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Cardiology/Cardiovasc paged

  1. 1. Cardiology/cardiovascular medicine i Description of the specialty and clinical needs of patients The subject of cardiology focuses on the wide range of disorders that can affect the structure and function of the heart itself. The term cardiovascular medicine is also frequently used, recognising the functional inter-relationship between the heart, systemic arterial and venous systems, and the vascular supply to the lungs. The process of atherosclerosis and the extremely important risk factor of diabetes mellitus commonly have significant adverse effects on organs and systems other than the heart. The concept of cardiovascular medicine, therefore, reflects the broad overall training and clinical attitudes that are required of a cardiologist. Recent developments have emphasised the importance of subspecialties within cardiology: ❚ Percutaneous coronary intervention (PCI) is a developing method of restoring an adequate arterial blood supply to ischaemia myocardium without recourse to coronary artery surgery. ❚ In the field of electrophysiology, the advent of implantable defibrillators, together with advances in invasive techniques for ablating atrial and ventricular arrhythmias, have led to therapeutic advances for patients with rhythm disorders. ❚ The selection of appropriate treatment for patients with heart failure has expanded considerably over the past five years. The National Institute for Clinical Excellence (NICE) has clarified the appropriate drug therapy for such patients and developments in pacing offer the possibility of improving the quality of life of patients with cardiac failure. ❚ The increasingly specialist needs of adult patients with congenital heart disease are now well recognised in cardiological circles. Units for providing both lifestyle and specialist cardiac advice to this group of patients are being established across the UK. ❚ Developments in non-invasive imaging continue to influence the way in which cardiac patients are investigated. Magnetic resonance imaging (MRI), echocardiography (ECHG) and radionuclide scanning are key components of the management of patients with cardiovascular disorders. General cardiology involves the care of many patients admitted on acute medical take with a broad range of disorders. Increasingly, patients require appropriate referral to cardiologists who have a subspecialty interest. ii Organisation of the service and patterns of referral Primary, secondary and tertiary levels Primary care Many cardiovascular disorders can be managed effectively with good cooperation between primary and secondary care. Recent development of rapid-access chest pain clinics and heart failure clinics provide examples of improvement in the management of patients who may be presenting with the first symptom of coronary heart disease, or in whom the diagnosis and treatment of heart failure needs to be established. Both primary and secondary prevention of coronary disease are important responsibilities in primary care. Symptoms of relatively minor disorders of cardiac rhythm, often presenting as palpitations, are a frequent reason for consultations 65
  2. 2. CONSULTANT PHYSICIANS WORKING WITH PATIENTS in general practice. In some primary care trusts (PCTs) there are no specific arrangements for appropriate management of the many patients who present with atrial fibrillation. Increasingly, primary care will follow up patients who have been seen and treated in secondary and tertiary care. The appropriate clinical management of patients with prosthetic heart valves and implanted electrophysiological devices will need to be communicated to the primary care setting. Training programmes for general practitioners with a special interest (GPSIs) in cardiology are likely to make a useful contribution to the primary/secondary care interface. Secondary care In recent years there has been striking success in ever more sophisticated cardiac diagnosis and therapy in district general hospitals (DGHs). This trend has been facilitated by a greater number of consultant cardiologists working in DGHs and by improved access to non- invasive investigations such as exercise tests, radionuclide scans, ECHG and non-invasive electrophysiological testing. The biggest change diagnostically lies in the increased numbers of cardiac catheterisation laboratories which are now located in DGHs. This not only saves patients from travelling to tertiary centres for coronary angiography (now a routine but invasive investigation), but also facilitates timely diagnosis for the large number of patients admitted to hospital with chest pain syndromes. Routine permanent pacing procedures are increasingly carried out in a DGH. This is an obvious benefit to elderly patients and will reduce the number of temporary pacing procedures that need to be performed. Future developments are likely to occur in the fields of PCI and electrophysiology. It seems likely that more interventional procedures will be performed in DGHs without on-site surgical cover. Similarly, patients who require an implantable defibrillator are likely to be managed in the DGH rather than a tertiary centre. Tertiary care After appropriate triage, many patients require and benefit from the subspecialty services available in tertiary centres. These