Tips for PCPs on Addressing and Preventing Heart Disease

Diagnosing and treating cardiac ailments can be difficult for primary care clinicians, with initial symptoms of serious heart disease, at times, mimicking less serious and transient issues.

In addition, those in primary care are usually juggling to try and address several medical issues within fairly short visits. For instance, patients may only feel comfortable enough to share or recall troublesome symptoms in the final minutes of a routine visit, such as an annual physical, said Bimal Ashar, MD, clinical director of General Internal Medicine at Johns Hopkins University School of Medicine, Baltimore.

“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.

Consider the following recommendations on diagnosing and addressing cardiac illnesses in primary care settings.

Minimizing Symptoms of Heart Disease

Patients may unknowingly make light of early symptoms of severe cardiac illnesses. In fact, this can even happen amongst fellow physicians, Ashar said. There is a tendency to shrug off signs, such as a persistent feeling of heartburn.

“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?’” Ashar said. “That mentality can creep into other symptoms that may be a little bit more ominous.”

Primary care physicians (PCPs) are often called to detect signs of cardiac disease that fall outside of classic textbook definitions for it, such as crushing chest pain radiating to the left arm accompanied by shortness of breath, Ashar said. Most patients present with less clear signs, he said.

This is the case “especially when we think about heart disease in women,” Ashar said. “Women having heart attacks may not present with that crushing chest pain and shortness of breath. Instead, they may present with more atypical-like jaw pain, arm pain, and nausea.”

Spotting Early Signs of Heart Failure

Recent papers drawing from patient experience in the United Kingdom and the United States — including the US Veterans Health Administration and Medicare Advantage programs — have pointed to missed opportunities in detecting heart failure in primary care. Researchers, including Clare Taylor, PhD, of Oxford University, Oxford, England, have called for increasing use of the brain natriuretic peptide (BNP) testing to aid in diagnosis of heart failure in primary care settings.

Physicians are often faced with competing and emerging guidelines and recommendations about when to test and treat cardiac conditions, such as heart failure with preserved ejection fraction (HFpEF), Ashar said. Additionally, some physicians in their 50s and 60s may not be familiar with newer, helpful tools, such as the H2FPEF Score calculator, said Ashar.

It is difficult for PCPs to stay current on all symptoms and conditions they may see in the office and apply that knowledge effectively, especially when they may have only 20 minutes with a patient. “Staying current is getting to be more important, given that there are now specifically designed treatments that can help treat conditions like HFpEF,” Ashar said.

Another potential challenge for PCPs is considering diagnoses that were once thought to be quite rare, Ashar said. Cardiac amyloidosis may mimic HFpEF symptomatically, but there can be clinical clues — such as low voltage on an ECG and a very high BNP level — that may point to the former, Ashar said.

“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,” Ashar said. “Given advances in treatment, delays in diagnosis can be very consequential.”

Addressing Postpartum Hypertension

“Patients who have had any hypertensive disorder of pregnancy or postpartum are at higher risk of heart disease earlier in life,” said Scott Hartman, MD, associate professor of family medicine at the University of Rochester Medical Center, Rochester, New York. Hartman served as a co-author on the Centers for Disease Control and Prevention-commissioned Million Hearts Hypertension in Pregnancy Change Package, a toolkit for outpatient clinicians aimed at improving patient outcomes.

Yet, postpartum hypertension can often be missed due in part to limited medical visits following pregnancy.

Insurers tend to cover one postpartum visit to check on the health of new mothers, with these visits often occurring about 6 weeks after these women give birth. In too many cases, this visit is missed entirely. A 2022 study based on records of patients with commercial health insurance found that only about 60% of new mothers or birthing people had at least one postpartum outpatient visit within 8 weeks of hospital discharge. The study results — published in AJOG Global Reports — also showed that around 30%-40% of patients with preexisting medical morbidity did not attend a postpartum visit.

But even when these visits do happen, postpartum hypertension can be overlooked. 

At these visits, for example, patients may be reconnecting with their PCPs after seeing mostly their obstetricians or midwives. The physician already has a long list of issues to cover with a returning patient, including checking on their experience with the delivery, persisting pain, mental health, and possible issues with nursing.

The Family Medicine Education Consortium’s IMPLICIT Network: The 4th Trimester Program can help in ensuring postpartum hypertension diagnoses are not missed, Hartman said. The American Academy of Family Physicians also offers a toolkit on postpartum care, including hypertension. The Million Hearts Hypertension in Pregnancy Change Package offers a downloadable toolkit with resources for clinicians engaging in prenatal and postpartum care, as well.

“Increasing emphasis on inpatient-outpatient care handoffs and transitions and communication between perinatal care and primary care clinicians offer important solutions to the prevention of hypertensive complications in the postpartum period,” Hartman said.

Preventing Heart Disease

For primary care, one of the critical roles in protecting the heart is helping patients develop and maintain habits that prevent cardiac illnesses, as well as identifying factors that could put patients at higher risk, such as genetics.

Jennifer Buckley, MD, chair of the Rhode Island Academy of Family Physicians, Providence, Rhode Island, makes a point of asking patients to talk about their health goals, thus carving out time for these important conversations. This gives patients time during their visit to identify areas where they may need extra help, such as working on their nutrition, mental health and stress management, tobacco cessation, and body movement and exercise plans.

“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.

This approach also helps Buckley work with patients to come up with simple ways to improve their health. For example, she sometimes pulls up videos on YouTube to show patients 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,’” Buckley said. “You have to figure out what is important for your patient at that point in time and then help them to develop a plan to achieve it.”

Kerry Dooley Young is a freelance journalist who has reported on medical research and health policy for more than 25 years.