Cardiology referral guidance
description
Transcript of Cardiology referral guidance
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 detailsVersion No. 14 For additional corrections,
admissions or comments please email [email protected]
Approved by Working Group
Approval date 03/12/09
Review date
Page 1
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.
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 Cardiologist
Suggested Referral
Emergency admission likely to be appropriate
Suggested referral to Secondary Care
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
Page 2
Ischemic heart disease (angina/chest pain)
Owner External resources 10 steps before you refer for Chest pain, link (British Institute of Cardiology,
2009). Management of Stable Angina link (SIGN, 2007) Page 22. Cardiac Rehabilitation Guidance, link (SIGN, 2002).
National Collaborating Centre for Chronic Conditions. Type 2 diabetes: national clinical guidelines for management in primary and Secondary Care (update). London: Royal College of Physicians; 2008.
Classification of Angina Severity According to the Canadian Cardiovascular Society, link, (Canadian Cardiovascular Society).
Version No
Approval date
Review date
What to consider in Primary Care before referring:
A detailed Clinical and Family History
Consider non cardiac reasons for chest pain
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 a higher incidence), family history, lifestyle etc.
Physical Examination (including but not limited to): Pulse rate and rhythm, BP, Presence/absence of murmurs, evidence of peripheral vascular disease, carotid bruits, signs/symptoms of thyroid disease
Investigations (including but not limited to): FBC, Fasting glucose, Fasting lipid profile, Thyroid function, resting 12 lead ECG, Biochem profile (renal function)
It is very important not to delay treatment, including risk factor management, while awaiting referral.
Initial treatment in Primary Care should include:
Acute symptomatic relief with GTN
Prophylactic treatment with beta-blocker followed by Dihydropyridine Calcium antagonist (Amlodipine) or, if beta-blocker contra-indicated, calcium antagonist (Diltiazem or Verapamil) followed by Isosorbide Mononitrate should be used.
Aspirin
Risk Factor management e.g. stopping smoking, weight loss, statin (reducing lipids to total chol <5 mmol), aspirin (if not contraindicated)
Hounslow Primary Care resources
Heart of Hounslow
Heart of Hounslow for primary care investigations including
- ECG, Ultrasound, X-Ray, Phlebotomy
- Anti Coagulation service
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
Page 3
Most angina management is by the patient’s GPReferral for angina is required for
Confirmation of diagnosis Unstable angina (worsening
pain and at rest) and suspected MI
Notes
CABG and angioplasty +/- stent reduce mortality and morbidity in unstable angina and acute MI, but in stable angina they only improve morbidity if full medical treatment has failed (generally defined as two anti anginal medications at full strengths
(It is covered by QOF)
Referral Threshold
First presentation of Angina/suspected angina
Secondary care resource (other than Cardiology OP referrals):
If no previously documented Coronary Heart Disease:
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
Previously diagnosed but worsening (already on maximum primary care treatment)
Post MI, Post CABG or Post PCI
Atypical but suspicious of CHD + clinical risk factors
Secondary Care Resource: If not currently under active management by a Cardiologist, consider referral to Cardiology as a new patient.
If under active or recent (≤12 months) management by a Cardiologist, consider referral for follow-up appointment.
(Where anti angina tablets are not adequately controlling symptoms, GP care is aimed at minimising symptoms to allow the patient to remain active and reducing risk factors through BP control, cessation of smoking, reducing lipids and prescribing aspirin (or alternative if contra-indicated).
Referral Threshold
Suspected acute AMI
Suspected unstable angina
999 for emergency admission
Urgent referral to Cardiology
Page 4
Page 5
Heart Failure Owner External resources 10 steps before you refer for Heart failure, link (British Journal of Cardiology,
Jan-Feb 2009).
Management of Chronic Heart Failure in adults in Primary and Secondary Care, link (NICE, 2003) Page 26.
Management of Chronic Heart Failure, link (SIGN, 2007) Page 16.
New York Heart Association Classification, link (BMJ).
