Palpitations Talk

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Text of Palpitations Talk

  • 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 (SVEs / VPCs)
      • 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 studyMay 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 31,27were 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