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CARDIOLOGY GUIDELINES

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									Bexhill & Rother PCG           Cardiology Guidelines                 November 2000




CARDIOVASCULAR
GUIDELINES

BEXHILL & ROTHER PCG

These guidelines have been produced by the PCG in advance of the Cardiology Education days
in November and December 2000. They incorporate guidelines and recommendations within
the Coronary Heart Disease National Service Framework (CHD NSF) as well as
recommendations of the British Hypertension Society and the Joint Societies Cardiac Risk
Assessment Chart. Other guidelines including those of the Scottish Intercollegiate Guidelines
Network, the Royal College of Physicians Stroke working party, the British Cardiac Society and
the European Society of Cardiology have been consulted. Dr David Walker, Dr John Rivett, Sr
Jeanette Ogden, Sr Sue Bliss, Mr S.M. Whitehead, Mr Andrew Sandison and Dr Mohammed
Chowdhury amongst others, have been involved in gathering this information.


As with all guidelines, it is the responsibility of the Clinician using them to make sure that they
are correct and up-to-date. The needs of an individual patient may require deviation from
these guidelines, which should not be seen as a rigid framework within which Clinical Practice
must take place. Doses of drugs and indications of drugs should be checked, and remain the
responsibility of the prescribing Clinician. The Guidelines are only valid until December 2001.


We hope that these Guidelines may be the first of a collection to address the way GPs
Diagnose, Investigate, Refer and Prescribe. Any feedback would be most welcome, and should
be addressed to Tim Baker or John Rivett at the PCG Offices.




                                      Page 1.1
Bexhill & Rother PCG             Cardiology Guidelines              November 2000



                                             Contents

Chapter 1.             The Coronary Heart Disease NSF                   Brief Summary
                                                                        Standards

Chapter 2.             The Conquest Hospital Cardiology Department


Chapter 3.             Smoking Cessation                                Outline
                                                                        The role of 1 care

Chapter 4.             Primary Prevention of CHD                        Aims & Standards


Chapter 5.             Secondary Prevention of CHD                      Aims & Standards


Chapter 6.             Stable Angina                                    Guidelines


Chapter 7.             Acute Coronary Syndromes                         (MI & Unstable Angina)


Chapter 8.             Revascularisation                                (CABG & Angioplasty)


Chapter 9.             Cardiac Rehabilitation                           Introduction
                                                                        Patient Information

Chapter 10.            Heart Failure                                    Guidelines


Chapter 11.            Hypertension                                     Introduction
                                                                        BHS Guidelines

Chapter 12.            Atrial Fibrillation                              Guidelines




                          Non-Cardiac Vascular Disease

Chapter 13.            Stroke                                           Local Services
                                                                        RCP Recommendations

Chapter 14.            TIA      (Dr M. Chowdhury)                       Guidelines


Chapter 15.            Vascular Surgery                                 Referral Guidelines
                              (Mr A. Sandison & Mr S. Whitehead)



Appendix 1.            DVLA Guidelines for Cardiovascular Disease


                                         Page 1.2
Bexhill & Rother PCG           Cardiology Guidelines                 November 2000



Chapter 1

The Coronary Heart Disease National Service Framework


The CHD NSF was published in early 2000. It consists of 12 standards, which cover CHD from
the first cigarette to the end of post-CABG rehab. It is well grounded in evidence, but also has
a very practical view as to the way forward. It is quite readable. There are some tough
standards for Hospitals, without large amounts of money being provided, as yet, to achieve
them. The standards which apply to Primary Care are perhaps easier, and to a large extent
based on what many GPs might feel is good quality Primary Care. Most of the key difficulties
relate to proper organisation of care, with maintenance of disease registers, working as a
team, and then delivering systematic care to patients identified as needing Primary or
Secondary Prevention measures. Appropriate use of Information Technology by GPs and
Nurses will be key to this. It may help to identify one GP and one Nurse in your practice, who
might lead the process, and will undertake to remain up to date with any changes in Cardiac
care, to audit the Practice’s performance and to feedback to others how things are going.

In the Bexhill & Rother PCG, we are trying to see if we can develop a CHD Scheme, analogous
to the “level 2” Diabetic scheme, with an associated Minimum Data Set, a core EMIS
template, and a defined educational and audit process for the Nurses and GPs involved. This
would build on the previous Bexhill Cardiac Follow-up scheme led by Dr Alastair Thompson.

The Standards are reproduced in full on the next page, but briefly, the most important for
General Practice are:

      Standard 2.     Reducing   the    prevalence   of   smoking   in   the   local   population.

      Standard 3.     Secondary prevention measures for those with Cardiovascular disease.

      Standard 4.     Primary prevention measures for those at significant risk of CHD.

      Standard 8.     Investigation, management and referral of people with possible angina.

      Standard 11. Investigation, management and referral of patients with heart failure.

The guidelines that deal with these particular standards will be found in later sections of this
document.

There are some “early milestones” which we are meant to achieve, which include:

      By Oct. 2000 every practice should have clinical teams that meet as a team at least
       once a quarter to plan and discuss results of clinical audit, and general clinical issues.

      By April 2001 every practice to have all medical records and hospital correspondence
       held so that they can be retrieved in date order, with drug therapy lists for those on
       long term Rx (might be on computer) and systematically developed and maintained
       practice-based CHD register in place, actively used to provide structured care to
       people with CHD.

      By April 2002, locally agreed protocols for assessment, treatment and follow-up of
       patients with CHD and/or Heart failure, being used to provide structured care.

      By April 2003, audit data from last 12 months looking at primary and secondary
       prevention, management of angina and heart failure.


                                        Page 1.3
Bexhill & Rother PCG        Cardiology Guidelines                    November 2000

The Twelve Standards

                       1.        The NHS & partner agencies should develop, implement and
                                 monitor policies that reduce the prevalence of coronary risk
                                 factors in the population, and reduce inequalities in risks of
                                 developing heart disease.

                       2.        The NHS & partner agencies should contribute to a reduction in
                                 the prevalence of smoking in the local population.

                       3.        General practitioners and primary care teams should identify all
                                 people with established Cardiovascular disease and offer
                                 them comprehensive advice and appropriate treatment to reduce
                                 their risks.

                       4.        General practitioners and primary care teams should identify all
                                 people at significant risk of cardiovascular disease but who
                                 have not yet developed symptoms and offer them appropriate
                                 advice and treatment to reduce their risks.

                       5.        People with symptoms of a possible heart attack should receive
                                 help from an individual equipped with and appropriately trained
                                 in the use of a defibrillator within 8 minutes of calling for help, to
                                 maximise the benefits of resuscitation, should it be necessary.

                       6.        People thought to be suffering from a heart attack should be
                                 assessed professionally, and if indicated, receive aspirin.
                                 Thrombolysis should be given within 60 minutes of calling for
                                 professional help.

                       7.        NHS trusts should put in place agreed protocols/systems of care
                                 so that people admitted to hospital with proven heart attack
                                 are appropriately assessed and offered treatments of proven
                                 clinical and cost-effectiveness to reduce their risk of disability and
                                 death.

                       8.        People with symptoms of angina or suspected angina should
                                 receive appropriate investigation and treatment to relieve their
                                 pain and reduce their risk of coronary events.

                       9.        People with angina that is increasing in frequency or severity
                                 should be referred to a Cardiologist urgently or, for those at
                                 greatest risk, as an emergency.

                       10.       NHS Trusts should put in place hospital-wide systems of care so
                                 that patients with suspected or confirmed CHD receive timely and
                                 appropriate investigation and treatment to relieve their
                                 symptoms and reduce their risk of subsequent coronary
                                 events.

                       11.       Doctors should arrange for people with suspected Heart Failure
                                 to be offered appropriate investigations (eg ecg, echo.) that will
                                 confirm or refute the diagnosis. For those in whom heart failure is
                                 confirmed, its cause should be identified – treatments most likely
                                 to both relieve their symptoms and reduce their risk of death
                                 should be offered.

                       12        NHS trusts should put in place agreed protocols/systems of care
                                 so that prior to leaving hospital, people admitted to hospital
                                 suffering from CHD have been invited to participate in a
                                 multidisciplinary programme of secondary prevention and
                                 cardiac rehabilitation. The aim of the programme will be to
                                 reduce the risk of subsequent cardiac problems and to promote
                                 their return to a full and normal life.

                                  Page 1.4
Bexhill & Rother PCG          Cardiology Guidelines                   November 2000
Chapter 2

The Conquest Hospital Cardiology Department

   We are based on level 2 in the Conquest Hospital, where we have our offices, laboratories,
    pacing room, CCU and James and Baird wards. We perform Diagnostic Angiography in the
    X-ray dept. where we also have access to radio-nucleotide exercise testing. We perform
    coronary angioplasties on our own lists at the new Cardiac Centre in Brighton, where other
    Consultants also perform Bypass Surgery and Electrophysiological Studies.


Department Staff

Dr Richard Wray,             General Medicine, General Cardiology, Lipids.
                             Secretaries: Miss Trish Hart & Mrs Debbie Avery Extn. 8318
                             Mobile no:    0777 5625538

Dr David Walker,             General Cardiology, Intervention and Pacing.
                             Secretaries: Mrs Ursula Cleaver & Clare Clarke       Extn. 6319
                             Mobile no:    0774 7795570

Drs Crook & Wierzbicki       Visiting Lipid specialist Consultants.
Dr Eric Rosenthal            Visiting Paediatric & Adult Congenital Heart Disease Cardiologist
Dr Sean O’Nunain             Visiting Consultant Cardiac Electophysologist.
                             All contacted via department.

Dr Hugh McIntyre,            Consultant DME, Special interest in Heart Failure.
Dr Isla Sitwell              Clinical Assistant, Cardiology clinics.
Dr Yvonne Underhill.         Clinical Assistant. Cardiology Clinics.

