Cardiology referral guidance

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Cardiology referral guidance

  1. 1. Page 1 Draft Cardiology Referral Guidance NHS Hounslow v14 7/12/09 Contents Page 1. Notes 2 Sub specialties 2. Ischemic heart disease (angina/chest pain) 3 3. Heart Failure 6 4. Murmurs/Valve disease 9 5. Atrial Fibrillation 11 6. Arrhythmia/Palpitations/Irregular heart beat 18 7. Uncontrollable Syncope - suspected cardiac cause 20 8. Hypertension 22 9. Cardiomyopathy 24 10. Dyslipidemia 25 Supplementary information 11. Available resources (and referral forms) 28-39 Version details Version No. 14 For additional corrections, admissions or comments please Approved by Working Group email hounslowpbc@nhs.net Approval date 03/12/09 Review date
  2. 2. Page 2 Draft Cardiology Referral Guidance – NHS Hounslow v14 7/12/09 Cardiology Referral guidance for Primary Care clinicians This is intended to be a guide only. It is not exhaustive and appropriate clinical judgement should be used for individual cases. When referring to Cardiology, please provide information in accordance with the core required information fields of the referral letter [LINK TBC] with particular attention to the following sections: Past history: relevant family history, significant co-morbidity, CHD risks factors. Investigations: state whether the patient has had any cardiac investigations (and attach results if available): e.g. echo. You may wish to consider some tests before referral, some of which may be available at Heart of Hounslow. Please note, if you are concerned about your patient's condition and require urgent assessment it is not necessary to undertake routine tests unless this will significantly alter your referral decision. Suggested Referral Emergency admission likely to be appropriate All new referrals for the attention of a Cardiologist, (excluding referrals for Rapid Access Chest Pain Clinic or Heart Failure Assessment clinic) should be sent via the Referral Facilitation Service [NAME TBC] (except for 999 Emergency admissions) unless patient is under active or recent (≤12 months) management by a specific Suggested referral to Secondary Care Cardiologist Continue to manage in Primary Care if appropriate Note: All follow up appointments following inpatient stays in hospitals, for the same condition, should be arranged via secondary care and NOT booked by GPs
  3. 3. Page 3 Owner External resources Ischemic heart Version No 10 steps before you refer for Chest pain, link (British Institute of Cardiology, 2009). disease Approval Management of Stable Angina link (SIGN, 2007) Page 22. Cardiac Rehabilitation Guidance, link (SIGN, 2002). (angina/chest date National Collaborating Centre for Chronic Conditions. Type 2 diabetes: Review date national clinical guidelines for management in primary and Secondary Care pain) (update). London: Royal College of Physicians; 2008. Classification of Angina Severity According to the Canadian Cardiovascular Society, link, (Canadian Cardiovascular Society). Hounslow Primary Care resources What to consider in Primary Care before referring: Heart of Hounslow A detailed Clinical and Family History Heart of Hounslow for primary care investigations including Consider non cardiac reasons for chest pain - ECG, Ultrasound, X-Ray, Phlebotomy Establish the risk factors e.g. age (65>), sex (Men have a greater risk of premature heart disease than women), ethnicity (South Asians, African-Caribbean origin have - Anti Coagulation service a higher incidence), family history, lifestyle etc. West Middlesex Physical Examination (including but not limited to): Pulse rate and rhythm, BP, Direct access to ECG, ETT Presence/absence of murmurs, evidence of peripheral vascular disease, carotid bruits, signs/symptoms of thyroid disease For Richmond and Twickenham GP’s only– Teddington Memorial Hospital Investigations (including but not limited to): FBC, Fasting glucose, Fasting lipid profile, Thyroid function, resting 12 lead ECG, Biochem profile (renal function) - Direct access to ECG, ETT, ECG and Holter It is very important not to delay treatment, including risk factor management, while - Direct access ECHO clinic (f) provided by WMUH staff once a week- awaiting referral. Hammersmith and Charing Cross (Imperial) Initial treatment in Primary Care should include: Direct access to ECG at Hammersmith and Charing Cross Acute symptomatic relief with GTN Chelsea and Westminster (Imperial) Prophylactic treatment with beta-blocker followed by Dihydropyridine Calcium One stop clinic antagonist (Amlodipine) or, if beta-blocker contra-indicated, calcium antagonist (Diltiazem or Verapamil) followed by Isosorbide Mononitrate should be used. Ashford and St Peter’s Aspirin Direct access to ECG at Ashford Risk Factor management e.g. stopping smoking, weight loss, statin (reducing Ealing Hospital lipids to total chol <5 mmol), aspirin (if not contraindicated) Direct access ECG, ECHO, 24 hour ambulatory BP monitoring, Holter
