cardiology referral guidance

57
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 Page 1

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Page 1: 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

Page 2: Cardiology referral guidance

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

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Page 3: Cardiology referral guidance

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).

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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

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Page 4: Cardiology referral guidance

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

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Page 6: Cardiology referral guidance

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).

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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

Page 7: Cardiology referral guidance

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

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Page 10: Cardiology referral guidance

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

Page 11: Cardiology referral guidance

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.

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Page 12: Cardiology referral guidance

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.

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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

Page 13: Cardiology referral guidance

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

Page 14: Cardiology referral guidance

Source: Atrial Fibrillation: the management of atrial fibrillation (Quick reference guide) (NICE clinical guidelines 36, NICE, June 2006).

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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

Page 23: Cardiology referral guidance

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

Page 24: Cardiology referral guidance

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

Page 25: Cardiology referral guidance

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

Page 26: Cardiology referral guidance

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

Page 27: Cardiology referral guidance

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.

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Page 28: Cardiology referral guidance

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

Page 29: Cardiology referral guidance

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

Page 30: Cardiology referral guidance

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.

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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

Page 31: Cardiology referral guidance

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.

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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

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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)

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(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)

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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)

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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)

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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

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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

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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)

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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:

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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

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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 ______________

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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

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