Version No
Approval date
Review date
What to consider in Primary Care before referring
Make the diagnosis
o History
o Physical Examination (including but not limited to Pulse rate and rhythm, BP, raised JVP, Presence/absence of murmurs, evidence of peripheral vascular disease, carotid bruits; observe for possible cachexia hidden by the oedema. Enquire about shortness of breath, on exertion, at rest)
o Investigations: ECG, Chest X-ray, U&E’s, Creatinine, FBC, TFTs, LFTs, glucose and lipids, Urinalysis, BNP
o Arrange for an ECHO
Note: presenting symptom of shortness of breath is also a symptom of asthma and chronic obstructive pulmonary disease. Tests like Peak flow or Spirometry help to distinguish heart failure from other diseases
Note: Examine for any ankle, leg or abdominal oedema. Consider an alternative cause (low protein diet, renal disease, venous stasis).
(Heart Failure is not a complete diagnosis; it is a symptom due to X; cause should always be investigated)
Hounslow Primary Care resources
BNP available through QUEST
Heart of Hounslow
Heart of Hounslow for primary care investigations including
- ECG, Ultrasound, X-Ray, Phlebotomy
- Anti Coagulation service
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
Page 6
Referral Threshold
Suspected Heart Failure
Secondary care resource (other than Cardiology OP referrals): 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
Known HF with deteriorating symptoms (decompensating)
Secondary care resource:
If under active management of Cardiologist consider referral for urgent follow-up appointment.
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
Page 7
Page 8
Page 9
Murmurs/valve disease
Owner External resources
Version No
Approval date
Review date
What to consider in Primary Care before referring
Clinical and Family History- Chest pain (especially with exercise), syncope, 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 especially in paediatric patients)
Preliminary Investigations including ECG
Auscultation (of first and second heart sounds)
Hounslow Primary Care resources
Heart of Hounslow
Heart of Hounslow for primary care investigations including
- ECG, Ultrasound, X-Ray, Phlebotomy
- Anti Coagulation service
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
Page 10
Referral Threshold
New murmur with associated symptoms
Secondary care Resource
New patient consider referral to Cardiology
(Outreach Clinic at Teddington Memorial Hospital for Richmond and Twickenham GPs only)
Referral Threshold
Known murmur / valve disease with deteriorating symptoms
Secondary care Resource
If under active management / monitoring by Cardiologist, consider referral for follow-up appointment
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 unexplained pyrexia - suspected endocarditis
999 for emergency admission.
Page 11
Atrial FibrillationOwner External resources
10 steps before you refer for AF link (British Journal of Cardiology, Nov-Feb 2008)
Atrial fibrillation Care Pathway, link (NICE, 2006) Pages 4 and 6.
Stroke Risk Stratification Chads 2 Score, link (Europace, 2006) Pages 651-745.
Atrial Fibrillation, link (SIGN, 2007) Page 12.
Version No
Approval date
Review date
Two possible presentations:
1. No symptoms – opportunistic case finding leads to suspicion of AF.2. Symptomatic presentation and clinical suspicion of AF e.g. palpitations, chest
pain, hypotension, dyspnoea, dizziness, embolism or more than mild heart failure.
What to consider in Primary Care before referring
Manual pulse palpitation to assess for an irregular pulse indicating underlying AF in patients who present with breathlessness or dyspnoea, palpitations, syncope or dizziness, chest discomfort or stroke/Transient Ischaemic Attack (TIA).(relevant co-morbidities)
Establish alcohol intake (either chronic or bingeing).
Measure blood pressure (half of all cases of AF are hypertensive).
Arrange for FBC, TFT’s and creatinine and electrolytes.
Examine for indications of heart failure, valvular disease, congenital heart disease or acute pericarditis or myocarditis.
Perform an ECG in all patients, whether symptomatic or not, with an irregular pulse in whom AF is suspected.