  4. 4. Page 4 Most angina management is by the Notes patient’s GP CABG and angioplasty +/- stent reduce mortality and morbidity in unstable angina and acute MI, but in stable angina they Referral for angina is required for only improve morbidity if full medical treatment has failed (generally defined as two anti anginal medications at full Confirmation of diagnosis strengths Unstable angina (worsening (It is covered by QOF) pain and at rest) and suspected MI Referral Threshold Secondary care resource (other than Cardiology OP referrals): First presentation of If no previously documented Coronary Heart Disease: Angina/suspected angina Consider referral to Rapid Access Chest Pain Clinic (usually recommended if patient meets criteria). Locations: - West Middlesex - Ashford - Ealing - Hammersmith and Charing Cross (Imperial) - Chelsea and Westminster - For GPs in Richmond and Twickenham, there is an Outreach Clinic for chest pain at Teddington Memorial Hospital Criteria for referral to Rapid access chest pain clinic (West Middlesex)- (all must apply) 1.New onset of exertional angina symptoms within the past 6 weeks 2.Male > 30 or female > 40 except in exceptional circumstances 3.Patients with controlled blood pressure (< 180/100) (RACPC is for diagnosis and patients will be discharged back to GP once a diagnosis of angina has been made or excluded) Referral Threshold Secondary Care Resource: Previously diagnosed but worsening (already on maximum If not currently under active management by a Cardiologist, consider referral to Cardiology as a new patient. primary care treatment) If under active or recent (≤12 months) management by a Cardiologist, consider referral for follow-up appointment. Post MI, Post CABG or Post PCI (Where anti angina tablets are not adequately controlling symptoms, GP care is aimed at minimising symptoms to allow the patient Atypical but suspicious of CHD + to remain active and reducing risk factors through BP control, cessation of smoking, reducing lipids and prescribing aspirin (or clinical risk factors alternative if contra-indicated). Referral Threshold 999 for emergency admission Suspected acute AMI Suspected unstable angina Urgent referral to Cardiology
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  6. 6. Page 6 Owner External resources Heart Failure Version No 10 steps before you refer for Heart failure, link (British Journal of Cardiology, Jan-Feb 2009). Approval Management of Chronic Heart Failure in adults in Primary and Secondary date Care, link (NICE, 2003) Page 26. Review Management of Chronic Heart Failure, link (SIGN, 2007) Page 16. date New York Heart Association Classification, link (BMJ). What to consider in Primary Care before referring Hounslow Primary Care resources Make the diagnosis BNP available through QUEST o History Heart of Hounslow o Physical Examination (including but not limited to Pulse rate and rhythm, BP, raised JVP, Presence/absence of murmurs, evidence of peripheral Heart of Hounslow for primary care investigations including vascular disease, carotid bruits; observe for possible cachexia hidden by - ECG, Ultrasound, X-Ray, Phlebotomy the oedema. Enquire about shortness of breath, on exertion, at rest) - Anti Coagulation service o Investigations: ECG, Chest X-ray, U&E’s, Creatinine, FBC, TFTs, LFTs, West Middlesex glucose and lipids, Urinalysis, BNP Direct access to ECG, ETT o Arrange for an ECHO For Richmond and Twickenham GP’s only– Teddington Memorial Hospital Note: presenting symptom of shortness of breath is also a symptom of asthma and chronic obstructive pulmonary disease. Tests like Peak flow or Spirometry - Direct access to ECG, ETT, ECG and Holter help to distinguish heart failure from other diseases - Direct access ECHO clinic (f) provided by WMUH staff once a week- Note: Examine for any ankle, leg or abdominal oedema. Consider an alternative cause (low protein diet, renal disease, venous stasis). Hammersmith and Charing Cross (Imperial) Direct access to ECG at Hammersmith and Charing Cross (Heart Failure is not a complete diagnosis; it is a symptom due to X; cause should always be investigated) Chelsea and Westminster (Imperial) One stop clinic Ashford and St Peter’s Direct access to ECG at Ashford Ealing Hospital Direct access ECG, ECHO, 24 hour ambulatory BP monitoring, Holter
  7. 7. Page 7 Referral Threshold Secondary care resource (other than Cardiology OP referrals): Suspected Heart Failure West Middlesex: Heart failure Clinic for further assessment, ECHO and BNP. Patient will be assessed, echo and other tests performed and management plan agreed. Teddington Memorial Hospital: Outreach Clinic for Richmond and Twickenham GPs with direct access Echo Clinic once a week for patients with shortness of breath; There is also access to ETT, ECG and Holter provided by WMUH staff Hammersmith and Charing Cross (Imperial) Walk in Rapid Access Clinic for Heart Failure One stop clinic at Chelsea and Westminster (Patient should be returned to Primary Care unless severe problem or structural heart disease confirmed: Once a diagnosis of heart failure has been confirmed ACEI or ARB should be commenced, starting at the lowest dose once per day. The dose should be doubled at a minimum of two-week intervals to a target of the maximum tolerated dose available. The blood pressure and blood taken for U&E will be checked at seven to 14 days, prior to initiation, and following each dose increase. This should be combined with a B-Blocker and a diuretic. The ACEI should be stopped and a referral to a specialist service should be considered if: the potassium level is above 6.0 mmol/L or creatinine more than 350 μmol/L, or more than double the baseline reading) Referral Threshold Secondary care resource: Known HF with deteriorating If under active management of Cardiologist consider referral for urgent follow-up appointment. symptoms (decompensating) Recommended referral to specialist clinic if any of these: Angina – needs further specialist investigations with view to revascularisation if indicated Refractory symptoms despite ACEi and Beta Blockers; still in NYHA Class III/IV (these patients may benefit from intensified medical treatment, revascularisation, biventricular pacing, transplantation) Suspected arrhythmias e.g. AF (difficult to control) or VT
