Palpitations Talk
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Transcript

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