include: ❚ PCI with on-site surgical cover ❚ coronary artery and valve surgery after appropriate liaison with cardiac surgeons ❚ adult congenital heart disease centres with appropriate support from specialists in cardiac imaging ❚ cardiac surgery ❚ invasive electrophysiology ❚ non-invasive imaging including cardiac MRI and sophisticated ECHG and radionuclide techniques. Most tertiary centres make significant contributions to research and development in both clinical and basic science disciplines. Clinical networks and community arrangements Cardiac networks are now established in most parts of the UK and play a vital role in coordination of primary, secondary and tertiary care. Networks typically serve a number of PCTs, secondary care trusts and one or two tertiary providers. Longer-term strategic decisions (for example concerning revascularisation or imaging strategies) should be developed within the structure of the network. Taking into account patients’ views from a number of sources, cardiac networks should ensure the success of the entire patient journey, focusing particularly on areas of interface between primary, 66
  3. 3. PART 2 ■ Cardiology/cardiovascular medicine secondary and tertiary care. Networks will also be involved in regular audit activity against national service framework (NSF) standards and will promote equity of access to healthcare within their sectors. Cardiac networks usually work closely with the coronary heart disease (CHD) collaborative to support innovation and sharing of practice and experience. Relationship with other services/agencies The changes in the pattern of delivery of cardiological care indicated above will, in an era of consultant appraisal and revalidation, inevitably affect the configuration of consultant cardiology posts. In particular, the relationship with general internal medicine (GIM) is likely to change. The professional demands on both interventional cardiologists and invasive electrophysiologists will be substantial in terms of maintaining clinical competencies (performing procedures) and keeping up to date with new developments in these highly technical specialties. Professionally, it is not possible for such consultants to maintain competency across the breadth of GIM. In the past, these competing competencies have not caused planning difficulties since the majority of such specialised cardiology posts have been located in tertiary care. In future, with the increased availability of cardiac catheterisation laboratories in secondary care (DGHs), pressure may come for interventional cardiologists to undertake general medical duties. In general, such pressures should be resisted. Cardiologists will have a close interest in acute medicine where the triage and treatment of acutely ill medical patients fall within the natural competency of a fully trained cardiologist. Furthermore, the appropriate management of patients with acute coronary syndromes, including acute myocardial infarction (MI), will increasingly fall exclusively within the remit of cardiologists in hospitals, particularly where there are on-site cardiac catheterisation facilities. The focus of cardiology input into acute medicine will tend to change from a general unselected on- call structure towards managing the large number of acute cardiology patients on the coronary care unit (CCU) or acute medical wards. These patients should be seen on a daily basis by a cardiologist. In such circumstances, responsibility for both acute medicine and interventional cardiology may be possible, but the much broader range of competencies required for the ongoing care of patients with general medical problems will not be compatible with maintaining competency in coronary intervention or invasive electrophysiology. By contrast, cardiologists with special training in heart failure, non-invasive imaging or adult congenital heart disease are likely to continue to make a substantial contribution to a general cardiology on-call service in addition to a subspecialty on-call commitment. iii Working with patients: patient-centred care Patient choice and involving patients in decisions about their treatment The majority of patients in clinical cardiovascular medicine do have symptoms but some have no active symptoms and require prophylactic drug or procedural therapy. In either case, following appropriate investigations patients will be advised by their consultant cardiologist about the options for treatment. All drug therapy including preventative therapy for coronary disease – antiplatelet agents, lipid- lowering drugs, antihypertensive agents, and anti-arrhythmic drug therapy or long-term treatment with anticoagulants – should always be discussed in detail with the patient. Indications for drug 67