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  10. 10. Page 10 Owner External resources Murmurs/valve Version No disease Approval date Review date What to consider in Primary Care before referring Hounslow Primary Care resources Clinical and Family History- Chest pain (especially with exercise), syncope, Heart of Hounslow exercise intolerance or a family history of sudden death in young people should prompt a complete examination (look for signs like failure to thrive, cyanosis Heart of Hounslow for primary care investigations including especially in paediatric patients) - ECG, Ultrasound, X-Ray, Phlebotomy Preliminary Investigations including ECG - Anti Coagulation service Auscultation (of first and second heart sounds) West Middlesex Direct access to ECG, ETT For Richmond and Twickenham GP’s only– Teddington Memorial Hospital - Direct access to ECG, ETT, ECG and Holter - Direct access ECHO clinic (f) provided by WMUH staff once a week- Hammersmith and Charing Cross (Imperial) Direct access to ECG at Hammersmith and Charing Cross Chelsea and Westminster (Imperial) One stop clinic Ashford and St Peter’s Direct access to ECG at Ashford Ealing Hospital Direct access ECG, ECHO, 24 hour ambulatory BP monitoring, Holter
  11. 11. Page 11 Referral Threshold Secondary care Resource New murmur with associated New patient consider referral to Cardiology symptoms (Outreach Clinic at Teddington Memorial Hospital for Richmond and Twickenham GPs only) Referral Threshold Secondary care Resource Known murmur / valve disease If under active management / monitoring by Cardiologist, consider referral for follow-up appointment with deteriorating symptoms All other patients consider referral to Cardiology as new patient. (Outreach Clinic at Teddington Memorial Hospital for Richmond and Twickenham GPs only) Referral Threshold Murmur associated with 999 for emergency admission. unexplained pyrexia - suspected endocarditis
  12. 12. Page 12 Owner External resources Atrial Fibrillation Version No 10 steps before you refer for AF link (British Journal of Cardiology, Nov-Feb 2008) Approval Atrial fibrillation Care Pathway, link (NICE, 2006) Pages 4 and 6. date Stroke Risk Stratification Chads 2 Score, link (Europace, 2006) Pages 651- Review 745. date Atrial Fibrillation, link (SIGN, 2007) Page 12. Two possible presentations: Hounslow Primary Care resources 1. No symptoms – opportunistic case finding leads to suspicion of AF. 2. Symptomatic presentation and clinical suspicion of AF e.g. palpitations, chest Heart of Hounslow pain, hypotension, dyspnoea, dizziness, embolism or more than mild heart Heart of Hounslow for primary care investigations including failure. - ECG, Ultrasound, X-Ray, Phlebotomy What to consider in Primary Care before referring - Anti Coagulation service Manual pulse palpitation to assess for an irregular pulse indicating underlying AF in patients who present with breathlessness or dyspnoea, palpitations, West Middlesex syncope or dizziness, chest discomfort or stroke/Transient Ischaemic Attack Direct access to ECG, ETT (TIA).(relevant co-morbidities) For Richmond and Twickenham GP’s only– Teddington Memorial Establish alcohol intake (either chronic or bingeing). Hospital Measure blood pressure (half of all cases of AF are hypertensive). - Direct access to ECG, ETT, ECG and Holter Arrange for FBC, TFT’s and creatinine and electrolytes. Examine for indications of heart failure, valvular disease, congenital heart - Direct access ECHO clinic provided by WMUH staff once a week- disease or acute pericarditis or myocarditis. Hammersmith and Charing Cross (Imperial) Perform an ECG in all patients, whether symptomatic or not, with an irregular Direct access to ECG at Hammersmith and Charing Cross pulse in whom AF is suspected. Arrange for Chest X Ray Chelsea and Westminster (Imperial) Reduce symptoms by prescribing rate-controlling medication (B-Blocker or One stop clinic calcium channel blocker) Ashford and St Peter’s Start the patient on appropriate anticoagulation- CHADS 2 Scoring system, while waiting for referral Direct access to ECG at Ashford (C stands for congestive heart failure, H stands for hypertension, A stands for Ealing Hospital age >75 years, D stands for diabetes, )S stands for CVA/TIA - Score 1 if any of Direct access ECG, ECHO, 24 hour ambulatory BP monitoring, Holter these are present or 2 for CVA/TIA) - If total score ≥2 anticoagulation with warfarin is recommended - If score <2 aspirin should be considered
  13. 13. Page 13 Referral Threshold Secondary Care Resource (other than Cardiology OP referrals): Symptomatic despite initial Walk in Rapid Access Clinic at Hammersmith and Charing Cross management One stop clinic at Chelsea and Westminster Treatment strategy uncertain Outreach Clinic at Teddington Memorial Hospital for Richmond and Twickenham GPs with ETT, ECG and Holter access Rhythm management required Open access ECG, ECHO, Holter at Ealing Hospital Open access ECG, ETT at West Middlesex When there is concern that a patient may have an underlying If the above clinics are not accessible, structural problem e.g. valve disease which may need New patient – consider referral to Cardiology. treatment Known to Cardiologist / under active care – consider referral for follow-up appointment. If suspect paroxysmal AF that has not been detected by standard (Refer for a 24hour ambulatory ECG monitor where you suspect asymptomatic episodes or where episodes are < 24 hours apart ECG use an event recorder ECG where symptomatic episodes are more than 24 hours apart) Referral Threshold 999 for emergency admission. Symptomatic, <48hrs onset
  14. 14. Page 14 Source: Atrial Fibrillation: the management of atrial fibrillation (Quick reference guide) (NICE clinical guidelines 36, NICE, June 2006).
