Cardiologists share tips on managing heart conditions in primary care

CVD has been the leading cause of death among Americans for the past decade, CDC data indicate, and this trend will likely continue amid the COVID-19 pandemic, experts said.

However, the high prevalence of CVD does not necessarily translate to widespread awareness of the condition among the primary care community, according to Francisco Lopez-Jimenez, MD, chair of the division of preventive cardiology at the Mayo Clinic.

For example, previous studies have reported that less than half (43%) of U.S. primary care physicians correctly diagnosed familial hypercholesterolemia among a cohort of patients with an LDL cholesterol level of 190 mg/dL or higher, and 42% of PCPs worldwide did not recognize that abdominal obesity, a form of normal-weight obesity, is a significant risk factor for CVD.

“Obviously, primary care physicians do a lot of work, and we appreciate that,” Lopez-Jimenez told Healio. “But there are a few things that we cardiologists wish could be done differently in primary care.”

Healio asked Lopez-Jimenez and Raj Khandwalla, MD, an assistant professor of cardiology at the Smidt Heart Institute at Cedars-Sinai Medical Center in Los Angeles, to provide insight on five CVD-related topics that PCPs can do more about.

CVD risk assessment

The assessment of chest pain and determining the degree of risk for CVD it causes is “one of the most difficult parts of cardiology in primary care,” Khandwalla told Healio.

The American Heart Association’s ASCVD Risk Score assesses patients’ 10-year risk for a major cardiovascular event.

“It is a useful tool to guide primary care physicians in determining a pretest probability of the likelihood of a patient having coronary disease,” Khandwalla said.

The 2021 American College of Cardiology/American Heart Association chest pain guideline is an excellent resource for primary care physicians, according to Khandwalla. It classifies chest pain into different categories: cardiac, possibly cardiac and non-cardiac. Cardiac chest pain tends to be described as central, pressure, squeezing, heaviness, tightness and exertional or stress related, whereas non-cardiac chest pain tends to be sharp, fleeting, pleuritic or positional, Khandwalla said.

“Coupling symptom quality with an ASCVD risk tool can help primary care physicians make a more accurate assessment of cardiovascular risk,” he said.

Together, these tools can help PCPs determine whether a patient needs to go to the emergency room, see a cardiologist, undergo a stress test or receive imaging, such as a coronary CT angiogram.

Familial hypercholesterolemia

One of the cardiovascular conditions that Lopez-Jimenez said PCPs can be more aware of is familial hypercholesterolemia. According to the Mayo Clinic, this is a genetic disorder that causes an individual’s total cholesterol to be much higher than the desirable cholesterol level of 200 mg/dL or lower.

Patients with the full genetic expression of familial hypercholesterolemia will have cholesterol levels of 400, 900, 800 and even 1,000 mg/dL, Lopez-Jimenez said.

“The problem is to identify those who only have just a partial expression of the gene,” he said. “In these patients, their cholesterol level is usually about 280 but is not necessarily extremely high to bring some obvious red flags.”

This problem is compounded by the high number of U.S. adults who have a non-genetic risk factor for above-normal cholesterol, such as obesity and following an unhealthy diet.

Therefore, anyone with high cholesterol should be asked to provide a thorough family medical history to help ascertain who has familial hypercholesterolemia, Lopez-Jimenez said. During this process, if the patient shares stories such as their “grandpa died of a heart attack at the age of 45 and two of their uncles died of a heart attack at the age of 50,” or if they have some unique findings in the physical examination, he recommended moving forward with a genetic test to ascertain if familial hypercholesterolemia is causing the high cholesterol.

In areas where genetic testing is not available or is difficult to get, PCPs can confirm if their patients have clinical manifestations of familial hypercholesterolemia, such as small white dots on their eyelids or irises and an Achilles tendon thicker than the normal 6 mm. These symptoms, along with high cholesterol, are other signs of familial hypercholesterolemia, and together with a high cholesterol and family history are usually enough to make the diagnosis, he said.

Heart failure with preserved ejection fraction

According to Lopez-Jimenez, some PCPs may not realize that some people with obesity, shortness of breath and low exercise tolerance may have heart failure with preserved ejection fraction.

A PCP “may think a patient who presents with such symptoms is simply out of shape or that those symptoms are due to being overweight, especially if testing has confirmed that the pumping function of the heart was normal,” Lopez-Jimenez said. Heart failure with normal pumping function, or so called with preserved ejection fraction, occurs when the organ cannot relax properly, he added, and this occurs more often than we think.

“An echocardiogram can determine if the heart failure is due to poor pumping function and may also show problems with the relaxing function, but the diagnosis of heart failure with normal pumping function is a clinical diagnosis and based on numerous clinical factors,” Lopez-Jimenez said.

Normal-weight obesity

Lopez-Jimenez said that some PCPs put too much stock in a patient having a “healthy” BMI. However, he warned that some patients may have normal-weight obesity, which is when “a patient has extra fat in general or in some parts of the body but their BMI is normal.” These patients “are at an increased risk for diabetes, metabolic syndrome, heart disease and dying from cardiovascular conditions,” he said.

A DEXA machine can diagnose normal-weight obesity, Lopez-Jimenez said, as can measuring a patient’s waist and hips with measuring tape. Unfortunately, DEXA’s measurements of body fat are not widely available nor are other methods to measure body fat. He explained that a simpler way to assess the patient is with a measuring tape. If the waist is bigger than the hips while BMI is less than 25, then the patient has normal-weight central obesity.

Role of stents in stable coronary disease

Khandwalla said the role of cardiac stents in stable coronary disease “is a very common misconception” among PCPs.

“The perception out there is that if you put a coronary stent in someone with stable chest pain or stable angina that you’re going to prevent heart attacks or prolong people’s life,” he continued. “Yet, we’ve had multiple studies now, including the ISCHEMIA trial, that demonstrated coronary revascularization, especially with [percutaneous coronary intervention], has not been shown to decrease endpoints of heart attack, death and death from cardiovascular cause.”

With that finding in mind, Khandwalla encouraged PCPs to monitor their patients’ symptoms, “especially if there is new chest pain or a decrease in exercise tolerance in people with previous MI and/or coronary stents or bypass surgery since they are still at risk for another event.”

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