Arrange for Chest X Ray
Reduce symptoms by prescribing rate-controlling medication (B-Blocker or calcium channel blocker)
Start the patient on appropriate anticoagulation- CHADS 2 Scoring system, while waiting for referral
(C stands for congestive heart failure, H stands for hypertension, A stands for age >75 years, D stands for diabetes, )S stands for CVA/TIA - Score 1 if any of these are present or 2 for CVA/TIA)
- If total score ≥2 anticoagulation with warfarin is recommended
- If score <2 aspirin should be considered
Hounslow Primary Care resources
Heart of Hounslow
Heart of Hounslow for primary care investigations including
- ECG, Ultrasound, X-Ray, Phlebotomy
- Anti Coagulation service
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 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
Page 12
Referral Threshold
Symptomatic despite initial management
Treatment strategy uncertain Rhythm management required When there is concern that a
patient may have an underlying structural problem e.g. valve disease which may need treatment
If suspect paroxysmal AF that has not been detected by standard ECG
Secondary Care Resource (other than Cardiology OP referrals):
Walk in Rapid Access Clinic at Hammersmith and Charing Cross
One stop clinic at Chelsea and Westminster
Outreach Clinic at Teddington Memorial Hospital for Richmond and Twickenham GPs with ETT, ECG and Holter access
Open access ECG, ECHO, Holter at Ealing Hospital
Open access ECG, ETT at West Middlesex
If the above clinics are not accessible,
New patient – consider referral to Cardiology.
Known to Cardiologist / under active care – consider referral for follow-up appointment.
(Refer for a 24hour ambulatory ECG monitor where you suspect asymptomatic episodes or where episodes are < 24 hours apart use an event recorder ECG where symptomatic episodes are more than 24 hours apart)
Referral Threshold
Symptomatic, <48hrs onset999 for emergency admission.
Page 13
Source: Atrial Fibrillation: the management of atrial fibrillation (Quick reference guide) (NICE clinical guidelines 36, NICE, June 2006).
Page 14
Page 15
Page 16
Page 17
Page 18
Page 19
Page 20
Page 21
Arrhythmia/ Palpitations/ Irregular heart beat
Owner External resources
10 steps before you refer for palpitations link (British Journal of Cardiology, July-August 2009)
Cardiology – Palpitations/Suspected Clinically Significant Arrhythmia, link (Centre for Change and Innovation – NHS Scotland, 2005).
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.
Version No
Approval date
Review date
What to consider in Primary Care before referring
Careful history (A good history will be key to determining likelihood of significant cardiac dysfunction) including associated symptoms, contributing factors, family history etc.
Examination: check pulse, BP
Key questions to ask: Onset(sudden/gradual), Nature (Sustained or brief and repetitive, Regular or chaotic, Accompanying dizziness, dyspnoea, chest pain), Offset, Frequency, Duration, Impact on lifestyle
Investigations: Undertake tests to include 12 lead ECG, thyroid function test, FBC, U&E, chest X-Ray.
Risk stratification
Consider management in primary care according to guidelines if minimally symptomatic, anticoagulation clearly indicated and possibility of structural heart disease ruled out.
Hounslow Primary Care resources
Heart of Hounslow
Heart of Hounslow for primary care investigations including
- ECG, Ultrasound, X-Ray, Phlebotomy
- Anti Coagulation service
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
Page 22
Referral Threshold
Significantly symptomatic / syncopal
Not sure about anticoagulation
Recurrent palpitations
Unremitting despite strategies to reduce symptoms or frequency
Abnormal ECG e.g. long QT interval, delta wave
History suggests tachyarrhythmia
Family history of inherited heard disease/SADS
Palpitations during exercise (threshold: usually 9 minutes in ETT; threshold may vary)
Secondary care resource (other than Cardiology OP referrals):
Walk in Rapid Access Clinic at Hammersmith and Charing Cross
Outreach Clinic at Teddington Memorial Hospital for Richmond and Twickenham GPs with ETT, ECG and Holter access
Secondary care resource:
If under active or recent management of a specific Cardiologist – consider referral for urgent follow-up appointment. Otherwise, consider referral to Cardiology as urgent new referral. Please append results of investigations performed.
(Ambulatory ECG is indicated in most cases.)