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  19. 19. Page 19 Owner External resources Arrhythmia/ Version No 10 steps before you refer for palpitations link (British Journal of Cardiology, July-August 2009) Palpitations/ Approval date Cardiology – Palpitations/Suspected Clinically Significant Arrhythmia, link (Centre for Change and Innovation – NHS Scotland, 2005). Irregular heart beat Review date Cardiac Arrhythmias in coronary heart disease, link (SIGN, 2007) Page 8. Adams KF, Lindenfeld J, Arnold JMO et al. HFSA 2006 Comprehensive Heart Failure Practice Guideline. J Cardiac Failure 2006; 12: e1-e122. What to consider in Primary Care before referring Hounslow Primary Care resources Careful history (A good history will be key to determining likelihood of Heart of Hounslow significant cardiac dysfunction) including associated symptoms, contributing factors, family history etc. Heart of Hounslow for primary care investigations including Examination: check pulse, BP - ECG, Ultrasound, X-Ray, Phlebotomy Key questions to ask: Onset(sudden/gradual), Nature (Sustained or brief and - Anti Coagulation service repetitive, Regular or chaotic, Accompanying dizziness, dyspnoea, chest pain), Offset, Frequency, Duration, Impact on lifestyle West Middlesex Investigations: Undertake tests to include 12 lead ECG, thyroid function test, Direct access to ECG, ETT FBC, U&E, chest X-Ray. For Richmond and Twickenham GP’s only– Teddington Memorial Hospital Risk stratification - Direct access to ECG, ETT, ECG and Holter Consider management in primary care according to guidelines if minimally - Direct access ECHO clinic (f) provided by WMUH staff once a week- symptomatic, anticoagulation clearly indicated and possibility of structural heart disease ruled out. Hammersmith and Charing Cross (Imperial) Direct access to ECG at Hammersmith and Charing Cross Chelsea and Westminster (Imperial) One stop clinic Ashford and St Peter’s Direct access to ECG at Ashford Ealing Hospital Direct access ECG, ECHO, 24 hour ambulatory BP monitoring, Holter
  20. 20. Page 20 Referral Threshold Secondary care resource (other than Cardiology OP referrals): Significantly symptomatic / Walk in Rapid Access Clinic at Hammersmith and Charing Cross syncopal Outreach Clinic at Teddington Memorial Hospital for Richmond and Twickenham GPs with ETT, ECG and Holter access Not sure about anticoagulation Recurrent palpitations Secondary care resource: If under active or recent management of a specific Cardiologist – consider referral for urgent follow-up appointment. Unremitting despite strategies to Otherwise, consider referral to Cardiology as urgent new referral. Please append results of investigations performed. reduce symptoms or frequency Abnormal ECG e.g. long QT (Ambulatory ECG is indicated in most cases.) interval, delta wave (Consider Echo in cases of murmurs and /or abnormal ECG, CXR)) History suggests tachyarrhythmia (Please state nature and frequency of symptoms to help determine the most appropriate monitoring device) Family history of inherited heard disease/SADS Palpitations during exercise (threshold: usually 9 minutes in ETT; threshold may vary) Referral Threshold 999 for emergency admission. Loss of consciousness
  21. 21. Page 21 Owner External resources Uncontrollable Version No Guidelines on Management (Diagnosis and Treatment) of Syncope – Update Syncope - Approval date 2004, link, (European Society of Cardiology, 2004). Cardiology – Syncope Patient Pathway, link, (Centre for Change and suspected Review date Innovation – NHS Scotland, 2005). cardiac cause What to consider in Primary Care before referring: Hounslow Primary Care resources Inquire for a family history of Sudden Cardiac Death under 40yrs, Hypertrophic Heart of Hounslow Cardiomyopathy or Channelopathies Heart of Hounslow for primary care investigations including To rule out : epilepsy, TIA, CVA, drug misuse and vaso-vagal attack - ECG, Ultrasound, X-Ray, Phlebotomy Examination; Supine and erect BP - Anti Coagulation service Investigations: ECG, Chest X ray (arrange 24 hour tape where possible), FBC, Thyroid Function, Electrolytes, Creatinine, Calcium West Middlesex Features suggestive of a cardiac cause Direct access to ECG, ETT  Symptoms when supine For Richmond and Twickenham GP’s only– Teddington Memorial  During exertion Hospital  Preceded by palpitations - Direct access to ECG, ETT, ECG and Holter - Direct access ECHO clinic (f) provided by WMUH staff once a week-  Presence of severe heart disease  ECG abnormalities pointing to underlying structural heart disease Hammersmith and Charing Cross (Imperial) Direct access to ECG at Hammersmith and Charing Cross Chelsea and Westminster (Imperial) One stop clinic Ashford and St Peter’s Direct access to ECG at Ashford Ealing Hospital Direct access ECG, ECHO, 24 hour ambulatory BP monitoring, Holter
  22. 22. Page 22 Referral Threshold Secondary care resource: Recurrent pre-syncope/syncope Consider referral to Cardiology for ECHO and 24 hour tape amongst other investigations For rot cause diagnosis if positive for any of the above investigations Outreach Clinic at Teddington Memorial Hospital for Richmond and Twickenham GPs (with ECHO, ETT, ECG and Holter) Referral Threshold Angina with syncope (usually abnormal ECG) 999 for emergency admission. Syncope with known structural heart disease Exercise induced syncope