Staff Grade.                 Chest Pain Clinic.
Specialist Registrar.                                                             Bleep 519

Mr Sean Gaughan              Senior Chief Cardiac Technician.                     Extn. 8898
Mr David Cotterill           Senior Chief Cardiac Technician,                     Extn. 8002
Miss Hayley Jones            Senior Chief Cardiac Technician,                     Extn. 8002

Jeanette Ogden               Senior Nurse, Rehabilitation Team                    Extn. 8442

Joanne Barrett               Heart Function Nurse                                 Extn. 8431
Sylvia Murphy                Heart Function Nurse                                 Extn. 8431

Sue Bliss                    Smoking Cessation Advisor                            Extn. 8289

Debbie Hemsley               Lipid Specialist & 2 prevention Nurse               Extn. 8162
Jacqui Lynas                 Cardiac Dietician

Janet Sinclair               Research Sister                                      Extn. 8162
Karen Walker                 Research Sister                                      Extn. 8162

Jayne Cannon                 Nurse in Charge of Cardiology Wards
Mrs Toni de Freitas          Cardiology administration manager.                   Extn. 8029

       Chest Pain Clinics

    Mondays, Wednesdays and Fridays. Updated information will be sent to all GPs when this
    clinic starts, hopefully in early 2001.


                                     Page 1.5
     Bexhill & Rother PCG          Cardiology Guidelines               November 2000
     Chapter 3

     Smoking Cessation

        Smoking Cessation Services

     The introduction of Bupropion (Zyban) has led to increased requests to GPs for prescriptions
     for Bupropion, and more referrals to Smoking Cessation Advisors, such as Sue Bliss at the
     Conquest. The Health Authority position is that Bupropion, an atypical anti-depressant, has
     been proven to double successful “quit rates” in well-motivated patients who receive intensive
     support by fully trained advisors. Therefore, Bupropion should only be prescribed in this
     context. This may be seen as an evidence-based policy, or one based on cost-containment.

     Other experts have suggested that Bupropion may lead to a doubling of the quit rate in any
     setting, so that a 1 year quit rate might improve from 5 to 10% in General Practice, with brief
     intervention only, and from 15 to 30% in highly supported smoking cessation environments.
     (Continuous abstinence for a full year was achieved in 18.4% in the most rigorous trials). This
     would follow the pattern with Nicotine Replacement Therapy (NRT), where NRT increases “quit
     rates” in any setting, but the highest absolute benefit is in specialist clinics.

     Given the long-term health and financial costs of smoking, there might be good arguments for
     prescribing Bupropion outside specialist clinics. We will not be able to fund, staff or start
     enough specialist clinics to deal with all the potential demand that might emerge. In Smoking
     Cessation, cost-effectiveness suggests that giving a small amount of time to lots of patients,
     rather than lots of effort to a few, is better….



     Assessment of motivation to quit
     1. Is the quit attempt the patient’s idea?
     2. Has the patient attempted to quit 2-3 times over the last five years?
3.       Has the patient used NRT, alternative therapies or other methods in their attempts?
4.       Is the patient willing to; a) Set a Quit Date?
                                 b) Attend a minimum of 6 support sessions?
                                 c) Have regular reviews over the next year?

     The answer to all these questions should be yes before referral to a Smoking Cessation Clinic
     is considered. The questions appear at the top of the new Smoking Cessation Referral form.


     Our local Smoking Cessation Advisor works at the Conquest and has a clinic at Bexhill Hospital

                               Sue Bliss, Smoking Cessation Advisor
                                          Conquest Hospital
                                      Tel 01424 755255 (8289)
                                          Fax 01424 758132

     There are specialist workers dealing with smoking in pregnancy, which is a government
     priority. There is little evidence for success, as yet, for interventions in those who do not
     spontaneously quit when they become pregnant. Such patients may not be motivated to quit.
     These team members will work with young families, and as a team in adult cessation groups.

            Brenda Lynes-O’Meara                                     Debra Nash
            The Health Hut, 66 London Road,                          Sure Start
            St Leonards-on-Sea                                       Hastings
            Tel 01424 448120                                         Tel. 01424 448140



                                          Page 1.6
Bexhill & Rother PCG           Cardiology Guidelines                 November 2000

Some facts about smoking & smoking cessation
   Nicotine is strongly addictive. The cigarette is the perfect delivery device, and gets nicotine
    to the brain faster than intravenous injection. There are psychoactive changes and
    pleasurable feelings within 7 seconds of inhalation.

   The industry Tar ratings are based on a totally non-representative test, which bears little
    relevance to reality. The strength of cigarettes largely depends on the size and location of
    holes within the filters. The fingers of most smokers occlude these. “Mild” cigarette users
    may also inhale more strongly. It is possible to get more tar and nicotine out of some
    “Mild” cigarettes, than some of the full strength brands.

   Smoking more than 6 cigarettes within a short time leads to a 95% chance of addiction.

   Relapse rates after quitting smoking are as high as those for Heroin. Many Heroin addicts
    say that stopping smoking is more difficult than getting off Heroin.

   There are true pharmacological effects of tolerance, dependence and withdrawal in most
    smokers. Only 5% of regular smokers really are “social” non-dependent smokers.

   The first cigarette of the day may be particularly important to a smoker, as it gets blood
    nicotine levels rapidly up to a level where acute withdrawal symptoms and cravings
    disappear. A first cigarette within 30 minutes of waking is a good indicator of nicotine
    addiction.

   10 cigarettes/day might cost £700 per year. 20 cigarettes/day from age 20 to 60 if put in a
    fund with 6% net interest might give £242,000 by retirement age!

   Smoking kills 120,000 people a year in the UK. These people die 16 years prematurely on
    average. A third of these deaths are from cardiovascular disease, 46,600 from Cancer.

   The average healthcare costs for smokers are up to 40% higher than those for equivalent
    non-smokers. The total NHS costs of smoking related illness are £1.7 billion a year. This
    does not include the cost to the economy of lost productivity, or passive smoking

   In cost per life-year saved, advice and self-help materials to encourage smoking cessation
    (even with a quit rate of <5%) is at least 50 times more effective than prescribing Statins
    for Secondary Prevention.

   Stopping smoking leads to rapid reductions in the risk of Myocardial Infarction, and
    reduction in the risk of Lung Cancer. Until a patient has a terminal smoking-related illness,
    it really is never to late to stop.

   Three minutes of advice from a GP leads to a quit rate between 3-5% above the baseline.
    60–100 mins time given to 20-30 patients cumulatively might therefore lead to one
    smoker quitting, and still being a non-smoker 1 year later. It might take a Smoking
    Cessation Advisor working in a clinic 20 hours of time to achieve the same results, even
    assuming the best quit rates with Zyban, however they are dealing with a difficult group.

   GPs see 70% of their smokers each year. GPs and Practice Nurses may be well placed to
    make a cheap effective intervention that could save our patients’ lives.

   There is little evidence of any positive psychological effects of cigarettes, beyond the
    prevention of the symptoms of tobacco withdrawal. Some people report greater
    concentration. Cigarettes have a laxative effect for some.

   People do gain weight after stopping smoking, with increased eating and a gain of up to
    6kg. This may be partially mediated by Serotonin. They may also cough and expectorate
    more, develop asthmatic symptoms briefly, become constipated and depressed.

                                      Page 1.7
Bexhill & Rother PCG           Cardiology Guidelines                 November 2000

Smoking Cessation Drugs

Bupropion (Zyban)

   A Dopamine and Noradrenaline uptake inhibitor, this drug has in some trials led 1 year quit
    rates of between 18-30%, compared with placebo rates of 5-6% and rates with Nicotine
    patches of perhaps 10%. These results are in motivated quitters in research clinics. The
    “real world” figures may be a bit lower.

   Advantages over NRT are the better success rates, cheapness to the patients and easy
    dose regime. Compliance is good and weight gain may be less. It may prevent some of the
    lowering of mood that many quitters suffer from. It may also reduce cigarettes smoked
    when a patient on Bupropion relapses, from being as satisfying.

   Disadvantages include the lack of “displacement activity” which the nicotine gums, nasal
    sprays and “inhalator” may give with satisfaction of “oral cues” to smoke. There are also
    genuine side-effects, as with any other anti-depressant drug, which include dry mouth,
    insomnia, tremor, depression, anxiety, sweating, fever, tachycardia, hypertension,
    flushing, tinnitus, headache and GI disturbances etc. etc. Refer to product literature.

   Contraindications include epilepsy, eating disorders, bipolar disorder, pregnancy and
    breast-feeding.

   The dose regime is 150mg daily for 7 days, then 150mg BD. (elderly 150mg once daily).
    Continue 7-9 weeks, but stop if no abstinence at 7 weeks. Refer to BNF for further details.

   The cost (to the NHS) is about £85 for an 8 week course of treatment.


Nicotine Replacement Therapy

   NRT has been around longer, and we know more about it. It has fewer side-effects and
    contra-indications than Bupropion. There is associated displacement activity in the
    methods other than patches. Dose titration to help withdrawal is possible.

   All the methods are slower and less efficient at delivering nicotine “hits” to the brain than
    cigarettes. Only the nasal spray comes anywhere close. Much of the activity of the
    “inhalator” comes from absorption of the nicotine inhaled by the lining of the mouth.

   The cost to the NHS is zero, as the patient pays. If we are really serious about stopping
    patients smoking, perhaps eligibility for a few weeks of free NRT should be considered?
    Many low-income smokers use tobacco or cigarettes from Europe, (often illegally imported)
    so NRT may not offer the cost-savings over cigarettes you might expect…

   The nicotine nasal spray is currently the only form of NRT that is usually prescribed by GPs
    (on private prescriptions) as it is currently a prescription only drug. Other forms of NRT will
    be sold to patients by Pharmacists, who will advice on use and dosage.

   Contra-indications listed in the BNF to NRT, include severe cardiovascular disease
    (including severe arrhythmias or immediate post-MI period); recent CVA or TIAs;
    pregnancy and breast-feeding and chronic generalised skin disease.

   Side effects include nausea, dizziness, headache and cold-like symptoms; dyspepsia,
    insomnia, myalgia, anxiety and irritability etc etc. Local oral nasal, throat or skin problems
    may also occur, depending on which preparation is used. Refer to product literature.

   The aim should be to gradually reduce dosage over 10-12 weeks. If there is no success
    after 3 months, think again.

