Can most “specialist” cardiac investigations be done in primary care? Steve Leslie Consultant Cardiologist (NHS Highland) ...
Palpitations <ul><li>Definition:  </li></ul><ul><li>‘ an awareness of ones heartbeat that is thought inappropriate to the ...
Causes <ul><li>Cardiac arrhythmia </li></ul><ul><ul><ul><li>Sinus tachycardia </li></ul></ul></ul><ul><ul><ul><li>Ectopics...
Diagnostic pathway <ul><li>History </li></ul><ul><li>Exercise induced </li></ul><ul><li>Associated syncope </li></ul><ul><...
History <ul><li>Frequency </li></ul><ul><li>Onset / offset characteristics </li></ul><ul><li>Perceived rate </li></ul><ul>...
History <ul><li>Past history </li></ul><ul><li>Drug history including OTC medicines </li></ul><ul><li>Decongestants (ephed...
Resting ECG <ul><li>Features to check </li></ul><ul><li>Sinus rhythm </li></ul><ul><li>PR interval </li></ul><ul><li>QRS d...
1. Normal ECG [email_address]
Brugada [email_address]
Wolff-Parkinson-White Syndrome [email_address]
Hypertrophic Cardiomyopathy [email_address]
Additional Investigations <ul><li>Capturing an ECG with symptoms </li></ul>
AV nodal re-entrant tachycardia P
Atrial Fibrillation
Holter monitoring (24hrs) Most of use if symptomatic during study  May detect asymptomatic abnormalities
Cardiomemo / King of Heart / Event recorder (patient activated device) Infrequent symptoms which have duration >few minute...
Implantable Loop Recorder REVEAL device Event recorder £75 (~£600 per device) Reveal £1500
Additional Investigations <ul><li>Structural abnormalities </li></ul><ul><li>Echocardiogram </li></ul><ul><li>Cardiac MRI ...
Issues for Highland patients <ul><li>Long distances </li></ul><ul><li>Long waits </li></ul><ul><li>Low risk patients </li>...
Direct Access Arrhythmia Monitoring Service <ul><li>29 month period </li></ul><ul><li>Referrals from GP ‘direct’ or ‘via c...
Results <ul><li>239 patients from 47 GP practices </li></ul><ul><li>Either direct (69%) or redirected (31%)  </li></ul><ul...
Outcomes <ul><li>230 (96%) returned to GP </li></ul><ul><li>42% negative / 54% positive </li></ul><ul><li>9 (4%) were refe...
Outcomes
Conclusions <ul><li>Malignant arrhythmias in low risk patients with palpitations are rare </li></ul><ul><li>Direct access ...
Follow-up <ul><li>639 ± 246 days (range 216 - 1119) </li></ul><ul><li>50 (21%) of the 239 patients had an outpatient appoi...
Conclusions <ul><li>Direct access seems effective </li></ul><ul><li>Waiting times remain an issue </li></ul><ul><li>Altern...
A tale of two hearts
2004 <ul><li>Attended GP (low risk) </li></ul><ul><li>Referred cardiology 3 months </li></ul><ul><li>Event recorder 7 mont...
2010 <ul><li>Attended GP (low risk) </li></ul><ul><li>Event recorder </li></ul><ul><li>Reassured </li></ul><ul><li>Total j...
Communication important <ul><li>Male 74 </li></ul><ul><li>Chest pain fatigue </li></ul><ul><li>Started bisoprolol – sympto...
Event recorders
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Palpitations Talk

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Palpitations Talk

  1. 1. Can most “specialist” cardiac investigations be done in primary care? Steve Leslie Consultant Cardiologist (NHS Highland) Arrhythmia monitoring
  2. 2. Palpitations <ul><li>Definition: </li></ul><ul><li>‘ an awareness of ones heartbeat that is thought inappropriate to the circumstances’ </li></ul>
  3. 3. Causes <ul><li>Cardiac arrhythmia </li></ul><ul><ul><ul><li>Sinus tachycardia </li></ul></ul></ul><ul><ul><ul><li>Ectopics (SVE’s / VPC’s) </li></ul></ul></ul><ul><ul><ul><li>SVT – AF / flutter </li></ul></ul></ul><ul><ul><ul><li>SVT – AVNRT / AVRT </li></ul></ul></ul><ul><ul><ul><li>VT </li></ul></ul></ul><ul><li>‘ Normal heart’ / ‘abnormal patient’ </li></ul>
  4. 4. Diagnostic pathway <ul><li>History </li></ul><ul><li>Exercise induced </li></ul><ul><li>Associated syncope </li></ul><ul><li>Chest pain </li></ul><ul><li>Family history of sudden cardiac death </li></ul><ul><li>Underlying structural heart disease </li></ul><ul><li>Examination </li></ul><ul><li>Resting ECG </li></ul><ul><li>ECG with symptoms </li></ul><ul><li>Additional investigations </li></ul>
