronary bypass surgery iii. Valve surgery iv. Congenital heart disease surgery v. Catheter interventional procedures b. Supervision and management of rehabilitation F. Counsel and Educate patients and their families a. Recognition of the importance of lifestyle factors on the development and exacerbation of cardiovascular disease. G. Use Information Technology to support patient care decisions and patient education H. Provide health care services aimed at preventing health problems or maintaining health I. Work with health care professionals, including those from other disciplines, to provide patient-focused care a. Have an awareness of the importance of physician and patient working as partners to promote optimal cardiovascular health J. Perform competently all medical and invasive procedures considered essential for the area of practice a. Cardiovascular physical examination b. Mechanics and interpretation of ECG c. Interpretation of chest radiographs d. Treadmill/bicycle stress test monitoring and interpretation e. Ambulatory ECG monitoring and interpretation f. Cardiopulmonary resuscitation (CPR), both basic life support (BLS) and advanced cardiac life support (ACLS) g. Treating dysrhythmias and conduction disturbances h. Use of external temporary pacemakers i. Management of acute myocardial infarction, postinfarction care, and complications j. Treatment of Acute congestive heart failure k. Treatment of hypertensive emergencies/urgencies l. Risk management Medical Knowledge Residents must demonstrate knowledge about established and evolving biomedical,clinical,and cognate sciences and the application of this knowledge to patient care. Residents are expected to demonstrate an investigatory an analytic thinking approach to clinical situations and know and apply the basic and clinically supportive sciences in cardiology including: A. Normal cardiovascular anatomy and physiology B. Changes in cardiovascular physiology with age and pregnancy C. Risk factors
  3. 3. 1. Coronary artery disease a. Hyperlipidemia b. Cigarette smoking c. Genetic predisposition d. Sedentary life style e. Hypertension f. Diabetes mellitus g. Obesity h. Nutrition i. Hormonal status j. Emotional stress 2. Valvular heart disease D. 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 E. 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 catheter b. Bedside hemodynamic monitoring using balloon flotation catheter 5. Electrophysiologic studies 6. Indications and contraindications of therapeutic interventions a. Coronary artery bypass b. Angioplasty techniques and stent placement c. Pacemaker insertion d. Valve replacement/repair, percutaneous balloon valvotomy e. Electrophysiologic ablation F. Relevant laboratory interpretation, including serum enzymes, isoenzymes and lipids G. Specific diseases/conditions 1. Coronary artery disease a. Stable/unstable angina b. Myocardial infarction, with and without complications 1. Cardiogenic shock 2. Dysrhythmias 3. Papillary muscle dysfunction and rupture
  4. 4. 4. Ventricular rupture 5. Aneurysm c. Sudden death 2. Syncope 3. Dysrhythmias a. Tachyarrhythmia 1. Supraventricular 2. Ventricular 3. Reentrant b. Bradyarrhythmia c. Ectopy 1. Atrial 2. Ventricular 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 shunts (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 13. Cardiomyopathies a. Congestive (dilated) b. Restrictive c. Hypertrophic cardiomyopathy d. postpartum 14. Pericardial disease 15. Infection-related
  5. 5. a. Viral myocarditis b. Subacute bacterial endocarditis c. Kawasaki’s disease 16. Other cardiac disorders a. Immunologic 1. Acute rheumatic fever 2. Autoimmune disorders b. Psychogenic c. Traumatic d. Nutritional e. Myxoma f. Thyroid dysfunction g. Marfan syndrome h. Drug-related such as cocaine, steroids and chemotherapeutic agents 17. Evaluation of cardiac patient for noncardiac surgery a. Cardiac risk including preoperative assessment tools b. Preoperative and postoperative management 18. Antibiotic prophylaxis for valvular disease H. Cardiovascular pharmacology Practice-based Learning and Improvement Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to use self-directed learning to further knowledge and competence in neurology by: A. analyze practice experience and perform practice-based improvement activities using a systematic methodology B. Locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems C. Obtain and use information about their own population of patients and the larger population from which their patients are drawn D. Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness E. Use information technology to manage information, access on-line medical information; and support their education F. Facilitate the learning of students and other health care professionals Interpersonal and Communication Skills
  6. 6. Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates. Residents are expected to: A. Create and sustain a therapeutic and ethically sound relationship with patients B. Use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills C. Work effectively with others as a member or leader of a health care team or other professional group Professionalism Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to: A. Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitments to excellence and on-going development B. Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices C. Demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities Systems-Based Practice Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to: A. Understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice B. Know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources C. Practice cost-effective health care and resource allocation that does not compromise quality of care D. Advocate for quality patient care and assist patients in dealing with system complexities a. Support of individual and family through consultation, evaluation, treatment and rehabilitation.
  7. 7. B. Know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance 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 goal 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 intracardiac 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. Wagner GS, Marriott, HJ. Marriott's Practical Electrocardiography 9th ed. Williams & Wilkins, 1994. 2. Heger JW, Niemann JT, Criley JM. Cardiology for the House Officer 4th ed. Williams & Wilkins, 1998. 3. Schlant RC, Alexander RW, eds. The Heart, Arteries and Veins 9th ed. New York: McGraw-Hill, 1998. 4. Braunwald E, ed. Heart Disease: A Textbook of Cardiovascular Medicine 6th ed. Philadelphia: Saunders, 2001. Web Resources 1. Cardiovascular medicine websites: 2. American College of Cardiology: Centers for Disease Control and Prevention: Adapted from AAFP and ACGME 2002 Published 7/80 Revised 7/88 Revised 7/95
  8. 8. Revised and Retitled 9/95 Revised for review: 1-25-01 Curriculum Guidelines Index | AAFP Home Page | Search