                                      Page 1.8
Bexhill & Rother PCG            Cardiology Guidelines               November 2000

The role of Primary Care

    There are four main tasks for Primary Care:


1.   Find out and record who your smokers are.
2.   Identify those who are motivated to quit.
3.   Advise and support, and if necessary, prescribe to these patients.
4.   Identify and refer those who are motivated to quit, but unable to do so with the support
     and expertise that your team has been able to offer.


    Ask about smoking at every opportunity.

    Advise all smokers to quit.

    Assess willingness to try, and to set a “Quit Date”

    Assist in quitting, with support, and NRT or Bupropion or referral if necessary.

    Arrange a follow-up. Even just telling a patient that you will be asking them again about
     their smoking increases quit rate.

    Tell patient to avoid alcohol & smokers. If they can avoid circumstances which are
     likely to lead to relapse, this will help.

    Suggest patient keeps money saved in a jar or moneybox and use to “reward”
     themselves for success.

    Suggest patient delays smoking by counting to 20, when urged to relapse. The craving
     may pass in this time, or patient may be able to escape from situation that is making them
     want to smoke.

    Tell patient to tell friends and relatives that quitting, and quit with partner. Any
     support may be helpful, and removal of smoking and cigarettes from home, may be
     especially important.

    Congratulate the patient on any success at all.

    Stress the importance of no-smoking, rather than reduced smoking. Someone
     smoking fewer or milder cigarettes may be getting as much tar and nicotine for the
     reasons detailed above. They may also return to previous habits, as they have not
     conquered their addiction. Quitting smoking is closer in concept to quitting Heroin than to
     dieting to lose weight. Complete Cessation is the goal.




                                       Page 1.9
Bexhill & Rother PCG            Cardiology Guidelines                November 2000


Chapter 4

Primary Prevention of CHD

   We would support the approach promoted by the NSF, which is a three-pronged attack ie:

       o   Public Health measures for the population; diet, education, exercise, anti-smoking.

       o   Smoking Cessation advice for any of our patients.

       o   More intense prevention measures for those at high future risk of Coronary Heart
           Disease events. The initial risk level is set at >30% /10years

   Such an approach will also help in the primary prevention of CVA, TIA and Peripheral
    Vascular Disease.

   Public Health Measures and Smoking Cessation are dealt with elsewhere in this document,
    so what follows relates to how to identify high CHD risk patients, and what to do for them.



Risk Assessment
   Whilst the initial risk level has been set at 30%, this will be reduced to 20% at some time
    in the future. This risk analysis approach is also used in the British Hypertension Society
    Guidelines, where a 10 year risk of >15 % triggers intervention at a lower level of blood
    pressure. Therefore accurate assessment of risk is vital. Given the future possible changes
    to levels of risk which trigger specific interventions, it is better to aim to calculate, record
    and code a patient’s risk as accurately as possible rather than just “>30%” or “<30%”.

   There are a number of Risk Assessment Tools, including the Sheffield and New Zealand
    tables, The Dundee Risk Disc, The Joint British Societies Risk Assessment Chart (found in
    the back of the most recent BNF), the computer programmes associated with this Chart,
    and various Drug Company provided computer programs. Some GP computer systems, will
    calculate a “Framingham Risk Estimate” from information coded within a Patient’s record,
    and this is the quickest, most accurate way of calculating CHD risk. However there are
    problems:

       o   These tools derive from the “Framingham Equation” and are appropriate for
           Caucasian men and women. Other racial groups may have either higher (e.g. South
           East Asian) or lower (Afro-Caribbean) risks than the tools might predict.

       o   A patient who has only just stopped smoking has a higher risk than a lifetime non-
           smoker, yet the tools do not discriminate. Therefore assessments may have to be
           tailored to reflect “lifetime smoking exposure”.

       o   Patients with CHD or familial Hyperlipidaemias are not included

       o   A family Hx of a first degree relative with CHD <60 (or men < 55, women <65),
           multiplies the risk by perhaps 1.5. It may be difficult to code a risk reflecting this.

   We would recommend use of computer programs which calculate risk using the
    Framingham Equation. The Joint British Societies Charts seem more accurate than other
    charts at calculating a risk, and offer a simple visual analogue which allows a patient to see
    how reducing their Total/HDL cholesterol ratio, or their blood pressure, or stopping
    smoking might take their risk from the red part of the chart to the orange, or the green.
    However The Joint Societies charts specifically exclude patients with established
    Hypertension.
                                      Page 1.10
Bexhill & Rother PCG           Cardiology Guidelines                 November 2000

   In order to calculate risk, you need to collect the following information:

       1.   Smoking History
       2.   Blood Pressure (Systolic)
       3.   Age
       4.   Sex
       5.   Diabetic?
       6.   Family History
       7.   Total Cholesterol/HDL ratio.
       8.   LV Hypertrophy (by voltage criteria) for some tools.

   If you look at the Joint British Societies Charts, you will see that the majority of those “in
    the red” (i.e. >30%/10yr CHD risk) are patients who will have already been diagnosed as
    Hypertensive, Diabetic or both. This observation accounts for the CHD NSF advice that
    detailed risk assessment for the entire population is not yet indicated, and that We should
    concentrate on assessing the CHD risk of those who have already been diagnosed
    as Hypertensive or Diabetic, but who have not yet developed CHD, TIA, CVA or
    PVD. Patients who already had developed those problems would qualify for the more
    intensive interventions for Secondary Prevention, detailed in the next chapter.

   In the Bexhill & Rother PCG , the average prevalences for Diabetes and Hypertension seem
    to be 2.5% and 10% respectively. There is some overlap, and some patients have already
    developed CHD. The new British Hypertension Society Guidelines will increase the number
    of patients diagnosed as Hypertensive. On the other hand, the available risk assessment
    tools relate to patients between 35-74. A rough guess might suggest that 10% of the
    patients on your list might need risk assessment. In a list of 2000 patients, that might
    mean 2 patients a week for 2 years. With use of computers and repeat prescription review
    appointments, this may not mean that much more work, as we should be seeing our
    Hypertensive and Diabetic patients every 6 months already. What will be more work is
    applying and monitoring the effects of primary prevention interventions to those who meet
    the >30% risk threshold.

   The recommended interventions for those without CHD or other occlusive arterial disease,
    with a CHD event risk >30%/10 years are:



The Recommended Primary Prevention Interventions are:

1. Advice on how to stop smoking, including advice on the use of Nicotine Replacement Rx.

2. Information on other modifiable risk factors, including personalised advice on how they be
   reduced. This includes Diet, Physical Activity, Alcohol, Weight, Diabetes.

3. Advice to and treatment to maintain blood pressure below 140/85 mmHg.

4. Statins to lower either serum cholesterol to <5mmol/L / reduced by 20-25% or
   LDL < 3mmol/L / reduced by 30%. (whichever is the greater reduction in each case).*

5. Meticulous Blood Pressure and Glycaemic Control in Diabetics

   * these are the modified reduction standards announced by Dr Roger Boyle, the National
    Director for Heart Disease, in October 2000, (BMJ letters, 28/10/2000) in response to
    criticism of the clarity of the original NSF targets, and their evidence base.

   Advice on management of Smoking, Blood Pressure and Lipids will be found in other
    chapters of this document.




                                      Page 1.11
Bexhill & Rother PCG            Cardiology Guidelines                November 2000


Chapter 5

Secondary Prevention of CHD

    Secondary prevention for those who already have occlusive cardiovascular
     disease is a priority as these patients have a high risk of further Cardiovascular events.

The Recommended Secondary Prevention Interventions are:

1)      Advice on how to stop smoking, including advice on use of Nicotine Replacement Rx.

2)      Information on other modifiable risk factors, including personalised advice on how they
        can be reduced. This includes Diet, Physical activity, Alcohol, Weight, Diabetes.

3)      Advice and Treatment to maintain blood pressure below 140/85 mmHg.

4)      Low dose Aspirin (75mg daily).

5)      Statins and dietary advice to lower either serum Cholesterol to < 5mmol/l /reduce
        by 20-25%, or LDL to < 3 mmol/l /reduce by 30% (whichever is the greater reduction
        in each case). These are the amended guidelines, from October 2000.

6)      ACE Inhibitors for people with proven left ventricular dysfunction.

7)      Beta-Blockers for people who have had a MI, unless contraindicated.

8)      Warfarin or Aspirin for those over 60 who are in Atrial Fibrillation.

9)      Meticulous Blood Pressure and Glycaemic Control in Diabetics




The target group for Secondary Prevention is:
    People with clinical evidence of CHD (Hx of MI, Angina, CABG or Angioplasty).

    People with a History of TIA.

    People with a History of Ischaemic Stroke.

    People with Peripheral Vascular Disease.




    However , there are some difficulties here.

        o   What age range do we use? Most research relates to the 35-74 year group, yet for
            most Cardiology interventions, Absolute Benefit increases with age as background
            risk increases. The NSF audit criteria specify this age range also, but the small print
            says we should apply the NSF standards to “all people, irrespective of age, who
            may benefit” . Until there is more research, particularly about Statins, do we know
            who will benefit?



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        o Most Practices will find that their Disease Registers do not differentiate between
           Ischaemic and Haemorrhagic stroke.




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       o   Angina & Peripheral Vascular Disease (PVD) may be “clinical” rather than “proven”
           diagnoses. Does PVD mean angiographically proven occlusion, or is an Ankle-
           Brachial Pressure Index of <0.8 sufficient? For the purposes of any future Bexhill &
           Rother PCG Cardiology Scheme, we will try to give firm diagnostic criteria, but the
           NSF seems vague on this.

       o   Building a good Disease Register for MI/CABG/Angioplasty/Angina is relatively easy.
           A search for patients with appropriate Read Codes, or taking Nitrates/Statins/low
           dose Aspirin/Clopidrogel/Nicorandil/Beta-Blockers/Diltiazem etc yielding perhaps
           90%. Maintaining the register is rather harder

       o   It may be a lot harder to identify patients who have had TIAs, Strokes or PVD.
           Luckily the early “milestone” is for a CHD Register not an arterial disease register.


   The first step is to identify the target patients to whom you wish to apply Secondary
    Prevention. Then you have to decide how you are going to assess and deal with them. The
    appropriate method will be different in different practices, depending on the size and
    setting of the practice, and the skills of the members of the Primary Health Care Team.
    What will be essential is a systematic approach, with good use of Information Technology.