  4. 4. CONSULTANT PHYSICIANS WORKING WITH PATIENTS therapy, including benefits and possible adverse reactions, should be understood by each patient. The rationale for invasive investigations, treatment with devices or cardiac surgery should always be discussed as part of the procedure for obtaining informed consent. In a minority of instances, the cardiologist will give a clear recommendation, which will be expected to substantially improve longevity or avoid a major risk of sudden death. In the majority of cases two or more options for therapy will usually be presented to the patient. The involvement of close relatives or carers facilitates discussion with the patient. Such discussions may involve relatively complex technical concepts. Booklets are available from both the British Heart Foundation (BHF) and the British Cardiac Society (BCS) to facilitate patient understanding. Ethnic and religious considerations should be addressed, for example when guidance on fasting might interfere with life-saving drug administration or when the administration of blood products is of relevance to invasive or surgical procedures. Opportunities for education and promoting self-care Effective, structured patient education is the key to long-term compliance with therapy. Education about cardiovascular disease is essential since patients with cardiac disorders may have healthcare beliefs that do not accurately relate to their individual cardiovascular pathology. Cardiac education should always be a central component of cardiac rehabilitation programmes. The most effective education programmes involve collaboration between cardiologists, nurses and other healthcare professions such as dietitians and physiotherapists. Lifestyle issues, with regard to primary and secondary prevention of coronary disease and the inter-relation between diabetes and vascular disease, are a key focus of patient education programmes. Patients with chronic conditions Patients with heart failure, hypertension or a pacemaker benefit from the continuity of care delivered by specialist clinics where cardiologists work in partnership with specifically trained nursing or technical staff. Arrangements for monitoring long-term treatment with anticoagulants such as warfarin can be successfully devolved to primary care. The role of the carer The carer for a patient with a cardiovascular disorder has a vital role. Carers provide emotional and intellectual support when patients are confronted with life-threatening decisions, support lifestyle changes and ensure the safe administration of long-term drug therapy. Most cardiovascular consultations are facilitated by the presence of a carer. Access to information, patient support groups and the role of the expert patient The most common source of information for patients is the Internet. Cardiologists should be accustomed to discussing developments in clinical care and research findings with patients who have accessed such material on the web. Both the BCS and the BHF have a series of patient-focused leaflets which provide information about cardiac investigations and treatment. 68
  5. 5. PART 2 ■ Cardiology/cardiovascular medicine Patient support groups, generally organised locally, have been a feature of cardiology for many years. The BCS has set up Heart Health Partnership UK (HHPUK), a national affiliation between local groups, and has links with the British Cardiac Patients Association. The BCS is currently collecting a database of patients who will advise them as expert patients. Availability of clinical records/results The availability of the results of clinical investigations is central to the effective management of patients with cardiac disorders. Liaison with primary care in a timely and accurate way enables effective preventative measures to be delivered. The timely availability of results for cardiac surgeons or other cardiological subspecialists is essential for a high quality clinical service. The availability of image servers to handle digitally the large amount of information contained in coronary angiograms has largely overcome the problems associated with storage and retrieval of film and CD angiographic images. iv Interspecialty and interdisciplinary liaison Multidisciplinary team working For many years cardiology has relied on multidisciplinary working with cardiac nurses, cardiac technicians and radiographers on an everyday basis. Pharmacists, physiotherapists and dietitians also contribute to the management of patients with cardiac disorders. Working with other specialists Cardiologists work closely not only with subspecialists within their own field but also with cardiac surgeons, general and acute physicians. The ability to work effectively with other specialists is an essential attribute for consultant cardiologists. Working with GP specialists The College and the BCS welcome the opportunity of developing the concept of GPSIs in cardiology. Such practitioners could make a very useful and effective contribution to meeting the demands of high quality cardiovascular care. This exciting new development will only be successful if it is linked to an effective training programme with a national curriculum and standard of assessment, and to a programme of continuing professional development (CPD) for the GP specialist. v Delivering a high quality service Characteristics of a high quality service ❚ accurate transfer of information, especially given the nature of many cardiac disorders ❚ patient access to both general cardiology and specialist cardiology in a timely manner, and before irreversible adverse outcomes such as myocardial infarction or sudden death occurs ❚ high quality IT and excellent secretarial services, particularly IT developments such as the electronic patient record ❚ efficient access and referral for cardiac surgery ❚ appropriate coordination of care for children and adults with both simple and complex congenital heart disease. 69