(Consider Echo in cases of murmurs and /or abnormal ECG, CXR))
(Please state nature and frequency of symptoms to help determine the most appropriate monitoring device)
Referral Threshold
Loss of consciousness999 for emergency admission.
Page 23
Uncontrollable Syncope - suspected cardiac cause
Owner External resources
Guidelines on Management (Diagnosis and Treatment) of Syncope – Update 2004, link, (European Society of Cardiology, 2004).
Cardiology – Syncope Patient Pathway, link, (Centre for Change and Innovation – NHS Scotland, 2005).
Version No
Approval date
Review date
What to consider in Primary Care before referring:
Inquire for a family history of Sudden Cardiac Death under 40yrs, Hypertrophic Cardiomyopathy or Channelopathies
To rule out : epilepsy, TIA, CVA, drug misuse and vaso-vagal attack
Examination; Supine and erect BP
Investigations: ECG, Chest X ray (arrange 24 hour tape where possible), FBC, Thyroid Function, Electrolytes, Creatinine, Calcium
Features suggestive of a cardiac cause
Symptoms when supine
During exertion
Preceded by palpitations
Presence of severe heart disease
ECG abnormalities pointing to underlying structural heart disease
Hounslow Primary Care resources
Heart of Hounslow
Heart of Hounslow for primary care investigations including
- ECG, Ultrasound, X-Ray, Phlebotomy
- Anti Coagulation service
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
Referral Threshold Secondary care resource:
Page 24
Recurrent pre-syncope/syncope
For rot cause diagnosis if positive for any of the above investigations
Consider referral to Cardiology for ECHO and 24 hour tape amongst other 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)
Syncope with known structural heart disease
Exercise induced syncope
999 for emergency admission.
Page 25
Hypertension Owner External resources
10 steps before you refer for Hypertension link (British Journal of Cardiology, Sep-Oct 2008)
Hypertensions: Management in adults in primary care: pharmacological update, link (The National Collaborating Centre for Chronic Conditions, 2004) Page 19.
Hypertension in older people, link (SIGN, 2001).
Version No
Approval date
Review date
What to consider in Primary Care before referring
Essential Hypertension-
Use an average of two seated BP readings from at least two visits to guide the decision to treat.
Take a standing reading in patients with symptoms of postural hypotension.
Measure BP on both of patient's arms with higher value identifying the reference arm for future measurement.
Test for proteinuria. Measure plasma glucose, electrolytes, creatinine, serum total cholesterol and HDL-cholesterol. Arrange a 12-lead ECG.
Estimate 10-year cardiovascular disease (CVD) risk in accordance with the Joint British Societies assessment scheme.
Consider managing according to hypertension guidelines.
Aims of treatment: To reduce diastolic BP to ≤90 mmHg and systolic BP to ≤140 mmHg.BP (mmHg)
Major Risk Factors
Recommended Action
Offer lifestyle advice initially and then periodically to all patients.<140/90 – Reassess in 5 years.>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 without established cardiovascular disease, the need for formal assessment of cardiovascular risk should be discussed. Reassess in 1 year.
>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 persistently >140/90.
≥160/100 +/- Offer drug therapy to patients with high BP persistently ≥160/100.
Offer non pharmacological guidance to manage blood pressure
Hounslow Primary Care resourcesHeart of Hounslow
Heart of Hounslow for primary care investigations including
- ECG, Ultrasound, X-Ray, Phlebotomy
- Anti Coagulation service
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
Page 26
Referral Threshold
Signs and symptoms suggesting secondary cause of hypertension.
Patients with symptoms of, or documented, postural hypotension (fall in systolic BP when standing of 20 mmHg or more).
Treatment ineffective (maximum medication of combination of 4 drugs)
Secondary care resource
Consider referral to Cardiology outpatient and/or appropriate specialist for further investigation and to confirm diagnosis and for management. Patient may be referred back to primary care with detailed management plan.
Consider referral to appropriate general physician (eg nephrology, care of the elderly, endocrinology etc.) if indicated
Referral Threshold
Accelerated (malignant) hypertension
Suspected phaeochromocytoma.