  23. 23. Page 23 Owner External resources Hypertension Version 10 steps before you refer for Hypertension link (British Journal of Cardiology, No Sep-Oct 2008) Approval Hypertensions: Management in adults in primary care: pharmacological date update, link (The National Collaborating Centre for Chronic Conditions, 2004) Review Page 19. date Hypertension in older people, link (SIGN, 2001). What to consider in Primary Care before referring Hounslow Primary Care resources Heart of Hounslow Essential Hypertension- Use an average of two seated BP readings from at least two visits to guide the Heart of Hounslow for primary care investigations including decision to treat. - ECG, Ultrasound, X-Ray, Phlebotomy Take a standing reading in patients with symptoms of postural hypotension. - Anti Coagulation service Measure BP on both of patient's arms with higher value identifying the reference arm for future measurement. West Middlesex Test for proteinuria. Measure plasma glucose, electrolytes, creatinine, serum Direct access to ECG, ETT total cholesterol and HDL-cholesterol. Arrange a 12-lead ECG. For Richmond and Twickenham GP’s only– Teddington Memorial Estimate 10-year cardiovascular disease (CVD) risk in accordance with the Hospital Joint British Societies assessment scheme. - Direct access to ECG, ETT, ECG and Holter Consider managing according to hypertension guidelines. Aims of treatment: To reduce diastolic BP to ≤90 mmHg and systolic BP to ≤140 - Direct access ECHO clinic (f) provided by WMUH staff once a week- mmHg. Hammersmith and Charing Cross (Imperial) BP Major Recommended Action (mmHg) Risk Direct access to ECG at Hammersmith and Charing Cross Factors Offer lifestyle advice initially and then periodically to all patients. Chelsea and Westminster (Imperial) <140/90 – Reassess in 5 years. One stop clinic >140/90 – Remeasure at min. of two subsequent clinics (at monthly intervals or more frequently in case of more severe hypertension). If raised BP persists in patients Ashford and St Peter’s without established cardiovascular disease, the need for formal assessment of cardiovascular risk should be discussed. Reassess in 1 year. Direct access to ECG at Ashford >140/90 + Offer drug therapy to patients with raised cardiovascular risk (10-year risk of CVD ≥20% or existing cardiovascular disease or target organ damage) with BP Ealing Hospital persistently >140/90. ≥160/100 +/- Offer drug therapy to patients with high BP persistently ≥160/100. Direct access ECG, ECHO, 24 hour ambulatory BP monitoring, Holter Offer non pharmacological guidance to manage blood pressure
  24. 24. Page 24 Referral Threshold Signs and symptoms suggesting secondary cause of hypertension. Secondary care resource Patients with symptoms of, or Consider referral to Cardiology outpatient and/or appropriate specialist for further investigation and to confirm diagnosis documented, postural hypotension and for management. Patient may be referred back to primary care with detailed management plan. (fall in systolic BP when standing of 20 mmHg or more). Consider referral to appropriate general physician (eg nephrology, care of the elderly, endocrinology etc.) if indicated Treatment ineffective (maximum medication of combination of 4 drugs) Referral Threshold Accelerated (malignant) hypertension 999 for emergency admission. Suspected phaeochromocytoma.
  25. 25. Page 25 Owner External resources Cardiomyopathy Version No Aetiology, diagnosis, investigation, and management of the cardiomyopathies link (BMJ). Approval date Review date What to consider in Primary Care before referring Hounslow Primary Care resources History Heart of Hounslow Suggested investigations in primary care: ECG, Chest X-ray, Routine Blood Heart of Hounslow for primary care investigations including Tests, ECHO and ETT - ECG, Ultrasound, X-Ray, Phlebotomy Stable Diagnosed- Once diagnosed, consider managing stable cardiomyopathy with - Anti Coagulation service recommended treatment regime in Primary Care. West Middlesex Direct access to ECG, ETT For Richmond and Twickenham GP’s only– Teddington Memorial Hospital - Direct access to ECG, ETT, ECG and Holter - Direct access ECHO clinic (f) provided by WMUH staff once a week- Hammersmith and Charing Cross (Imperial) Direct access to ECG at Hammersmith and Charing Cross Chelsea and Westminster (Imperial) One stop clinic Ashford and St Peter’s Direct access to ECG at Ashford Ealing Hospital Direct access ECG, ECHO, 24 hour ambulatory BP monitoring, Holter
  26. 26. Page 26 Referral Threshold Secondary care resource: Consider referring suspected cases to Cardiology for confirmation of diagnosis and treatment plan. Please attach test results as Suspected applicable and any relevant details
  27. 27. Page 27 Owner External resources Dyslipidemia Version No 10 steps before you refer for Lipids link (British Journal of Cardiology Sep- Approval Oct 2009) date Heart Disease: Quick Reference Guide, link (SIGN, 2007) Pages 30-31. Review date What to consider in Primary Care before referring Hounslow Primary Care resources History and preliminary investigations (risk factors to consider) Heart of Hounslow o Age (males > 45 years, females > 55 years or menopause < age 40) o Family history of premature coronary artery disease; definite myocardial Heart of Hounslow for primary care investigations including infarction (MI) or sudden death before age 55 in father or other male - ECG, Ultrasound, X-Ray, Phlebotomy first-degree relative, or before age 65 in mother or other female first- degree relative - Anti Coagulation service o Current cigarette smoker West Middlesex o Hypertension (systolic blood pressure > 140 mmHg or diastolic blood pressure > 90 mmHg confirmed on more than one occasion, or current Direct access to ECG, ETT therapy with antihypertensive medications) For Richmond and Twickenham GP’s only– Teddington Memorial o Fasting Blood Sugar indicates Diabetes or a known diabetic Hospital o Lipid profile and identify the pattern of lipo-protein abnormality. o Exclude secondary causes (Thyroid profile (hypothyroidism), certain - Direct access to ECG, ETT, ECG and Holter drug treatments, glucose intolerance and diabetes, obesity etc) - Direct access ECHO clinic (f) provided by WMUH staff once a week- o Assess cardiovascular risk (Framingham score) Hammersmith and Charing Cross (Imperial) Manage in Primary Care according to guidelines regarding cardiovascular risk Direct access to ECG at Hammersmith and Charing Cross assessment and subsequent appropriate interventions (including diet, activity, blood pressure lowering therapy, lipid lowering therapy (Statin), and antiplatelet therapy) Chelsea and Westminster (Imperial) Note; patient needs to be monitored with LFT if on Statins as evidenced by good practice One stop clinic Ashford and St Peter’s Direct access to ECG at Ashford Ealing Hospital Direct access ECG, ECHO, 24 hour ambulatory BP monitoring, Holter