  6. 6. CONSULTANT PHYSICIANS WORKING WITH PATIENTS Resources required for a high quality service Specialised facilities ❚ PCI for both acute and chronic presentations of coronary artery disease ❚ non-invasive imaging techniques such as ECHG, cardiac MR, isotope scanning and spiral CT scanning ❚ resynchronisation therapy and transplantation for management of patients with advanced heart failure ❚ interventional electrophysiology and implantation of cardiac defibrillators. Provision of resources for the above needs to balance ease of geographical access for patients with high quality subspecialised investigation and treatment. Both human and technological resources need to be used in a cost-effective manner. vi Quality standards and measures of the quality of specialist services Specialist society guidelines The specialty advisory committee (SAC) in cardiology has developed a competency-based curriculum and is involved in the project to develop new methods of clinical assessment. The SAC and affiliated groups: the British Cardiovascular Intervention Society (BCIS), the British Pacing Electrophysiology Group (BPEG), the British Paediatric Cardiac Association (BPCA) and the British Society for Echocardiography (BSE), are all working to develop competency-based standards and measures of quality. The SAC and the education department of the College will be assisting these groups in developing methods based on modern standards. National Institute for Clinical Excellence (NICE) guidelines The College and the BCS have worked with NICE to develop a number of policies relevant to cardiology. Existing and imminent guidance covers: ❚ IIb IIIa inhibitors ❚ use of intracoronary stents ❚ drug-eluting stents ❚ treatment of heart failure ❚ use of clopidogrel in patients with acute coronary syndromes ❚ interventions in cardiology other than PCI, for example alcohol ablation for septal hypertrophy and valvuloplasty ❚ myocardial perfusion scintigraphy for the diagnosis and management of angina and MI ❚ smoking cessation ❚ MI early thrombolysis ❚ dual-chamber pacing ❚ clopiodgrel and dipyridamole in the prevention of occlusive vascular events ❚ implantable cardioverter defibrillators for the treatment of arrhythmias. Current NICE guideline documents will all be reviewed, and the College and BCS will contribute to those reviews. In addition, an ongoing programme is considering new areas of cardiology that will require a report from NICE ( 70
  7. 7. PART 2 ■ Cardiology/cardiovascular medicine Clinical governance Cardiology has been the vanguard of developing clinical governance at both national and local levels. The central cardiac audit database collects sufficient patient information to permit adjusted comparisons of clinical care. To obtain full benefit from the national programme requires quality IT to be installed in all cardiac centres. The Clinical Effectiveness and Evaluation Unit (CEEu) of the College has worked with the BCS in developing the Myocardial Infarction National Audit Project (MINAP), which is generally perceived to have improved the timing and quality of drug prescribing for patients with acute MI. CLINICAL WORK AND/OR LABORATORY WORK OF CONSULTANTS IN CARDIOLOGY Contributions made to acute medicine Cardiology welcomes the advent of the concept of acute medicine. Currently, most cardiologists will be involved either in a general medicine acute take rota or will be part of a cardiology on-take service. Based in a DGH, the cardiologist’s role usually focuses on patients within the CCU and its associated ‘step down’ clinical care area. Growing evidence in the literature documents the benefits of PCI as optimal treatment for patients with ST segment-elevation MI and early revascularisation for non-ST segment-elevation MI or unstable angina. The direction for cardiology will undoubtedly be to focus attention in the A&E department and medical acute admissions unit. In this context, the cardiology service will become an integral part of the overall pattern of delivering acute medical care. Direct clinical care Three patterns of direct patient care are recognised within cardiology: ❚ Consultants based entirely in a DGH This may be with or without access to on-site invasive cardiology (cardiac catheter lab). Consultants will often, though not necessarily, be involved in acute general medical takes. They will deliver a cardiological consultation service to the hospital and provide advice to general physicians, surgeons and obstetricians will form a considerable part of their workload. Consultant attendance on CCU ward rounds will be the norm with each consultant leading, on average, two CCU ward rounds per week. ❚ Consultants based both in a DGH and in a tertiary centre These consultants are less likely than those in the first category to be involved in general medical takes. The development of acute medicine is welcomed by cardiology because of the high incidence of patients with acute coronary syndromes in A&E and on medical admission units. Cardiologists with a particular interest in PCI will wish to work with the acute medical team. Other cardiologists will bring their expertise in electrophysiology, adult congenital heart disease, non-invasive imaging or management of heart failure to patients whose care is delivered in the tertiary care setting. ❚ Consultants located geographically entirely within tertiary centres A relatively small number of cardiologists are in this category. Work is focused on the subspecialty interest outlined above. Other specialist activity including activities beyond the local services Besides a role in general cardiology and acute medicine, most cardiologists will be expected to develop an area of special interest. These areas of interest have been outlined in the introduction to this paper. Consultants would be expected to provide evidence of the quality of such special interests, for example through the appraisal process, continuing medical education (CME) 71