999 for emergency admission.
Page 27
Cardiomyopathy Owner External resources
Aetiology, diagnosis, investigation, and management of the cardiomyopathies link (BMJ).Version No
Approval date
Review date
What to consider in Primary Care before referring
History
Suggested investigations in primary care: ECG, Chest X-ray, Routine Blood Tests, ECHO and ETT
Stable Diagnosed- Once diagnosed, consider managing stable cardiomyopathy with recommended treatment regime in Primary Care.
Hounslow Primary Care resources
Heart of Hounslow
Heart of Hounslow for primary care investigations including
- ECG, Ultrasound, X-Ray, Phlebotomy
- Anti Coagulation service
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
Referral Threshold Secondary care resource:
Page 28
SuspectedConsider referring suspected cases to Cardiology for confirmation of diagnosis and treatment plan. Please attach test
results as applicable and any relevant details
Page 29
Dyslipidemia Owner External resources
10 steps before you refer for Lipids link (British Journal of Cardiology Sep-Oct 2009)
Heart Disease: Quick Reference Guide, link (SIGN, 2007) Pages 30-31.
Version No
Approval date
Review date
What to consider in Primary Care before referring
History and preliminary investigations (risk factors to consider)
o Age (males > 45 years, females > 55 years or menopause < age 40) o Family history of premature coronary artery disease; definite myocardial
infarction (MI) or sudden death before age 55 in father or other male first-degree relative, or before age 65 in mother or other female first-degree relative
o Current cigarette smoker o Hypertension (systolic blood pressure > 140 mmHg or diastolic blood
pressure > 90 mmHg confirmed on more than one occasion, or current therapy with antihypertensive medications)
o Fasting Blood Sugar indicates Diabetes or a known diabetico Lipid profile and identify the pattern of lipo-protein abnormality.o Exclude secondary causes (Thyroid profile (hypothyroidism), certain
drug treatments, glucose intolerance and diabetes, obesity etc)o Assess cardiovascular risk (Framingham score)
Manage in Primary Care according to guidelines regarding cardiovascular risk assessment and subsequent appropriate interventions (including diet, activity, blood pressure lowering therapy, lipid lowering therapy (Statin), and antiplatelet therapy)
Note; patient needs to be monitored with LFT if on Statins as evidenced by good practice
Hounslow Primary Care resources
Heart of Hounslow
Heart of Hounslow for primary care investigations including
- ECG, Ultrasound, X-Ray, Phlebotomy
- Anti Coagulation service
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
Page 30
Referral Threshold
Those with extreme values with 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)
Secondary care resource:
Consider referral to Cardiology outpatients
Referral Threshold
If there is evidence of severe acute 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
Secondary care resource:
Consider urgent specialist referral.
Page 31
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
Page 32
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 HospitalFax 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 angina2. Heart Failure3. Valve disease or evaluation of murmur4. Symptomatic murmur
(See attached referral letters for details)
(2) Ashford and St Peter’s
Opening Times: 9-5pm Monday to FridayStandard 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 origin2. 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)
Page 33
(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)
Page 34
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)
Page 35
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)
Page 36
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.
1Name Referring DrDOB AddressAddress
Tel NoTel No Fax NoHospital No Referral Date
Risk Factors (Tick if Present)
Summary of Chest Pain including duration
SmokerDiabetes MellitusHypertensionHyperlipidaemiaFamily History of Premature Coronary Vascular disease (1st Degree Relative M<55 F<60)
2Date symptoms started
3Relevant Past Medical HistoryExamination Findings
4BP ____ / ____
5
Cardiac Murmur (Tick if present) 6
7Current Medication
8Other Information including any Blood results
9Suitable for referral (All must apply)1. New onset of exertional angina symptoms within the past 6 weeks ٱ2. Male > 30 or female > 40 except in exceptional circumstances ٱ3. Patients with controlled blood pressure (< 180/100) ٱ
10Not suitable for RACPC but for Cardiology OP ( if any apply )
1. Recurrence or worsening of symptoms in a patient with known angina ٱ2. Heart Failure3. Valve disease or evaluation of murmur ٱ4. 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
Page 37
Referral for Rapid Access Chest Pain ClinicPlease 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
Page 38
Page 39
Page 40
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
Date of Birth
Practice Address
Telephone Telephone
Interpreter required?
