4/4/06njm

**Cardiology Topics for Primary Care Providers**

** **

-   Moderator: James M. Galloway, MD, FACP, FACC\
    Director, Native American Cardiology Program

We have had a wonderful exchange regarding the priorities of
cardiovascular care in a patient with atypical symptoms, unclear
medications, a questionable history and a missing vital piece of
history.\* The most important immediate component of the history that
had been left out of the scenario was the patient\'s current pain
status.

This is essential in determining the need for immediate admission or
transport, testing and observation. For instance if he is having chest
pain at the time of evaluation or, say, less than 8 hours prior to
arrival (regardless of the presence or absence of current ECG changes),
your approach, including the assessment of enzymes, would be
substantially different than if his last episode was a month ago or
more. 

We discussed the limitations of negative enzymes when performed within
eight to 12 hours from the onset of chest pain, the importance of an
immediate and repeated ECGs (particularly if the first is
negative/normal), medical intervention with aspirin and, if Acute
Coronary Syndrome is indeed present, beta blockers and BP control with
ACE-I and the preventive role of statins in the long term therapy If
without contraindications.** **

 

We then discussed the opportunities to improve the quality of
cardiovascular care and prevention at our local sites. Dr. Chad Thompson
shared standardized inpatient orders he created for all to use or modify
as needed.

 

The complete listing of guidelines from the AHA and the ACC on CV Care
and Prevention can be found at:
<http://www.acc.org/clinical/topic/topic.htm#H>

 

In addition, the IHS National Guidelines site offers cardiovascular best
practice resources, along with many other guidelines and resources
indexed alphabetically and sub-divided by organ system at:
<http://www.ihs.gov/NonMedicalPrograms/NC4/nc4-clinguid.cfm>

 

Dr Dekker had requested slides from the American Heart Association\'s
Epi Conference and those obtained from the speakers were shared with the
participants and placed at:

<http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#cardio>

 

The captured whole Discussion and multiple other Resources are here:

<http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#cardio>

Native American Cardiology Program  web page\
<http://www.ihs.gov/medicalprograms/cardiology/card/index.cfm>

I would like to take this opportunity to thank each of you for your
thoughts, wisdom and dedication to our underserved friends, family and
colleagues within Indian Health. I am proud to work with such a great
cadre of incredible clinicians and individuals\...All the best! 

Warm regards,\
Jim

**\* History:**

A 62 year old diabetic, hypertensive Navajo gentleman arrives in your
clinic waiting room and is ushered into your office. Through a
translator, he complains that, in addition to the fatigue he has been
feeling, the bloating feeling he gets with the blue pill and the right
knee pain that occurs when he works hard, he has also noticed an unusual
feeling in his lower chest at rest and with exertion, although at times
it may worsen with meals.

His answers related to precipitating factors and duration of episode
through a translator are confusing and seem to change with each time
asked. However, you have a sense that this has been going on 'for a
while' (probably months as best you can tell) and last somewhat less
than a day. He denies any pleuritic component to the pain and has never
had anything like this before.

His current meds include one 81 mg aspirin daily, metformin 500 twice
daily, lisinopril 20 daily. You look in the chart and he has an LDL of
108 and a HgbA1c of 8.0 and a current BP of 138/84.