   Models of Care might include

       o   Practice Nurse led clinics with GP support.
       o   GP & Nurse jointly run clinics, perhaps with GP dealing with medication, and Nurse
           with lifestyle factors.
       o   Outside Cardiac Liaison Nurse coming into surgery to implement secondary
           prevention.

   The local Cardiologists feel that, on balance of current evidence, Simvastatin (20-
    40mg nocte) and Pravastatin (40mg nocte) are the best first choices for
    prescribing a Statin. Atorvastatin (10-40mg) may be better if the baseline T.Chol
    is 7.5, or the Triglyceride level is greatly raised (as often occurs in Diabetics).
    Cerivastatin, although apparently cheaper, may need to be started at the high
    end of its dose range (400mg/day) and may be best reserved for those who do
    not tolerate other Statins.



The NSF Read Codes for CHD and other diagnoses include:

   CHD                             G3
   Angina                          G33
   MI                              G30
   Heart Failure                   G58
   Atrial Fibrillation             G573
   Stroke                          G66
   PVD                             G70

These are “high level codes” and more detailed “daughter” codes may be appropriate. Other
codes that may be useful are specified in the Bexhill & Rother PCG minimum data code set,
and the codes specified within the Diabetes level 2 scheme and future Bexhill & Rother PCG
Cardiology scheme details.

   Audit is important to prove what we have done, to meet the primary care milestones of
    the NSF, and most importantly, as a tool to help us improve our services to the patients.

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Chapter 6

Stable Angina

   Angina is the result of partial obstruction of a Coronary Artery by atheroma. It may
    develop gradually, or occur more suddenly as the result of thrombosis at the site of an
    atheromatous plaque.

   Risk factors include smoking, raised LDL Cholesterol, low HDL cholesterol, Hypertension
    and Diabetes. It is more common in men, and as age increases. Family history is
    significant. Diagnosis in women and Diabetics may be more difficult.

   The most characteristic pattern is of retrosternal chest pain on physical or emotional
    exertion, which is relieved by rest. Exertion in cold weather or after food may be more
    likely to lead to angina. It may also occur with sex. The discomfort may be in the arms,
    epigastrium, jaw or back instead of/in addition to the retrosternal area. It usually lasts for
    no more than 10 minutes after exercise ceases, indeed, typically anginal pain for longer
    than 15 minutes is an indication for calling a 999 ambulance. Pain which is clearly pleuritic,
    or focused in a small area, or left sub-mammary in the young is unlikely to be anginal.

   Some people may get an Angina equivalent, with no chest pain, but limited exercise
    tolerance, breathlessness and recovery after rest, but no signs, symptoms or ECG/Echo
    evidence of Heart Failure. Diabetics, and those who have previously had CABGs may
    present in this way, and should be regarded as having Angina until proven otherwise.

   Whilst many patients can have early investigations done in primary care, and some of the
    most important treatments can and should be started by GPs, proper objective
    diagnosis of angina needs referral, and investigation by a Cardiologist. This may
    require exercise ECG or exercise radio-nucleotide scanning, and/or Angiography. For some
    groups, especially women, a negative exercise ECG does not exclude angina. Before the
    full range of Secondary Prevention Interventions (see Chapter 5) are applied, it is sensible
    to be certain that the patient actually has Coronary Artery Disease!

   A rapid access Chest Pain Clinic should be available from April 2001 onwards, for the
    assessment of recent onset angina.



GP Assessment
   History, Rate of Progression, Risk Factors, Family History, Examination, BP.

   Look for other causes of chest pain, (Musculoskeletal pain, Reflux Oesophagitis), and
    causes of Angina other than CHD (anaemia, thyroid disease, valvular disease etc)

   Resting ECG, (may suggest LVH, old M.I.s, chronic ischaemia). Normal does not exclude
    angina.

   FBC, UEC, TSH, Fasting Glucose & Lipids, LFTS & CK (baseline for Statin Rx)

   Start Aspirin, trial of GTN (with pain, and prior to exercise which usually gives symptoms).

   Advice re diet and smoking.

   Consider advice about work, especially if Occupational Driving Licence or Pilots Licence.

   Beware rapidly developing or uncontrolled symptoms which may require urgent
    referral by fax. or phone.
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Angina Guidelines for GPs


             Patient with new
             onset of Angina




         ? Rapidly Worsening                           Consider admission.
                                              Yes
         ? Unrelieved by rest                          Otherwise Refer Chest
                                                       Pain Clinic urgently.


                  No

        1)      Start Aspirin
        2)      Trial of GTN
        3)      Check Risk Factors/FHx.
        4)      Examine, BP.
        5)      Fasting Glucose/Lipids,
                UEC, TSH, LFTS, CK, FBC.
        6)      12 Lead ECG




         ? Under 75 years old               Under 75
                                                        Refer Chest pain clinic
                                                        ? Start Beta-Blocker (or
                                                        Diltiazem if contra-indicated)


             Over 75

                                                        Refer Chest pain clinic if
     Diagnosis Certain ?                    No          diagnosis uncertain.
     No Anaemia, Thyrotoxicosis or                      Refer Cardiologist if valvular
     LVF or Valvular disease ?                          disease or LVF suspected.
                                                        Treat any underlying cause.

                Yes


        1. Secondary Prevention
           as per CHD NSF.
        2. Beta-Blocker or
           Diltiazem as first drug.
        3. Long-acting nitrate or
           nicorandil as second.
        4. Use maximum tolerated
           dose of each before
           adding next.
        5. Refer for help rather
           than adding third drug.




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Chapter 7

Acute Coronary Syndromes
This chapter is designed to give GPs a brief overview of current inpatient care for acute
coronary syndromes, as patients may request additional explanation from GPs after discharge.
It is not designed to be a complete guide to diagnosis and management.



1. Myocardial Infarction


Diagnosis

   The chest pain of AMI is usually central, crushing and severe, and typically is associated
    with SOB, nausea and sweating.
   The pain may radiate to the arms or neck.
   Older patients and diabetics may have little pain and present with LVF or hypotension.

Half the mortality from AMI occurs due to ventricular arrhythmias in the first hour and so early
admission is essential. Patients with chest pain for > 15 minutes should call a 999 ambulance.

Management

   Monitor on CCU (no age restriction)
   Oxygen and IV diamorphine
   Aspirin 300mg
   Thrombolysis – currently reteplase or streptokinase are used at the Conquest according to
    age and site of infarct. There are some contra-indications to thrombolysis.
   IV or subcutaneous heparin may follow.
   IV nitrates may be required for on-going pain or BP control
   IV -blockers reduce the risk of myocardial rupture and help control BP in the early stages
   Patients with hyperglycaemia will be put on an Insulin infusion, and patients with
    established NIDDM will be transferred to Insulin for 3-6 months. This reduces early
    mortality. (evidence from the DIGAMI trial).
   Gradual mobilisation aiming for discharge at 5-7 days
   Pre-discharge exercise testing may be performed to assess need for in-patient angiography

Consideration is given to long term treatment with:-
 Aspirin
 -blockers – reduce mortality, beneficial for at least 1 year post-MI
 ACE inhibitors – Ramipril currently favoured at the Conquest (AIRE study)
 Statins

Coronary angiography and PTCA (Angioplasty)

Angiography + PTCA during initial admission, post MI, may be done in the following groups:-

   Urgently where thrombolysis is contraindicated or there is cardiogenic shock, with a view
    to urgent PTCA (Primary PTCA)
   Urgently where thrombolysis has failed to achieve reperfusion (salvage PTCA)
   Recurrent ischaemic chest pain on mobilisation prior to discharge
   Positive exercise test pre discharge
   To investigate surgical complications of MI (Papillary muscle rupture, VSD etc.)
   To investigate ventricular arrhythmias (Late ie >24 hours post MI)



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2. Unstable Angina Pectoris or Non Q wave MI

Unstable angina and Non-Q wave infarcts are often considered together as the aims of
treatment are similar – ie to prevent more extensive myocardial damage. The early mortality
for these conditions is lower than for Q wave MI, but long-term progression to further
infarction is more common. Active management to avoid recurrent Unstable Angina or MI is
therefore essential.

Current management includes where appropriate:-
 Bed rest
 Aspirin, -blockers (or Diltiazem)
 IV nitrates
 Subcutaneous Low Molecular weight heparin (Enoxaparin at the Conquest Hospital)
 Glycoprotein IIb-IIIa antagonists (powerful anti-platelet agents such as Abciximab) for
   high risk cases, guided by Troponin T or I levels (see NICE guidelines)
 Early (in-patient) coronary angiography, guided in some cases by exercise testing
 Appropriate referral for revascularisation – see Chapter 8




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Chapter 8

Revascularisation


This chapter is designed to give GPs and Practice Nurses a brief overview of currently available
techniques used to treat patients with Ischaemic Heart Disease.


Angioplasty (PTCA)

History
   First done in 1977. Previously done in peripheral arteries.
   It works by a complex combination of disruption of the responsible atheromatous plaque,
    and effects on the arterial wall. The plaque is split, with tearing of smooth muscle in the
    blood vessel wall, and desquamation of the endothelium. This would lead to immediate
    occlusion and an infarct were it not for the use of Heparin and anti-platelet drugs. With the
    use of these drugs, repair takes place with regeneration of the endothelium and
    remodelling of the vessel. Some of the healing response (“intimal hyperplasia”) can lead to
    restenosis.

Clinical Indications

   Stable Angina.
   Unstable Angina (FRISC II now shows the benefits of invasive treatment).
   Acute MI (primary or salvage PTCA) – can reduce morbidity/mortality compared with
    thrombolysis.
   Post-infarction Angina.

Case Selection

   Single vessel disease is easier than multi-vessel disease, but stenting has made multi-
    vessel PTCA safer.
   Proximal lesions are generally easier to reach, but modern stents and balloons make
    tortuous anatomy easier to navigate than before.
   Diffuse distal disease is unlikely to be successfully dealt with by angioplasty.
   Difficult lesions that used to be avoided such as total occlusions, left main stems,
    bifurcations and multi-vessel disease, are now frequently and successfully dealt with.
   PTCA may be useful where surgery is contraindicated, e.g. age or chest disease.