Yes No
Language
Fax
Hospital Number
Referral date
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
For routine enquiries call 020 8746 5936
For urgent queries bleep 4895 via switchboard (0208 746 8000)
Cardiology SpR
Bleep 4180 or 5259 via switchboard (0208 746 8000)
Page 41
Page 42
Page 43
Heart Failure Referral form
Patient Name:
(Please Print)
DOB: Address:
Patient :
GP Practice:
GP :
GP :
History of presenting complaint: Limitations: SOB Orthopnoea Cough Chest Pain Palpitations Fatigue Leg Oedema Mobility Dizziness
Previous Medical History:
Page 44
Medications:
Allergies:
Baseline Observations 10.1.1.1.1.1.1.1.1 Blood Results
Heart Rate Heart Rhythm Resps
Na: Urea:
K: Creatinine:
Haemoglobin: Albumin:
Date Taken:
Oedema:Pedal:
Y/N
Sacral:Y/N
BP Weight
Investigations Date Abnormalities Noted (if none, please state)
ECG(please enclose copy)
CXR
BNP (optional)
Signature Name (please print) Date
Page 45
Page 46
Page 47
Page 48
Cardiology DepartmentDirect Access GP Referral Form
11 Ealing Hospital
NHS Trust
SERVICE CO-ORDINATOR:
Direct line: Fax: Email:020 8967 5298 020 8967 5007 [email protected]
Patient Details GP Details
Surname:Forename:DOB:NHS #!Address:
Postcode:
___________________________________________________________________□□□□□□□□□□___________________________________________________________________
Name
Practice address:
PostcodeTel. No:
__________________________________________
____________________________________________________________________________________
Mobile:Work Tel:Home Tel:
_________________________________________________________________________________
Fax:Email:
__________________________________________
EXPRESS INVESTIGATION ONLY (with Consultant report)
ECG.........................................................................................................Echocardiography....................................................................................24 Hour ECG...........................................................................................24 Hour BP..............................................................................................Event recorder.........................................................................................
EXPRESS CLINICAL OPINION
Chest Pain..............................................................................................Breathlessness........................................................................................Palpitations.............................................................................................Syncope/Dizziness.................................................................................Hypertension..........................................................................................
□□□□□
□□□□□
History, Examination & InvestigationsPlease attach a referral letter with other detailse.g. past history, drug history, results, ECG
Signature_____________ Date ______________
Page 49
ECGWhat is it?It’s a recording of the electrical activity of theHeart. It shows whether the heart is beatingproperly.The test involves the you lying on a couch andelectrodes being placed on the arms, legs andchest area. Duration: 10 min
ECHOCARDIOGARPHY (Echo)What is it?It’s a scan of your heart using ultrasound whichuses sound waves to produce an image of yourheart on a Monitor. It gives information on howwell your heart and its valves works.The test involves you lying on a couch. Gel isput on the chest so that pictures can be taken.Duration: 30-45 min
EXERCISE STRESS TESTWhat is it?It helps the Doctors to see how your heart respondsto stress. It provides information onwhether there might be narrowings in the bloodvessels to the heart.The test involves the electrodes being placedon 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 rateand rhythm over 24 hours.The test involves a small monitor attached tothe chest by three leads and taken home for 24hours. Attaching the monitor takes 10-20 minutes.
24hr BLOOD PRESSURE MONITORINGWhat is it?It provides a constant reading of your bloodpressure over 24 hours.The test involves a blood pressure monitor attachedto the arm of the patient and taken homefor 24 hours. Attaching the monitor takes 10-20
minutes.
369 Fulham RoadLondonSW10 9NHTel: 020 8746 8000
CARDIOLOGYONE STOPSHOP CLINIC
Page 50