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)
1.Normal ECG
Brugada
Wolff-Parkinson-White Syndrome
Hypertrophic Cardiomyopathy
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