Technique

   There is now a range of catheters, guide wires and balloons with different sizes, shapes
    and coatings for dealing with different lesions.
   Successful in >95%.

Complications

   Access site, eg bleeding (immediate), femoral false aneurysms (a few days later, contact
    cardiac registrar).
   Arrhythmias – uncommon apart from a few ventricular ectopics.
   Chest Pain – occurs at the time of balloon inflation; sedation is given.

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 Dissection
 Spasm – frequently occurs, intracoronary nitrates used.




                                   Page 1.20
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   Thrombo-embolism – 5%
   Emergency CABG, if acute occlusion cannot be reopened (<1% with stenting).
   Restenosis – 30-40%, but 10-20% with stenting.
   Death - <1% in most series, depending on case selection.

PTCA versus CABG

   PTCA is less invasive, with faster recovery and earlier return to work.
   PTCA has a lower early complication rate.
   PTCA may be more likely to require repeat intervention, (although much of the data is
    before stents came in). However delaying surgery may be useful.
   PTCA patients may need more anti-anginals in the long term, due to restenosis.
   Diabetics do better with CABG.
   Comparable mortality at 5 years.
   PTCA does not involve going on Cardiopulmonary Bypass, and the associated risk of
    neurological damage.


Stenting

   Developed in 1987.
   Allows more complex and difficult angioplasty, with complications dealt with immediately.
   Treatment of choice for acute Coronary Artery dissection, acute occlusion and sub-optimal
    results at angioplasty. Also for dealing with restenosis, with vein graft stenosis, and when
    doing proximal LAD angioplasty, when acute occlusion may be fatal.
   Following recent NICE guidelines all vessels between 2.5 and 3.5mm should be stented
    when angioplasty is done. This leads to a reduction in restenosis, and 85-90% of patients
    having at least one stent at angioplasty.


New Drugs used during Angioplasty & stenting

   Drugs acting on Platelets include Ticlodipine, which was widely used (off-licence) but is
    now largely superseded. Clopidrogel is now used with Aspirin, or as an alternative to
    Aspirin for 2-3 weeks after stenting.
   The Glycoprotein IIb-IIIa antagonists are increasingly used during angioplasty, and
    sometimes during unstable angina. The best-known drug is Abciximab (Reopro).
   Direct anti-thrombin drugs such as Hirudoid/Hirulog, have been used in trials but not
    routinely.


Other percutaneous techniques

   Rotablation – a kind of intracoronary drill, used in calcific lesions, blockages in stents etc.
   Directional atherectomy – a cutting technique especially favoured in the USA.
   Laser wire for total occlusions – Available at St Thomas’s.
   Intravascular ultrasound – a widely available useful technique, particularly good at
    assessing stent expansion.
   Intracoronary Brachytherapy – a technique using localised radiotherapy to reduce the
    risk of restenosis. A trial is currently in progress at Kings’.
   Thrombus extraction Catheters.
   Doppler and pressure wires - newer techniques for assessing lesion severity.
   Coated Stents- Gold, Heparin, Carbon etc, to reduce stenosis and thrombosis.
   Percutaneous Trans-myocardial Revascularisation (TMR). This was initially
    performed by Cardiac Surgeons with the heart exposed. Now it is done on a beating heart
    (ie off-bypass), using a small left chest incision, and a CO2 laser to make channels in
    ischaemic heart muscle. Currently it is used in patients with intractable angina on full
    medical therapy, especially where the anatomy is unfavourable for PTCA or CABG.

                                      Page 1.21
Bexhill & Rother PCG          Cardiology Guidelines               November 2000

Coronary Artery Bypass Grafting


   CABG is an effective treatment for angina, and also has prognostic benefit in certain
    groups. Despite all the new techniques listed above, it is being done increasingly
    frequently. This operation comprises 80% of the workload of Cardiac Surgeons. The CHD
    NSF has set a target of 750 CABGs and 750 PTCAs per million population per year, and
    although our Health Authority has one of the higher rates in southern England, we can
    expect more CABGs and PTCAs done on our patients as we get better at referring and
    treating angina, and as treatment post-MI becomes more intensive.
   Apart from the inpatient stay (5-8 days), and the problems resulting from having a midline
    sternotomy, one of the main problems with CABG, is that it involves going on cardio-
    pulmonary bypass (“heart-lung” machine). This allows the heart to be stopped during
    surgery. Major embolic complications, such as stroke, rarely occur, but minor degrees of
    cognitive and neurological impairment are more common. Newer off-bypass techniques are
    getting around this problem in some clinical situations.
   Patients requiring CABG are referred by the Cardiologists at the Conquest, to the Sussex
    Cardiac Centre, at Brighton. The Consultant Surgeons there are Mr Forsyth, Mr Trivedi and
    Mr Pugsley. Surgical post-op complications can be referred back to them.

Indications

   Better prognosis; eg Left Main Stem, or triple vessel disease with impaired LV function.
   Failed PTCA.
   PTCA technically impossible, or unlikely to achieve satisfactory long term result.
   Diabetics do better with CABG than PTCA (higher rate of restenosis in Diabetics having
    PTCA.
   Where thoracotomy required for other reasons, eg valve replacement.

Arterial versus Venous Grafts

   Venous grafts, from leg or arm veins, have roughly a 50% patency rate at 5-10 years.
    Trials using the Left Internal Thoracic Artery (LITA), also known as the left internal
    mammary artery (LIMA), show much greater longevity. Now LIMA and RIMA grafts are
    commonly used. Some centres also use Radial artery grafts, to do “total arterial”
    operations.

Off-Bypass Grafts

   Some grafts can now be done “off-bypass” using techniques such as “MIDCAB” and
    “PORTCAB”. A special device called an “octopus” is used to hold the artery still, allowing
    the surgeon to sew the graft onto the beating heart. This reduces embolic complications. It
    also allows the operation to be done, in some cases, through a minimally-invasive incision.
    It may be especially useful in the elderly and those with cerebro-vascular disease.




                                    Page 1.22
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Chapter 9

Cardiac Rehabilitation

 “…the sum of activities required to influence favourably the underlying cause of the disease as
well as the best possible physical, mental and social conditions, so that people may, by their
own efforts preserve or resume when lost, as normal a place as possible in the community.
Rehabilitation cannot be regarded as an isolated form or stage of therapy but must be
integrated within secondary prevention services of which it forms only one”…
                                                   (World Health Organisation definition)

   The clinical effectiveness and cost-effectiveness of Cardiac Rehab. is well established
    following acute MI, before and after CABG and Angioplasty, for those with Stable Angina
    and Heart Failure, and those having Cardiac Transplants. It has not been shown to be
    helpful for those with Unstable Angina. Cardiac rehab. may reduce mortality by up to 20-
    25% over three years. Compare this with Statin and ACEI usage….

   We are lucky in our area in having a well-established Cardiac rehab. team and programme,
    with expertise, a good audit database and an excellent uptake. Whether Primary Care
    Teams have been good at continuing rehab. interventions when the Cardiac rehab. team
    have finished their role, or referring patients who have not been admitted, is another
    matter. We are indebted to Jeanette Ogden, the Lead nurse from the team, for much of
    the information that follows:-


a) What Rehab. actually is – the four “phases”


Phase 1 – Before Discharge from Hospital

NSF suggestions

   Assessment of physical, psychological and social needs for cardiac rehab.
   Negotiation of written individual plan to meet these needs, (copy to patient and GP)
   Initial advice on lifestyle, e.g. smoking, physical and sexual activity, diet, alcohol, work.
   Prescription of effective medication (see chapters 5 & 7). Education re its use, benefits &
    harms.
   Involvement of relevant informal carer(s).
   Provision of information about Cardiac Support Groups.
   Provision of locally relevant written information about cardiac rehab.

How the Conquest Rehab. team achieve this.

   Visit wards daily to identify patients.
   Individual assessment and management of patients likely to benefit, looking at physical,
    psychological and social needs.
   Ensure understanding of diagnosis and treatments.
   Give written going home guidelines. Discussion of recovery process and exercise plan.
   Advice on appropriate action if chest pain recurs.
   Initial risk factor assessment and advice on lifestyle modification.
   Hospital Anxiety and Depression (HAD) score to assess psychological needs.
   Negotiation of plan to meet these needs. Information given re Cardiac Rehab. course.
   Referrals to other team members as indicated, eg Dietician, Lipid Nurse, Smoking
    Cessation advisor, Psychology services.
   Involvement of partner and/or carers where possible.


                                     Page 1.23
Bexhill & Rother PCG         Cardiology Guidelines               November 2000
 Level of information given at this stage may need to be tailored to patients comprehension
   and receptiveness.




                                   Page 1.24
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Phase 2 – Early Post-Discharge Period


NSF suggestions

   Full assessment of Cardiac Risk, including physical, psychological and social needs for
    cardiac rehab; and a review of the plan for meeting these needs.
   Provision of lifestyle advice and psychological interventions from trained therapists who are
    supported by a Cardiologist.
   Maintain involvement of relevant carers, review involvement with support groups.
   Offer resuscitation training for family members.

How the Conquest Rehab. team achieve this.

   Home visit by BHF nurse 2-7 days post discharge to ensure support and equity of follow-
    up. This visit is arranged prior to discharge or by phone shortly after discharge.
   Involving of partners and relatives in recovery process, taking the opportunity to give to
    primary prevention advice.
   Assessment of physical and psychological recovery. ECG if needed.
   Reassess and complete risk factor assessment, and need for other team member input.
   Provide and repeat lifestyle advice, discussing recovery and exercise plan.
   Check secondary prevention medication prescription, compliance and side-effects, liasing
    with GP as necessary.
   Encourage attendance at phase 3 sessions. Consider home rehab. if this is inappropriate.
   Assess social support and liase with local agencies such as Age Concern, HARC etc.




Phase 3 – Four Weeks after an Acute Cardiac Event


NSF Suggestions

   As phase 2 plus:
   Structured exercise sessions to meet the assessed needs of the patient. This may need to
    be more than 6-12 weeks to reduce Angina.
   Maintain access to advice and support from people trained to advise about exercise,
    relaxation, psychological interventions, health promotion and occupational advice.