  28. 28. Page 28 Referral Threshold Secondary care resource: Those with extreme values with Consider referral to Cardiology outpatients pure hypercholesterolemia. Generally, these can be defined as total cholesterol (TC) >7.5 mmol/L and/or fasting triglycerides (TG) >7.5 mmol/L. All patients with TG >20 mmol/L need to be referred given the risk of pancreatitis. Those who fail to show an effective response to treatment (whether by virtue of the type and severity of their dyslipidaemia or their intolerance of first-line agents) (maximum dose of higher intensity statins like atorvastatin 80 mg or rosuvastatin 20/40 mg) and/or addition of ezetimibe9 or even colesevelam. In situations of mixed dyslipidaemia, there are potential roles for combining stains with Niacin or Fenofibrate) Referral Threshold Secondary care resource: If there is evidence of severe acute Consider urgent specialist referral. complications, especially for: elderly patients who are unwell, dehydrated or febrile swollen tender muscles on clinical examination significant electrolyte disturbance (hyperkalaemia, hypocalcaemia) oliguria biochemical suggestion of renal failure suspected rhabdomyolysis
  29. 29. Page 29 Suggested Initial Investigations (needs to be tailored to individual patient’s presenting symptoms and differential diagnosis) Full blood count (to exclude anaemia) Fasting plasma glucose (to exclude diabetes) Fasting lipid profile (the extent of this analysis will depend on local guidelines) Thyroid function Biochemistry profile (renal function- Urea and electrolytes Resting ECG (An abnormal ECG supports a diagnosis of Coronary artery disease and also identifies a patient at an increased risk. However a normal resting ECG does not exclude coronary artery disease) Chest X- Ray Liver Function Tests (especially in suspected Heart Failure and patients indicated for or on Statins) Brain Natriuretic Peptide (BNP) Test. (This test helps to diagnose and assess the severity of heart failure) 24 Hour Tape (Holter) ECHO ETT
  30. 30. Page 30 Available Resources Rapid Access Chest Pain Clinic The Rapid Access Chest Pain Clinic (RACPC) allows specialist assessment of patients with suspected new onset Angina within the National Service Framework for coronary heart disease targets of two weeks from referral. The clinic provides a one-stop service involving clinical assessment and investigations to confirm or exclude coronary artery disease. The RACPC also sets the patients onwards to evidence-based treatment (revascularisation). (1) West Middlesex: Location: Outpatient department 2, main building, West Middlesex Hospital Fax Referral form along with Copies of any relevant investigations (lipids, fasting glucose, ECG) to 020 8321 6242. Tel. No 0208 321 6241 Referral Criteria (all must apply) 1. New onset of exertional angina symptoms within the past 6 weeks 2. Male > 30 or female > 40 except in exceptional circumstances 3. Patients with controlled blood pressure (< 180/100) Not suitable for RACPC but for Cardiology OP (if any apply) 1. Recurrence or worsening of symptoms in a patient with known angina 2. Heart Failure 3. Valve disease or evaluation of murmur 4. Symptomatic murmur (See attached referral letters for details) (2) Ashford and St Peter’s Opening Times: 9-5pm Monday to Friday Standard referral letter can be faxed directly on (01784) 884554. An appointment request is usually faxed directly to the department and appointments are available within 24 to 48 hours. Transport can be provided which is directly arranged by the RAC administration team and carers or relatives are able to accompany patients for support throughout their day long visit to the clinic. (See attached referral letters for details) (3) Hammersmith Hospital Bookings can be made by the GP or the patient only by telephoning the clinic receptionist on 0208 383 3943 between 8:45am and 4.30pm on any working weekday (faxed/mailed referral forms will not be processed). The clinic is closed at weekends and on Bank Holidays. Patients must bring a completed RACPC referral form with them when they attend. Patients may be referred if: 1. They have undiagnosed chest pain which may be cardiac in origin 2. They have not been seen in a cardiology clinic within the last 2 years (Please refer these patients back a Cardiologist). 3. They are not thought to have unstable angina or acute myocardial infarction (Such patients should go directly to the Accident & Emergency department). (See attached referral letters for details)