  8. 8. CONSULTANT PHYSICIANS WORKING WITH PATIENTS attendance, membership and contribution to the affiliated groups of the BCS. Attendance at regional, national and international meetings would be expected. Clinically related administration Contributing to local networks, patient pathways, and working in a multidisciplinary environment to develop healthcare delivery, all form part of the clinical duties of a cardiologist. Active liaison with cardiac surgeons, general and acute physicians, primary care and cardiological subspecialists is necessary for the delivery of the highest quality care to individual patients. Work to maintain and improve the quality of care This work encompasses duties in clinical governance, professional self-regulation, CPD and education and training of others. For many consultants at various times in their careers it may include research, serving in management and providing specialist advice at local, regional and national levels. Leadership role and the introduction of service developments Service developments within cardiology invariably require multidisciplinary working, for example with cardiac technicians, specialist cardiac nurses or clinical managers. Cardiologists continue to have a leadership role within the field of service development and consequently need to maintain their team-working and leadership skills. Cardiologists work with local management to develop integrated care pathways and to implement NICE guidelines in routine clinical care. The entire patient journey from GP referral to completion of cardiac care, and equity of access for patients are key objectives within cardiovascular medicine. Education and training Because cardiovascular disease is the most common cause of death and highly prevalent in the population, education and training are essential at all levels, from patients to undergraduates, house officers, senior house officers (SHOs) and specialist registrars (SpRs). The SpR training programme is curriculum driven and competency based. There has been a substantial increase in the number of SpRs in cardiology and most consultant cardiologists will be involved in training SpRs, as organised by specialty training committees in the relevant deaneries. Formal training programmes are organised by the BCS where one day a year is given specifically to SpR training issues, plus locally organised training days. Mentoring and appraisal of medical staff and other professional staff Appraisal and assessment of SpRs is an increasing responsibility for the consultant cardiologist. Mentoring for professionals allied to medicine (PAMs) will help to develop a highly skilled clinically competent group of healthcare workers who will contribute to the delivery of high quality cardiovascular care. Continuing medical education Cardiologists’ CME is regulated by the Federation of the Royal Colleges of Physicians. The BCS, through its annual scientific meeting and the Education in Heart series, provide CME, now accredited by the European Board for Accreditation in Cardiology (EBAC). 72
  9. 9. PART 2 ■ Cardiology/cardiovascular medicine Research – clinical studies and basic science The British Society for Cardiovascular Research (BSCR) and the British Atherosclerosis Society are affiliated groups of the BCS and both recognise the importance of basic science. Nationally, research is supported by the BHF at clinical and basic science levels through project and programme grants, chairs, senior fellows, intermediate fellows and junior fellows. The medical director of the BHF is a member of the BCS council. Consultant cardiologists are encouraged, either individually or in collaboration with their full-time academic colleagues, to conduct high quality cardiovascular research. Regional and national work All deaneries have specialist training committees in cardiology comprising consultant cardiologists, educational supervisors and SpR representatives. The BCS encourages the involvement of all consultant cardiologists and a new system of regional representatives has been set up. The society is run on a day-to-day basis by the president, president elect, secretary, assistant secretary, treasurer and chair of the programme committee. Affiliated groups address the subspecialist areas of ECHG, heart failure, intervention, nuclear medicine, pacing/electrophysiology, primary care, rehabilitation, technology (cardiac technicians), training and nursing. The College has a system of regional representatives in place who will also act as regional representatives for the BCS. The SAC deals with all issues with regard to SpR training and the curriculum. The joint specialty committee provides the link between the College and the BCS. There are a number of Department of Health (DH) working parties advising on