If you work in general adult or family, internal, or hospital medicine, you are likely quite familiar with the management of cardiac patients. With problems like hypertension and dyslipidemia rampant in patients in the United States, and readily available guidelines through the American College of Cardiology and JNC 8, management of these conditions is likely a daily activity for you. But, what happens if you are brand new to the role, when you find something you aren’t comfortable managing, or just a problem about which you would like a specialist’s opinion?
Here are 3 easy steps to make sure you know what to do to consult cardiology like a pro!
Step #1 – Get your story together.
Accurate storytelling is a MUST when consulting cardiology. We need to understand the patient’s story in their words and use their experiences as examples to help stratify their level of illness. The note should include a clear and concise chief complaint, a detailed history of present illness, and up-to-date past medical/surgical histories. The medication list should be current, but it should also include any history of medications the patient has recently taken which may contribute to their cardiac story and accurate diagnosis. A full list of allergies/hypersensitivities is also essential. Since cardiac conditions are often genetically-linked, an accurate family history is also necessary. Having the patient keep a log of symptoms and any accompanying information (medication timing, situational occurrence) is also helpful. Ask yourself “do I have all the piece of the puzzle or is there anything I’m neglecting”.
Step #2 – Dig in before you punt.
Yep, you need to do your own homework. Have you checked any labs or trends? You should have baseline labs to include CBC, metabolic panel (to include renal and hepatic function tests), TSH, fasting lipid panel, and anything else you think pertinent to the condition or problem. What rhythm is the patient in? When was their last EKG? Is the patient’s atrial fibrillation and rate control poorly controlled? Check a TSH, and follow it up with further thyroid studies, if indicated. Does your patient report myalgias on a statin? How are their LFTs? Serum CK? Does your patient have any daily weight trends? What about a BNP for that patient in heart failure? A1c for that diabetic who has uncontrolled sugars and vague cardiac symptoms? It all is important. And the more you can put together, the easier it is to justify spending the cardiologist’ time and the patient’s money!
Step #3 – A picture is worth a thousand words.
There is almost certainly an imaging study to evaluate with cardiac dysfunction. What tests have you done prior to referral? You’ll want to have an EKG done and on file for review, preferably with labs done around the same timeframe.
Consider further rhythm testing. Do the patient’s symptoms happen multiple times a day? Consider a 24-to-48-hour Holter. Do they happen every couple of weeks or only monthly? Consider a 30-day event monitor. Are you concerned about the structure and pump of their heart from findings of a new murmur or vague dyspnea? Check a transthoracic (2D) echocardiogram as a baseline. What about their myocardial perfusion? If they are having chest pain with exertion or an anginal-equivalent such as dyspnea with exertion or significant otherwise-unexplainable fatigue, etc., consider a stress test. Do they have known coronary artery disease? Do their symptoms warrant a repeat stress test? Is their ejection fraction less than expected/normal? Again, consider a stress test.
A quick note on ordering stress tests:
Choosing a type of stress test can be difficult, but you should consider a few things, including the following factors: the patient’s ability to perform adequate exercise, their resting EKG (do they have a LBBB or ventricular pacing that will make EKG changes difficult to determine?), the clinical indication for performing the test (structural heart changes? Angina?), the patient’s body habitus (will the patient’s body habitus prevent visualization or interpretation of stress radionuclide myocardial perfusion imaging with SPECT or stress echocardiography?), and any history of prior coronary revascularization (consider testing that will localize ischemia, such as stress radionuclide myocardial perfusion imaging or stress echocardiography). Do you need evidence of viability? Documentation of myocardial scarring? Consider a cardiac MRI.
If you’ve checked off these boxes and prefer assistance managing your patient’s cardiac condition (or prefer a specialist’s opinion in ruling out a cardiac condition), then consider a referral to cardiology. Your thorough detective work can shave days off the evaluation process leaving your patient to benefit from prompt evaluation by cardiology. Also, you just might find you make some cardiology friends in the process of your workup!
-Elissa Russell, MSN, APRN, FNP-BC
Your friendly former Cardiology APRN