How the Conquest Rehab. team achieve this.

   6 week programme combining exercise, education and addressing of psychological needs.
   Exercise prescription is individualised using risk stratification.
   BP, Heart Rate, Weight, Abdominal girth monitored.
   Recheck HAD score.
   Lipids checked at 6-12 weeks post event. ECG, 24hr-tape, exercise ECG as indicated.
   Follow up of test results, arrangement of out-patient appointments.
   Identification of complications requiring early medical review.
   Give information re phase 4 rehab. and Heart Support Group.
   Assess suitability and motivation to participate in phase 4. Arrange phase 4 rehab.
   Send discharge letter to GP on completion of course.




                                     Page 1.25
Bexhill & Rother PCG           Cardiology Guidelines              November 2000


Phase 4 – Long-term Maintenance of Changed Behaviour

NSF Suggestions

    Long-term follow-up in Primary Care
    Offer involvement with support groups.
    Referral to specialist cardiac, exercise, smoking cessation or psychological services as
     indicated

How the Conquest Rehab. team achieve this.

    Healthy Hearts at Ocean Fitness, 2hrs once a week.
    Continuing exercise programme using Cardiac Rehab. Nurse and Exercise Specialist input.
    Involvement of Heart Support Network.
    12 month follow-up questionnaire. Initiate action on unresolved issues.


b)    Referrals to the Cardiac Rehab. team

    Not every one who might benefit from Cardiac Rehab. passes through the Conquest
     Hospital. So referrals are also accepted from other hospitals, from tertiary centres, and
     from GPs and other members of Primary Health Care Teams. Referrals may be by
     telephone or letter, and should give patients cardiac risk factors and history.

    Currently the Cardiac Rehab. Team is happy to accept referrals of those with a Hx of MI,
     Stable Angina, Pre/Post PTCAStent, Pre/Post Cardiac Surgery, Pre/Post automatic Defib.
     Implantation and those with CHD evident on angiography. Although rehab. has proven
     benefits in Heart Failure, this is not yet offered.


c) Audit of Rehab.

    There is a well-defined database devised by the BHF that the local rehab. team already
     uses. The CHD NSF specifies tough audit criteria for Cardiac Rehab. teams and early post-
     MI/revascularisation secondary prevention, including non-smoking, BMI<30% and regular
     exercise in >50% of this group at 1 year. The NSF also sets a minimum target of >85% of
     patients with these diagnoses being enrolled in a proper scheme. It is clear, that using
     their database, 12 month follow-up questionnaires and ongoing audit, the Rehab. team are
     better placed than most clinical teams to meet the audit requirements of the NSF.


d) The Role of the Primary Health Care Team

    It should be obvious from the above, that most of Phase 4 Rehab. belongs in the
     community and in Primary Care. This means we have to develop better links with the
     Cardiac rehab team, agree on secondary prevention and Rehab. interventions, learn
     together and communicate better, and share data and audit.

    Different models of improving the interface between the Cardiac Rehab Team and Primary
     Care, might involve informal contacts, Cardiac Outreach Nurses, or CHD follow-up and
     Secondary prevention clinics in Primary Care. The Bexhill & Rother PCG is currently
     working on a local scheme, similar to the Diabetic scheme, to provide CHD follow-up,
     Secondary prevention and Phase 4 rehab. within Primary Care.

    We should also be aware that many of the most effective interventions do not necessarily
     involve prescribing medication.


                                    Page 1.26
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Chapter 10
HEART FAILURE

Introduction

   A clinical syndrome caused by a reduction in the heart’s ability to pump blood around the body.
    Breathlessness, ankle oedema and increased risk of sudden death may result. Most cases in the UK are
    due to CHD, with perhaps a third resulting from hypertensive heart disease. The mean age of
    presentation is 76 in the UK, with two males for every female.

   The prognosis for Heart Failure is often poor, although ACE Inhibitors have improved matters. The
    mortality for Heart Failure is often compared with Cancer, but the high risk of sudden death makes
    prediction for individual patients difficult. There is certainly evidence that many admissions of patients
    with Heart Failure could have been prevented.

   Making an accurate diagnosis in Heart Failure (HF) is not easy in General Practice. Probably half the
    patients in the community with HF remain undiagnosed, and half the patients we have traditionally
    treated as having HF do not have it. Symptoms such as Orthopnoea, oedema and Paroxysmal
    Nocturnal Dyspnoea (PND) are very likely to mean that a patient has HF, but less than a third of HF
    patients actually have them. Basal crackles are not a very specific sign.

   Accurate diagnosis of HF requires investigation, e.g. ECG and Echocardiography. As diagnosis of HF
    now means we will be likely to give a patient the largest dose of an ACE Inhibitor or AT 2 Antagonist that
    they can tolerate, and then add Spironolactone, Echocardiography should be the Gold Standard for
    diagnosis of Heart Failure. ECG and CXR combined may support a diagnosis, and some Cardiologists
    say that if both ECG and CXR are normal, HF is unlikely, but the information that an Echo gives is
    unrivalled.

   We hope that a One-Stop Heart Failure Clinic will become available at the Conquest. This would be for
    patients who had no murmurs or symptomatic Coronary Heart Disease. They would be seen, have an
    echocardiogram, and then be sent back to GPs with a firm diagnosis, and guidelines for future
    treatment.

   Echocardiograms are not currently available at the same visit as outpatient appointments in any clinics
    outside the Cardiology Dept. Currently the majority of echocardiograms are performed by technicians,
    and their interpretation often requires detailed training in echocardiography – particularly in areas such
    as valve disease and diastolic dysfunction.

   The advances in echocardiography and the increasing diagnosis of Diastolic Dysfunction, combined with
    the trend for prescribing -blockers in LVF mean that we cannot recommend or support “open-access”
    echocardiography. Nevertheless there is much we can get on and do.



                                     GP Investigation of Heart Failure

        1)      History, including symptoms of CHD and Respiratory Disease.
        2)      Examination, including BP and Heart Sounds. Baseline Weight.
        3)      FBC, UEC, Glucose, TSH, Lipids (if CHD, Hypertension or Diabetes).
        4)      12 lead ECG.
        5)      CXR, PEFR or Spirometry if respiratory disease might explain symptoms.




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Bexhill & Rother PCG              Cardiology Guidelines                    November 2000

Current local referral guidelines.


                                        Patient with ? HF




    Symptomatic IHD.                   All other patients with           Elderly, with long Hx of
    or recent MI or possible           possible Heart Failure            Hypertension, or stable IHD,
    Valvular disease.                                                    and no murmurs




    Refer General Cardiology         Refer Cardiology for one-stop       GP investigations, then
    clinic urgently.                 clinic (general, or HF one-stop     consider trial of ACE
    Admit if unwell                  clinic, when it becomes
                                     available)
                                                                         inhibitor.
                                                                         Refer if fails to help.




Non-Pharmacological Treatment of LVF

   Avoid Salt-rich foods.

   Offer Smoking Cessation advice and treatment.

   Aim to reduce weight in a slow controlled manner, if obese.

   Alcohol 1-2 units/day only. Avoid completely in Alcoholic Cardiomyopathy.

   Exercise programmes may help. Cardiac Rehab. programmes are shown to be effective.

   Other primary and secondary prevention interventions as indicated in chapters 4 & 5.


Usual Pharmacological Treatment of LVF

   Stop any drugs that might be causing LVF, e.g. NSAIDS and many Calcium Antagonists.

   Consider using an ACE Inhibitor up to the maximum tolerated dose. The Cardiology Consultants
    currently recommend Ramipil, Perindopril or Lisinopril. Do UECs before, after 2 weeks, 6 months and
    yearly thereafter. Dose changes or addition of diuretics may require further tests after 1-2 weeks. Be
    aware of the risk of Renal Artery Stenosis, especially in Diabetics or Arteriopaths. MR angiography may
    be indicated.

   Spironolactone is now known to improve prognosis in moderate-severe heart failure, and should be
    started in most people with echo-proven LV dysfunction. 25mg a day is enough. Renal function and
    potassium must be monitored closely.

   Loop Diuretics. Bumetanide (which is better absorbed than Frusemide, if RVF is present), should be
    used if signs of fluid retention. Patients who need more than 2mg Bumetanide a day should see a
    specialist at least once. Diuretics may need to be reduced or omitted for a day or two when an ACE
    inhibitor is started. Do not use Metolazone or Thiazide diuretics in combination with loop diuretics
    without specialist advice.




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Bexhill & Rother PCG                Cardiology Guidelines                   November 2000


   Digoxin. May be useful in moderate or severe Heart Failure (NYHA grades III – IV), if symptoms
    persist.

   AT2 Antagonists. Consider if intolerable cough from ACE Inhibitor. Although most trials showing
    prognostic benefit in LVF and Hypertension relate to ACE Inhibitors (which should remain first choice),
    there is trial data showing benefit with Losartan.

   -Blockers. These are being increasingly used in heart failure, under specialist supervision only.
    Carvedilol, Metoprolol and Bisoprolol are among the most commonly used drugs.


Other Treatments

   Hydralazine/ISDN.        A combination that Cardiologists will sometimes use if ACE Inhibitors are not
    tolerated

   AF. Treatment with Digoxin, Amiodarone, or Cardioversion may improve the heart’s ability to function
    as a pump. Warfarin is usually indicated.

   Angina.     Nitrates, -blocker or long acting Calcium antagonists may help increase exercise tolerance
    when patients have both angina and Heart Failure. Revascularisation may help angina. Prognostic
    effect on LVF is less certain.

   Transplantation        Patients <65, with severe CHF, not amenable to revascularisation, may be
    considered for Cardiac Transplant.

   Statins       May be needed if the patient meets 1 or 2 CHD NSF Criteria.

   Immunisations         Patients with LVF should have once-only Pneumococcal vaccine, and annual flu
    vaccination.


Palliative Care

   While some patients will continue an almost normal life, many will die suddenly. Others will go though a
    terminal phase of illness similar to that often occurring with Cancer, requiring palliation with Oxygen,
    morphine, and Nursing and Social care. There can be few more intensely fear provoking experiences
    than being unable to breathe at rest. Carers will need support.


