The Challenge of Cardiac Diagnosis

Diagnosing and treating heart conditions presents a unique challenge for primary care physicians (PCPs). Initial symptoms of serious heart disease can often mimic less severe, temporary ailments.Adding to this complexity, PCPs typically manage multiple health concerns during brief patient visits.

Dr. Bimal Ashar, clinical director of General Internal Medicine at Johns Hopkins University School of Medicine, notes that patients may only disclose concerning symptoms, such as heart palpitations, at the end of their appointments. On their way out the door, they [patients] say, ‘I didn’t mention that I’m getting these heart palpitations every now and then — sometimes they’ll last for minutes,’ Ashar said.

Recognizing Subtle Signs of Heart Disease

Early symptoms of severe cardiac illnesses are frequently enough underestimated by patients and even fellow physicians. A common exmaple is dismissing persistent heartburn. As Dr. Ashar explains,As we age,we start to ignore more and more symptoms. ‘Yes, yeah, my back’s bothering me, but I’m now in my upper 50s, and you know that happens, right?’ That mentality can creep into other symptoms that may be a little bit more ominous.

PCPs must often identify cardiac disease signs that deviate from classic textbook descriptions.Most patients do not present with the typical crushing chest pain radiating to the left arm accompanied by shortness of breath.

Detecting Early Signs of Heart Failure

Recent studies from the United Kingdom and the United States, including analyses of the US Veterans Health management and Medicare advantage programs, highlight missed opportunities in detecting heart failure in primary care. Researchers advocate for increased use of brain natriuretic peptide (BNP) testing to improve diagnosis.

Staying current with evolving guidelines and recommendations for cardiac conditions, such as heart failure with preserved ejection fraction (HFpEF), poses a challenge for physicians. Newer tools, like the H2FPEF Score calculator, may also be unfamiliar to some.

Dr. Ashar emphasizes the importance of staying informed, stating, Staying current is getting to be more important, given that there are now specifically designed treatments that can help treat conditions like HFpEF. He also notes that PCPs should consider rarer diagnoses, such as cardiac amyloidosis, which can mimic HFpEF but has distinct clinical clues like low voltage on an ECG and a very high BNP level.

This may be less important to primary care providers who have easy access to cardiologists, but for those who don’t, a condition like cardiac amyloid can easily be missed. given advances in treatment, delays in diagnosis can be very consequential.

Dr. Bimal Ashar, Johns Hopkins University School of Medicine

Addressing Postpartum Hypertension: A Critical Window

Postpartum hypertension frequently enough goes unnoticed due to limited medical visits after pregnancy. While insurers typically cover one postpartum visit around six weeks after birth, many women miss this appointment. A 2022 study revealed that only about 60% of new mothers attended a postpartum outpatient visit within eight weeks of hospital discharge. moreover, 30%-40% of patients with preexisting medical conditions did not attend a postpartum visit.

Dr. Scott Hartman, associate professor of family medicine at the University of Rochester Medical Center, emphasizes the long-term risks: Patients who have had any hypertensive disorder of pregnancy or postpartum are at higher risk of heart disease earlier in life.

Even when postpartum visits occur, hypertension can be overlooked as physicians address numerous other concerns. Resources like the Family Medicine Education Consortium’s IMPLICIT Network: the 4th Trimester Program, the American Academy of Family Physicians‘ toolkit on postpartum care, and the Million Hearts Hypertension in Pregnancy Change Package offer valuable support.

Increasing emphasis on inpatient-outpatient care handoffs and transitions and dialog between perinatal care and primary care clinicians offer important solutions to the prevention of hypertensive complications in the postpartum period.

Dr. Scott Hartman, University of Rochester Medical Center

Preventing Heart Disease: A Proactive Approach

Primary care plays a crucial role in preventing heart disease by helping patients develop healthy habits and identifying risk factors. Dr. Jennifer Buckley, chair of the Rhode Island Academy of Family Physicians, prioritizes discussions about patient health goals.

This approach allows patients to identify areas where they need support, such as nutrition, mental health, stress management, tobacco cessation, and exercise. I have found that this is something that has opened up the conversation in a way that is really patient-centered, because they can go anywhere with it, buckley said.

Dr. Buckley also uses resources like YouTube videos to demonstrate accessible fitness options, such as 10-minute high-intensity interval training, seated strength training, or yoga. I’ll say, ‘Let’s watch this together.Look what this person is doing. You can do this in your home.’ You have to figure out what is critically important for your patient at that point in time and then help them to develop a plan to achieve it, she explained.