  31. 31. Page 31 (4) Chelsea and Westminster The Rapid Access Chest Pain Clinic (RACPC) provides a specialist assessment of people who present to their GP with symptoms suggestive of new onset angina. All patients will be seen at their convenience within a maximum waiting time of two weeks. It is a nurse lead service with cardiologist support and provides: rapid assessment of patients with suspected angina provide information on treatment options available regarding their diagnosis rapid diagnosis and development of a management plan including revascularisation if necessary estimates of cardiac risk provide information regarding modifiable risk factors reassurance to patients and their families who we believe do not have significant coronary artery disease The clinics are run daily and appointments are booked to suit the patient. Referral sources GP practices Patients attending Accident and Emergency with typical symptoms Referral Criteria Inclusion: Chest pain of new or recent onset with possible ischemic origin Known ischemic heart disease with new onset of symptoms Shortness of breath on exertion presumed to be cardiac in origin Exclusion: Suspected acute myocardial infarction or an unstable acute coronary syndrome should be referred to Accident and Emergency Those who request to be seen by a doctor (See attached referral letters for details) (Patient information leaflets can be downloaded from http://www.chelwest.nhs.uk/services/medicine/cardiology.htm#Rapid) (5) Ealing Hospital (See attached referral letters for details)
  32. 32. Page 32 Heart Failure Clinic – West Middlesex University Hospital Three outpatient clinics are run each week, on Wednesday, Thursday afternoon (1.30 - 5.00pm) and Friday morning between 9.30pm and 1pm. There is a direct-line telephone service for patients from 8.30am until 5.30pm, Monday to Friday. A specialist nurse can be contacted via switchboard (020 8560 2121 or 020 8560 2121) on bleep 077 from 8.30am until 5.30pm, Monday to Friday The outpatient service runs as follows:  A weekly Rapid Access Heart Failure Clinic (RAHFC) intended to provide a one stop diagnostic facility involving clinical assessment with Echocardiography and Brain Natriuretic Peptide (BNP) assay.  A weekly Heart Failure Clinic (HFC) to allow continued monitoring of more complex, dependent cases and including the frail elderly and those with multiple chronic diseases.  Heart Failure Specialist Nurse Clinics three times weekly to provide comprehensive education for patients and to manage appropriate titration of drugs (ACE Inhibitors and Beta-Blockers). They offer a community based service with home visits and monitoring and we are aiming to develop a community based clinic service. They are developing a rehabilitation group for heart failure patients and strengthening our links with palliative care Locations Outpatient department 1, main building (Wednesday) Outpatient department 2, main building (Thursday and Friday) (See attached referral letter for details)
  33. 33. Page 33 Heart of Hounslow – Polyclinic Services offered Out of hours consultation Ultrasound X-Ray Phlebotomy Anti Coagulation service Pharmacy- dispensing (This is not an exhaustive list of services in Heart of Hounslow but reflects the relevant ones for patients with suspected or confirmed cardiology conditions)
  34. 34. Page 34 The Rapid Access Chest Pain Clinic allows specialist assessment of patients with suspected new onset angina within two weeks of referral. The clinic provides a one-stop service involving clinical assessment and investigations to confirm or exclude coronary disease. 1 Name Referring Dr DOB Address Address Tel No Tel No Fax No Hospital No Referral Date Risk Factors Summary of Chest Pain including duration (Tick if Present) Smoker Diabetes Mellitus Hypertension Hyperlipidaemia 2 Date symptoms started Family History of Premature Coronary Vascular st disease (1 Degree Relative M<55 F<60) 3 Relevant Past Medical History Examination Findings 5 4 BP ____ / ____ Cardiac Murmur (Tick if present) 7 Current Medication 6 8 Other Information including any Blood results 9 Suitable for referral (All must apply) 1. New onset of exertional angina symptoms within the past 6 weeks ‫ٱ‬ 2. Male > 30 or female > 40 except in exceptional circumstances ‫ٱ‬ 3. Patients with controlled blood pressure (< 180/100) ‫ٱ‬ 10 Not suitable for RACPC but for Cardiology OP ( if any apply ) 1. Recurrence or worsening of symptoms in a patient with known angina ‫ٱ‬ 2. Heart Failure 3. Valve disease or evaluation of murmur ‫ٱ‬ 4. Symptomatic arrhythmia ‫ٱ‬ Patients with suspected ischaemic heart disease having recurrent pains at rest or on minimal exertion require 999 admission. Appointments will not be made unless the referral form is complete and the blood pressure is controlled. Patients from outside the catchment’s area will not be guaranteed an appointment Please Fax Referral form along with Copies of any relevant investigations (lipids, fasting glucose, ECG) to 020 8321 6242. Tel.No 0208 321 6241. Signed Print Name Date
  35. 35. Page 35 Referral for Rapid Access Chest Pain Clinic Please complete sections 1 to 5 1) Patient Details: Name Address: D.O.B: Sex: M F Town/City: Contact Phone No: Postcode: Mobile Phone No: 2) GP Details: * Fax no. Name: Surgery: *E-mail: Signed: Date: If suspected MI or Unstable Angina for >15 minutes, or cardiac sounding pain at rest, please refer to on-call physicians or dial 999 3) How Strongly do you suspect angina? Unlikely Possible Likely Exertional chest pain (or other suspected angina symptom) Yes No Have symptoms been stable within the last 6 weeks Yes No Male at least 30 years or female at least 40 years of age Yes No Not previously investigated for angina within last 12 months Yes No Is patient available for an appointment over the next 2 weeks Yes No Is the patient capable of walking on a treadmill? Yes No 5) Brief relevant history and/or other information/medication NEXT STEPS 1) Please complete ALL patient details to include mobile number so appointments can be arranged 2) *Please provide an e-mail address and fax number so a report can be sent a.s.a.p. 3) Please print and fax form to 0800 9234668 4) Please give information sheet to your patient Incomplete forms cannot be processed