Audit

   Throughout the NSF there is an emphasis on Audit. As far as 1 care is concerned, we are asked to look
    at:-

                     The number and % of registered patients we have with a diagnosis of HF.
                     The number and % with confirmed HF/LV Dysfunction taking ACE Inhibitors.

   Later, the PCG/PCT and Trust may be asked to report:-

                     The number and % diagnosed as having HF, who have ever undergone an Echo.
                     Mortality, Admission and Palliative care uptake for those with Heart Failure.




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Chapter 11

Hypertension

   The 1999 British Hypertension Society Guidelines move away from the old approach of
    “Stepped-Care” with a “one-size-fits-all” treatment threshold, towards a more
    individualised system with different thresholds of risk at which treatment starts, and tough
    standards for treatment success. With usage of Ambulatory Blood Pressure Monitoring
    (ABPM), which is now incorporated within the BHS guidelines, we may treat some patients
    less intensively, but spend more time on those who will benefit most.



    Three questions you need to ask when deciding whether to start Rx

       1)      What is the patient’s Blood Pressure?
       2)      Is there any Target Organ Damage, Cardiovascular Disease or Diabetes?
       3)      What is the patient’s 10 year Cardiac Risk?




1) Measuring Blood Pressures

   All adults should have their BP measured routinely at least every 5 years until age 80.

   Use a sphyg. with validated accuracy that is properly maintained and calibrated.

   Patients seated with cuff at heart level, with cuff size appropriate for arm size.

   Diastolic BP is recorded as disappearance of the sounds (phase V).

   Minimum of 2 measurements at each of several visits. Record to nearest 2 mmHg.

   Consider standing BP in the elderly or diabetics to exclude orthostatic hypertension.


Ambulatory Blood Pressure Measurement (ABPM or CABP)

   ABPM may correlate better with risk of future CHD events than single clinic BPs.

   It is really the risk of future CHD or target organ damage that we are trying to reduce
    rather than the BP, which is a “substitute end-point”.

   At the moment access to ABPM is via the Cardiology Department. The PCG is trying to
    change this. Protocol-led usage of ABPM machines within Practices might be one way.

   Mean daytime ABPM BP is lower than mean clinic BP, so treatment thresholds and targets
    are lower . A daytime mean ABM of 140/80 is roughly equivalent to a clinic BP of 160/90.

                  Indications for Ambulatory BP Measurement

       1)      When   Clinic BP shows unusual variability.
       2)      When   “White-Coat Hypertension” is suspected.
       3)      When   Hypertension is resistant to treatment with three or more drugs.
       4)      When   symptoms suggest the possibility of hypotension due to treatment.




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2) Investigating Hypertension


                      Why do investigations in Hypertension ?

       1)     To   look for any underlying cause.
       2)     To   look for co-existing Diabetes and Coronary Heart Disease
       3)     To   look for Target Organ Damage (eyes, heart, kidneys)
       4)     To   calculate future CHD risk
       5)     To   act as a baseline for future changes due to Hypertension or treatment




                       Routine Investigations in Hypertension

       1)     Urine Dipstick for Blood, Protein and Glucose.
       2)     Electrolytes & Creatinine,
       3)     Fasting Glucose and Lipids.
       4)     12 lead ECG.
       5)     Examination including Heart size and sounds, carotid & renal bruits.


   In younger patients (particularly below 40 years old) the initial emphasis may be on
    excluding underlying causes, with additional investigations including 24hr Urinary
    VMAs/5HIAA, Cortisol levels, Renal Ultrasound, Echocardiography, ABPM etc.

   In Diabetics cardiac risk is automatically higher, and the risk of Renal Artery Stenosis is
    also high. MRA of Renal Arteries may be indicated, especially if the patient already has
    occlusive arterial disease elsewhere, or if more than two drugs are needed to control BP.

   Consider examining the fundi in diabetics and those with severe hypertension,




3) Assessing Cardiac Risk


   Here, as in Primary Prevention of CHD, the idea is to take age, sex, smoking history,
    Systolic Blood Pressure, presence or absence of Diabetes and/or Left Ventricular
    Hypertrophy, and calculate the risk of developing CHD in the next 10 years.

   As mentioned in chapter 4, there are various available risk assessment tools, based on the
    “Framingham Equation”. The Sheffield charts seem less accurate in determining risk, and
    the New Zealand tables are now on a 5 year basis. As a visual analogue the Joint British
    Societies CHD risk charts are hard to beat, but they specifically exclude patients
    with established hypertension or LVH. This rather negates their point….

   There are good free-standing computer risk prediction programmes available from drug
    companies, or associated with the Joint Societies charts. One of the best ways of
    calculating risk for EMIS practices, is to use the embedded Framingham 10 year CHD risk
    Estimate formula which can be used to calculate risk from within templates. This gets rid of
    the need to flip between programmes during consultations.

   While the Primary Prevention interventions within the CHD NSF trigger at a 30% risk, the
    risk level which the BHS use for deciding the treatment threshold is 15%. As future
    thresholds may change, it is useful to make sure you record your patients estimated risk in
    a form which allows easy display, and easy searching.
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4) Deciding when to treat Hypertension


         The British Hypertension Society Guidelines

        Thresholds for Intervention

                                    Initial Blood Pressure



           >200           160-199           140-159               135-139         <135
            /110          100-109            90-99                 85-89           /85




            *                 **                       ***


                    >160/10           140-159         <140/90
                    0                  90-99


                      Target Organ             No Target Organ
                        Damage                 damage,
                            or                     No Diabetes,
                    CVS Complications
                                               No
                            or
                         Diabetes              Cardiovascular
                            or                 complications.
                   10yr CHD risk >15%          and
                                               10y CHD risk<15%



                 Treat                   Observe, reassess
                                           CHD risk yearly
                                                                   Reassess
                                                                    Yearly
                                                                                    Reassess
                                                                                   in 5 years



    *     Unless malignant phase/hypertensive emergency, confirm over 1-2 weeks then treat.

    **    If Target Organ Damage, Cardiovascular Complications or Diabetes present, confirm over
           3-4 weeks then treat. If all absent, re-measure weekly, and treat if BP persists at this
           level for 4-12 weeks.

    *** If Target Organ Damage, Cardiovascular Complications or Diabetes present, confirm
         over 12 weeks then treat. If all absent, check monthly and treat if estimated risk >15%




                                               Special Groups

   For Patients with Diabetes, below the age of 80 we should treat if BP > 140/85.

   For Patients with Established CHD, a Hx of Ischaemic Stroke, TIA or proven
    Peripheral Vascular Disease, the CHD NSF secondary prevention guidelines should be
    followed, with maintenance of BP below 140/85.

   For Patients with established proteinuria or renal disease, treat if BP >130/70.



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Bexhill & Rother PCG          Cardiology Guidelines          November 2000
 For Elderly Patients isolated systolic hypertension (>160/<90), carries increased risks
   and reducing Systolic BP to below 160 is justified.




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Bexhill & Rother PCG                   Cardiology Guidelines                        November 2000

5) How to treat Hypertension

      Lifestyle modification is important, and should not be forgotten.

                              Recommended Lifestyle Modifications

      For Blood Pressure lowering:-
          1)    Weight loss via reduced fat and calorie intake.
          2)    Regular dynamic physical exercise, (e.g. brisk walking for 20 minutes a day).
          3)    Reduced use of salt in food preparation, and reduced consumption of salty food.
          4)    Increased intake of fruit and vegetables. ( BHS recommend 7 portions/day!)
          5)    Limit alcohol consumption. (<21 u/wk for men, <14 u/week for women)

      For Cardiovascular Disease Prevention:-
          1)    Stop smoking.
          2)    Reduce intake of saturated fat, and replace with mono- or polyunsaturated fat.
          3)    Increased intake of oily fish.
          4)    Regular physical exercise.


      The CHD NSF guidelines for Primary and Secondary Prevention should be applied
       where relevant, which may involve Aspirin, Statins, ACE inhibitors where proven Left
       Ventricular Dysfunction, Beta-Blockers where previous MI, and Warfarin in some cases of
       AF.

      Beyond that, the choice of drugs may depend on Patients’ and GPs’ preferences and
       coexisting pathology. The BHS guidelines provide some useful guidance. Some experts
       have felt that they understated the prognostic benefits of using ACE inhibitors in those who
       do not have LV dysfunction or Diabetes, and that ACE inhibitors should be used earlier.



                                           Indications                              Contraindications

     Drug Class              Compelling            Possible                 Possible              Compelling
     Alpha-Blockers          Prostatism            Dyslipidaemia            Postural              Urinary
                                                                            Hypotension           incontinence
     ACE Inhibitors          Heart Failure         Chronic Renal            Renal                 Pregnancy.
                             LV Dysfunction        Disease. *               Impairment *          Renal Artery
                                                   Type II Diabetic         Peripheral Vasc.      Stenosis
                                                   Nephropathy.             disease. #
     AT 2 Receptor           ACE inhibitor         Heart Failure.           Peripheral Vasc.      Pregnancy.
     Antagonists.            cough, when           Intolerance of           disease. #            Renal     Artery
     (Sartans)               ACEI indicated        other drugs.                                   Stenosis.
     Beta-Blockers           M.I.                  Heart failure.           Heart failure.        Asthma/COPD
                             Angina                (in specialist care      Dyslipidaemia         Heart Block
                                                   as may worsen)           Periph.Vasc.Dis.
     Calc. antagonists       Systolic              Angina.
     (dihydropyridine)       Hypertension in       Elderly Patients.
     e.g. Lacidipine         the elderly
     Calc. antagonists       Angina                M.I.                     Beta-Blockers.        Heart Block
     (rate-limiting)                                                        (no -blockers        Heart Failure
     e.g. Diltiazem.                                                        with Verapamil)
     Thiazides               Elderly Patients                               Dyslipidaemia         Gout

    * ACEIs may be beneficial in chronic renal failure, but close supervision and specialist advice needed.
    # Caution with ACEIs and AT 2 antagonists in Peripheral Vascular Disease. Risk of Renal Artery Stenosis.