manpower, PCI for acute infarction and academic medicine. Current workforce numbers are: ❚ approximately 700 WTE consultant cardiologists ❚ 411 SpRs in cardiology. The BCS cardiac workforce working group has made detailed recommendations for future service provision.1 ACADEMIC MEDICINE The duties, responsibilities and areas of work of academic physicians The duties and responsibilities of academic cardiologists are diverse. They range from a substantial focus on basic science research in the areas of atherosclerosis, heart failure, cardiomyopathy and electrophysiology, to clinical science, leading clinical trials relating to risk assessment and treatment for patients with conditions as varied as acute coronary syndromes or heart failure. Clinical contribution to NHS Clinically based academic cardiologists make important contributions to the NHS in terms of the organisation and delivery of both healthcare and training programmes. 73
  10. 10. CONSULTANT PHYSICIANS WORKING WITH PATIENTS Teaching The commitment of any individual academic will depend on his or her research interest; both undergraduate and postgraduate teaching are growing areas of responsibility for academic cardiologists. In general, these responsibilities are shared with NHS consultant colleagues. Research The BHF provides major financial support in terms of endowed chairs and project and programme grants. The system of junior BHF fellowship provides a valuable link between NHS training programmes and academic cardiology. WORKFORCE REQUIREMENTS FOR CARDIOLOGY Current workforce numbers There are currently approximately 700 WTE consultant cardiologists in the UK. Number of consultants required to provide a specialist service to a population of 250,000 The fifth joint report on the provision of services for patients with cardiac disorders by the BCS and the College recommended that there should be one cardiologist per 50,000 head of population and therefore five cardiologists for a population of 250,000.2 National consultant workforce requirements A target of at least 1,500 cardiologists is the figure recommended by the 2002 joint report. This estimate includes work in acute medicine but does not include a desirable increase in the number of academic cardiology units, or take into account the development of emergency angioplasty in the future. This target of 1,500 cardiologists is achievable and would equate to 7.7 WTE consultant cardiologists per 250,000 population. The BCS workforce planning group has estimated the number of cardiologists required and the number of subspecialists. The report is available at The increases projected in the recommendations are clearly not achievable in the short term. CONSULTANT WORK PROGRAMME/SPECIMEN JOB PLAN Consultant cardiologists work in a variety of different clinical settings and possess a wide range of clinical skills. The following job plan can be regarded as general advice. Some cardiologists work predominantly in outpatients; some have general responsibilities for inpatients and some are procedure based, for example interventionalists or electrophysiologists. 74
  11. 11. PART 2 ■ Cardiology/cardiovascular medicine Programmed activities Activity Workload (PAs) Direct clinical care Within the team of cardiologists, any individual would expect to devote 7.5 PAs on average to a selection of these activities. CCU ward rounds 0.5–1 Inpatient care plus referrals 1–2 Outpatient work 2–3 Specialised investigative or therapeutic clinical duties 2–6 Clinical administration (eg liaison with referring sources and on-ward referral for intervention or cardiac surgery; administration of waiting lists; working with nurse practitioners; writing reports/case summaries) 1 Total number of direct clinical care PAs 7.5 on average Supporting professional activities (SPA) Work to maintain and improve Education and training, appraisal, 2.5 on average the quality of healthcare departmental management and service development, audit and clinical governance, CPD and revalidation, research Other NHS responsibilities eg medical director/clinical director/lead Local agreement consultant in specialty/clinical tutor with trust External duties eg work for deaneries/Royal Colleges/specialist Local agreement societies/Department of Health or other with trust government bodies etc A team of cardiologists will need to address the issues of: ❚ lead clinician ❚ audit ❚ delivery of higher specialist training ❚ general management ❚ clinical governance and risk management ❚ regional and national work: a) postgraduate deanery with the specialty training committees b) BCS and affiliated groups – intervention electrophysiology, heart failure etc (see Clinical work and/or laboratory work of consultants in cardiology) c) manpower, education, clinical practice, programme committee for annual scientific conference and council committees d) Royal College of Physicians – SAC, joint specialty committee, CME ❚ membership of national subspecialty groups promoting quality issues in clinical care ❚ IT for collecting reliable data in relation to clinical activities ❚ cardiac networks. 75
  12. 12. CONSULTANT PHYSICIANS WORKING WITH PATIENTS References 1. British Cardiac Society. Cardiac workforce requirements in the UK, April 2004. 2. Fifth report on the provision of services for patients with heart disease. Heart 2002;88(Suppl 3):iii1–56. 76