Palpitations Talk

Can most “specialist” cardiac investigations be done in primary care?

Steve LeslieConsultant Cardiologist (NHS Highland)

Arrhythmia monitoring

Palpitations

• Definition:

• ‘an awareness of ones heartbeat that is thought inappropriate to the circumstances’

Causes

• Cardiac arrhythmia• Sinus tachycardia• Ectopics (SVE’s / VPC’s)• SVT – AF / flutter• SVT – AVNRT / AVRT• VT

• ‘Normal heart’ / ‘abnormal patient’

Diagnostic pathway

• HistoryExercise inducedAssociated syncopeChest painFamily history of sudden cardiac deathUnderlying structural heart disease

• Examination• Resting ECG• ECG with symptoms• Additional investigations

History

• Frequency• Onset / offset characteristics• Perceived rate• Description of regularity• Duration• Associated symptoms• Aggravating / relieving factors

History

• Past history• Drug history including OTC medicines

Decongestants (ephedrine)AlcoholCardio-active drugs (QT

interval ?)

Resting ECG

• Features to checkSinus rhythmPR intervalQRS durationST segment shape (LVH/Brugada)T waves (? Cardiomyopathy)

ecg.highland@nhs.net

1.Normal ECG

ecg.highland@nhs.net

Brugada

ecg.highland@nhs.net

Wolff-Parkinson-White Syndrome

ecg.highland@nhs.net

Hypertrophic Cardiomyopathy

ecg.highland@nhs.net

Additional Investigations

• Capturing an ECG with symptoms

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 minutes and are reasonably tolerated

Implantable Loop Recorder

REVEAL device

Event recorder £75 (~£600 per device)

Reveal £1500

Additional Investigations

• Structural abnormalitiesEchocardiogramCardiac MRIExercise Tolerance TestCardiac Catheterisation /

angiography

Issues for Highland patients

• Long distances• Long waits• Low risk patients• Direct access• Review

Direct Access Arrhythmia Monitoring Service

• 29 month period• Referrals from GP ‘direct’ or ‘via consultant’• Patients received ‘Holter’ or ‘event recorder’

• Negative / positive / malignant

Results

• 239 patients from 47 GP practices• Either direct (69%) or redirected

(31%) • Female (65%) • Age 55 (± 17) years • Event recorder (53%) Holter (47%)

Outcomes

• 230 (96%) returned to GP• 42% negative / 54% positive• 9 (4%) were referred to consultant• 3 discharge immediately• 6 seen in clinic

Outcomes

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?

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.

Conclusions

• Direct access seems effective• Waiting times remain an issue• Alternative approaches could be

considered in areas with remote populations.

A tale of two hearts

2004

• Attended GP (low risk)• Referred cardiology 3 months• Event recorder 7 months• Reassured

• Total journal 10 months

2010

• Attended GP (low risk)• Event recorder• Reassured

• Total journal 9 days

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

Event recorders

Thank you