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  38. 38. Page 38 RAPID ACCESS CHEST PAIN CLINIC Hotline fax 020 8746 8814 If you suspect a cardiac cause to your patient’s chest pain, we welcome your patient irrespective of: Address Any previous assessment Any previous cardiac history or revascularisation Patient Details General Practitioner Detail (or stamp) Name Referring GP Address Practice Address Date of Birth Telephone Telephone Interpreter Yes No Fax required? Language Hospital Referral date Number Referral Criteria (please tick boxes) New onset exertional chest pain Pain free at rest and no clinical suspicion of an acute coronary syndrome Patients with known IHD under follow-up with recent deterioration of symptoms Details and symptoms and past cardiac history Any relevant past medical history Current medication ILLEGIBLE OR INCORRECTLY COMPLETED FORMS WILL BE RETURNED AND RESULT IN DELAYS TO THE RACPC Cardiology Clinical Nurse Specialist Cardiology SpR For routine enquiries call 020 8746 5936 Bleep 4180 or 5259 via switchboard (0208 746 8000) For urgent queries bleep 4895 via switchboard (0208 746 8000)
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  41. 41. Page 41 Heart Failure Referral form GP Practice: Patient Name: DOB: Patient : GP : GP : History of presenting complaint: Limitations: SOB Orthopnoea Cough Chest Pain Palpitations Fatigue Leg Oedema Mobility Dizziness Previous Medical History: Medications: Allergies: Baseline Observations 10.1.1.1.1.1.1.1.1 Blood Results Heart Rate Heart Rhythm 10.1.1.1.1.1.1.1.2 Resps Na: Urea:
  42. 42. Page 42 Oedema: BP Weight K: Creatinine: Pedal: Y Haemoglobin: Albumin: / N 10.1.1.1.1.1.1.1.3 Date Taken: Sacral: Y / N Investigations Date Abnormalities Noted (if none, please state) ECG (please enclose copy) CXR BNP (optional) Signature Name (please print) Date
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  46. 46. Page 46 Cardiology Department 11 Ealing Hospital Direct Access GP Referral Form 11.1 NHS Trust SERVICE Direct line: Fax: Email: CO-ORDINATOR: 020 8967 5298 020 8967 5007 Cardiology@eht.nhs.uk Patient Details GP Details Surname: ___________________________ Name _____________________ Forename: ___________________________ _____________________ DOB: _____________ NHS #! □□□□□□□□□□ Practice address: _____________________ Address: ___________________________ _____________________ ___________________________ Postcode _____________________ Postcode: _____________ Tel. No: _____________________ Mobile: ___________________________ Fax: _____________________ Work Tel: ___________________________ Email: _____________________ Home Tel: ___________________________ 1.1 EXPRESS INVESTIGATION ONLY (with Consultant report) □ ECG......................................................................................................... □ Echocardiography.................................................................................... □ 24 Hour ECG........................................................................................... □ 24 Hour BP.............................................................................................. □ Event recorder......................................................................................... 1.2 EXPRESS CLINICAL OPINION □ Chest Pain.............................................................................................. □ Breathlessness........................................................................................ □ Palpitations............................................................................................. □ Syncope/Dizziness................................................................................. □ Hypertension.......................................................................................... History, Examination & Investigations Please attach a referral letter with other details e.g. past history, drug history, results, ECG Signature_____________ Date ______________
  47. 47. Page 47 ECG What is it? It’s a recording of the electrical activity of the Heart. It shows whether the heart is beating properly. The test involves the you lying on a couch and electrodes being placed on the arms, legs and chest area. Duration: 10 min ECHOCARDIOGARPHY (Echo) What is it? It’s a scan of your heart using ultrasound which uses sound waves to produce an image of your heart on a Monitor. It gives information on how well your heart and its valves works. The test involves you lying on a couch. Gel is put on the chest so that pictures can be taken. CARDIOLOGY ONE STOP Duration: 30-45 min EXERCISE STRESS TEST SHOP CLINIC What is it? It helps the Doctors to see how your heart responds to stress. It provides information on whether there might be narrowings in the blood vessels to the heart. The test involves the electrodes being placed on the chest and the patient walking on a treadmill. Duration: 20-30 min HOLTER MONITOR (24hr ECG) What is it? It provides a constant reading of your heart rate and rhythm over 24 hours. The test involves a small monitor attached to the chest by three leads and taken home for 24 hours. Attaching the monitor takes 10-20 minutes. 24hr BLOOD PRESSURE MONITORING 369 Fulham Road What is it? London It provides a constant reading of your blood pressure over 24 hours. SW10 9NH The test involves a blood pressure monitor attached Tel: 020 8746 8000 to the arm of the patient and taken home for 24 hours. Attaching the monitor takes 10-20 minutes.

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