  5. 5. History <ul><li>Frequency </li></ul><ul><li>Onset / offset characteristics </li></ul><ul><li>Perceived rate </li></ul><ul><li>Description of regularity </li></ul><ul><li>Duration </li></ul><ul><li>Associated symptoms </li></ul><ul><li>Aggravating / relieving factors </li></ul>
  6. 6. History <ul><li>Past history </li></ul><ul><li>Drug history including OTC medicines </li></ul><ul><li>Decongestants (ephedrine) </li></ul><ul><li>Alcohol </li></ul><ul><li>Cardio-active drugs (QT interval ?) </li></ul>
  7. 7. Resting ECG <ul><li>Features to check </li></ul><ul><li>Sinus rhythm </li></ul><ul><li>PR interval </li></ul><ul><li>QRS duration </li></ul><ul><li>ST segment shape (LVH/Brugada) </li></ul><ul><li>T waves (? Cardiomyopathy) </li></ul><ul><li>[email_address] </li></ul>
  8. 8. 1. Normal ECG [email_address]
  9. 9. Brugada [email_address]
  10. 10. Wolff-Parkinson-White Syndrome [email_address]
  11. 11. Hypertrophic Cardiomyopathy [email_address]
  12. 12. Additional Investigations <ul><li>Capturing an ECG with symptoms </li></ul>
  13. 13. AV nodal re-entrant tachycardia P
  14. 14. Atrial Fibrillation
  15. 15. Holter monitoring (24hrs) Most of use if symptomatic during study May detect asymptomatic abnormalities
  16. 16. Cardiomemo / King of Heart / Event recorder (patient activated device) Infrequent symptoms which have duration >few minutes and are reasonably tolerated
  17. 17. Implantable Loop Recorder REVEAL device Event recorder £75 (~£600 per device) Reveal £1500
  18. 18. Additional Investigations <ul><li>Structural abnormalities </li></ul><ul><li>Echocardiogram </li></ul><ul><li>Cardiac MRI </li></ul><ul><li>Exercise Tolerance Test </li></ul><ul><li>Cardiac Catheterisation / angiography </li></ul>
  19. 19. Issues for Highland patients <ul><li>Long distances </li></ul><ul><li>Long waits </li></ul><ul><li>Low risk patients </li></ul><ul><li>Direct access </li></ul><ul><li>Review </li></ul>
  20. 20. Direct Access Arrhythmia Monitoring Service <ul><li>29 month period </li></ul><ul><li>Referrals from GP ‘direct’ or ‘via consultant’ </li></ul><ul><li>Patients received ‘Holter’ or ‘event recorder’ </li></ul><ul><li>Negative / positive / malignant </li></ul>
  21. 21. Results <ul><li>239 patients from 47 GP practices </li></ul><ul><li>Either direct (69%) or redirected (31%) </li></ul><ul><li>Female (65%) </li></ul><ul><li>Age 55 (± 17) years </li></ul><ul><li>Event recorder (53%) Holter (47%) </li></ul>
  22. 22. Outcomes <ul><li>230 (96%) returned to GP </li></ul><ul><li>42% negative / 54% positive </li></ul><ul><li>9 (4%) were referred to consultant </li></ul><ul><li>3 discharge immediately </li></ul><ul><li>6 seen in clinic </li></ul>
  23. 23. Outcomes
  24. 24. Conclusions <ul><li>Malignant arrhythmias in low risk patients with palpitations are rare </li></ul><ul><li>Direct access seems effective at triage </li></ul><ul><li>May help address wider demand capacity issues </li></ul><ul><li>Safe? </li></ul>
  25. 25. Follow-up <ul><li>639 ± 246 days (range 216 - 1119) </li></ul><ul><li>50 (21%) of the 239 patients had an outpatient appointment following their arrhythmia monitoring. </li></ul><ul><li>19 of these were existing cardiology patients. </li></ul><ul><li>Of the remaining 31, 27 were returned to GP care following a single cardiology outpatient review. </li></ul>
  26. 26. Conclusions <ul><li>Direct access seems effective </li></ul><ul><li>Waiting times remain an issue </li></ul><ul><li>Alternative approaches could be considered in areas with remote populations. </li></ul>
  27. 27. A tale of two hearts
  28. 28. 2004 <ul><li>Attended GP (low risk) </li></ul><ul><li>Referred cardiology 3 months </li></ul><ul><li>Event recorder 7 months </li></ul><ul><li>Reassured </li></ul><ul><li>Total journal 10 months </li></ul>
  29. 29. 2010 <ul><li>Attended GP (low risk) </li></ul><ul><li>Event recorder </li></ul><ul><li>Reassured </li></ul><ul><li>Total journal 9 days </li></ul>
  30. 30. Communication important <ul><li>Male 74 </li></ul><ul><li>Chest pain fatigue </li></ul><ul><li>Started bisoprolol – symptomatic brady </li></ul><ul><li>GP cardiocall – SVT rate 150 </li></ul><ul><li>Consultant – flutter </li></ul><ul><li>Admit Lawson but arrange transfer for pacemaker if more bradycardic </li></ul>
  31. 31. Event recorders
  32. 32. Thank you
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