                                               Page 1.34
Bexhill & Rother PCG            Cardiology Guidelines                 November 2000

Dosing & Combination Therapy

   Start with lowest recommended dose. Allow at least 4 weeks to observe full response,
    unless it is necessary to lower blood pressure more urgently.

   If partially effective but well tolerated, increase dose (except thiazides).

   If ineffective or partially effective, change drug or add a drug with a complementary
    action. If not well tolerated change drug to another class.

   More than one drug will be needed to do the job properly in most patients.

   -Blockers with ACE Inhibitors, and Calcium antagonists with diuretics are considered by
    the BHS Guidelines to be less logical combinations than most others. Verapamil and -
    blockers should never be prescribed together.


6) How low is low enough?

   The BHS suggests the following targets:

                                 Measured in clinic                   Mean Daytime ABPM
                                                                     Or home measurement
Blood Pressure         No diabetes        Diabetes             No diabetes      Diabetes
Optimal                <140/85            <140/80              <130/80          <130/75
Audit Standard         <150/90            <140/85              <140/85          <140/80


   Once BP has been stabilised by drug and lifestyle changes, the BHS suggests that follow-
    up should be every 3-6 months, with measurement of BP and weight, and annual urine
    testing for proteinuria. Some treatment regimes (ACE Inhibitors etc) and co-existent
    diseases (Diabetes & Thyroid disease etc.) will require regular blood tests.


7) Who to refer?

                i.     Urgent Treatment needed; Malignant Hypertension etc
               ii.     To look for suspected underlying causes.
              iii.     To deal with therapeutic problems and failures.
              iv.      Pregnancy and Children (to whom these guidelines do not apply).
               v.      Possible White-Coat Hypertension (until GPs have ABPM machines).




                                      Page 1.35
Bexhill & Rother PCG           Cardiology Guidelines              November 2000


Chapter 12

Atrial Fibrillation

    An arrhythmia in which the atria contract more than 300 times a minute, and
     Ventricular contraction is no longer co-ordinated with atrial contraction, leading
     to irregular ventricular contractions, and an irregular peripheral pulse. This
     leads to inefficient functioning of the Heart as a pump, due to the loss of the
     pump-priming function of the atria, variable filling of the ventricles, and in some
     cases, over-rapid ventricular rates. Turbulent flow increases, as does the risk of
     clot formation within the heart, and the risk of thromboembolism leading to
     Stroke may be the most dangerous aspect of AF.

    Some patients may have Atrial Flutter, with an atrial rate of 280-300, and often a
     2:1 block giving a regular ventricular rate of 140-150. This may lead to
     progressive breathlessness and haemodynamic compromise and may require
     admission for conversion to Sinus rhythm.

    The CHD NSF contains few recommendations about AF, other than the
     importance of rate control in Heart Failure, and prophylaxis for
     Thromboembolism. However AF is important, especially given our elderly local
     population, so we have chosen to include some local guidelines based on the
     recommendations of Dr David Walker. Some parts derive from the European
     Society of Cardiology Guidelines (1998) as regards primary care treatment of AF.
     A group of cardiologists across the Health Authority is currently working on a set of AF
     guidelines, which may replace these guidelines in 2001.


                                   Types of Atrial Fibrillation

Paroxysmal - intermittent runs of AF, which may lead to breathlessness or faintness.
 Persistent - continuous AF, usually recent onset; which can be converted back to
                                         SR.
        Permanent - continuous AF which cannot be converted back to SR.



    The incidence of AF is roughly 5% of those >65 years old, and 10% of those over
     75.

    AF can be associated with:
                                    Chest Infections
                                    Valvular disease, CHD, Heart Failure
                                    Thyrotoxicosis
                                    Pulmonary Embolism
                                    Alcohol


A)      Diagnosing Atrial Fibrillation

                                     Page 1.36
Bexhill & Rother PCG        Cardiology Guidelines           November 2000
   Persistent or Permanent AF is often found incidentally during examination at
    routine BP checks, or anytime a patient’s pulse is taken. Alternatively the patient
    may notice palpitations or reduced exercise tolerance. An initially suspicious
    peripheral pulse should lead to listening to the Heart for irregular irregularity.
    Patients with multiple ectopics may be initially difficult to tell apart from those
    with AF. A 12 lead ECG will provide proof one way or the other, as well as
    providing additional information.

   Paroxysmal AF may be suspected when there is a history of recurrent faintness,
    breathlessness, palpitations or falls. Unless you see a patient when they chance
    to be in AF, 24-hour ECG or “event monitoring” ( such as a cardio-memo) may
    be needed.

   Examination will include the heart, chest and Carotids, and looking for thyroid
    signs.




                                 Page 1.37
Bexhill & Rother PCG            Cardiology Guidelines               November 2000



                                      Investigations in AF

                                   12-lead ECG
                             UEC, Glucose, TSH, FBC
                         Fasting Lipids if CHD suspected.
                           CXR if persistent chest signs
              24hr tape or cardio-memo if paroxysmal AF suspected
     Echocardiography if murmurs/failure, or as part of workup by Cardiologists


   Permanent AF is obviously only diagnosed once attempts to convert the rhythm
    by DC shock or drugs have failed. The most important predictor of success in
    converting AF back to Sinus Rhythm is how long the patient has been in AF, so a clear
    history of when AF started, or when the patient was last known to be in Sinus Rhythm
    is very useful.


B) Treating AF

   There are four key treatment questions to be addressed by the Cardiologist and
    GP:


       1)      How to keep patients with Paroxysmal AF in Sinus Rhythm.
       2)      How to get patients with Persistent AF back into Sinus Rhythm.
       3)      How to control the Ventricular Rate of patients in Permanent AF.
       4)      How to reduce the risk of Thrombo-embolism.



1) Keeping Patients with Paroxysmal AF in Sinus Rhythm

           Normal Heart             No treatment if infrequent/well-tolerated attacks.
                                     If severe symptoms, -blocker/flecainide,            ?
       Amiodarone.

           Diseased Heart           -blockers or Amiodarone (especially if CCF).

           Digoxin is no use        It neither prevents paroxysms nor works fast
            enough to
            in paroxysmal AF         be used to slow them down acutely.


2) Getting Patients in Persistent AF back into Sinus Rhythm

           AF  2/7                 Admit for early assessment, IV heparin,
                                     Convert electrically or with Amiodarone              or
       Flecainide.
                                     No long term Warfarin required if successful.



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Bexhill & Rother PCG      Cardiology Guidelines           November 2000
          AF > 2/7            DC cardioversion more likely to succeed than
           medication.
                               Anticoag. essential (reduces embolic risk 6% to 1%).
                               INR 2.3-3 for  4/52 before and 4/52 after. Longer
term
                               Warfarin if large LA/LVF or high risk of recurrence.

          AF > 3/12     DC conversion works in 75%, but 80% relapse.
                              Amiodarone may reduce relapse rate to 60%.
                              Left Atrial size may give some guide to likelihood of
                              Success. (A small LA being more favourable).




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Bexhill & Rother PCG           Cardiology Guidelines                November 2000

3)      Controlling rate in Permanent AF.

           Digoxin effective at rest, but not on exercise.

           -blockers, Verapamil, Diltiazem effective at rest or on exercise, and give
            additional benefits if Angina or Hypertension.

           Combination therapy may be necessary.

           Consider amiodarone  Digoxin if LVF.

           As a last resort, Radio-frequency AV node ablation with pacemaker
            implantation.


4)      Prevention of Thromboembolism.


                                Patients in Permanent AF




    High Risk (12% CVA/yr)                Moderate Risk              Low Risk Patients

       -One or more of:-

       Previous CVA/TIA.                  Age 65-75                    Age below 65
         >75 years old.              No other risk factors          No other risk factors
           Diabetes.
       CHD/Heart Failure.
         Hypertension.

         WARFARIN                ASPIRIN OR WARFARIN                     ASPIRIN

 (Unless contra-indicated)
 Reduces CVA risk by 65%




C) Atrial Fibrillation - Who to refer ?


    New onset AF                            Admit if in LVF/unwell, or onset in last 2 days.
                                             Otherwise, refer but start Rx as below.
                                             Will need echo, Warfarin  DC Cardioversion.


    Known Permanent AF                      Routine Cardiology referral if:-

        o Underlying Diagnosis Uncertain –          ? Valve Disease,
                                                    ? Cardiomyopathy/CCF.
                                     Page 1.40
Bexhill & Rother PCG       Cardiology Guidelines            November 2000

      o For assessment of rate control


      o To assess long term embolic risk -    ? LA dilatation




                                Page 1.41
Bexhill & Rother PCG            Cardiology Guidelines              November 2000



D) Starting Treatment in General Practice.


                               Patient with AF



    Paroxysmal                 Persistent                     Permanent
                                                               (i.e. known Hx AF)



If frequent,
or poorly                          ? less than 2/7               Underlying
tolerated                                                      Cardiac/other
                                                              path. Suspected?
                              No             Yes

                                                                         Yes
        Refer               Refer             Admit for      No
                                                                                  Refer
     Cardiologist                                                              Cardiologist
                           Cardiolo          Cardioversion

                             gist


    In the meantime        In the meantime,
       try low-dose         consider starting                      Rate
     -blocker if not    Sotalol or Amiodarone,                   Control
    contraindicated        & Warfarin, (if not                     OK?
                            contraindicated)

                                                             Yes         No    Combination
                                                                               Therapy
If frequent                                                                    Digoxin
attacks                                                                         -blocker or
                                                                                Verap/Dilt.
                                                                                 or Amiod.
                                                                                      .
             CONSIDER WARFARIN/ASPIRIN


               Refer Cardiology if difficulties with diagnosis/therapy




Starting Regimes In General Practice

     Amiodarone –      200mg TDS 1 week, 200mg BD 1 week, 200mg OD thereafter,
                        Warfarin dose may need adjusting, so early anticoag. clinic
      follow-up.
     Warfarin –        Warfarinisation can be started gently in this situation, with doses
      of

                                       Page 1.42
Bexhill & Rother PCG           Cardiology Guidelines             November 2000
                       5mg each evening for three days, and dosage thereafter based
INR done
                       on the fourth day, and as required thereafter. In the frail, small
and very
                       elderly, the starting dose might be reduced to 3mg daily initially.
                       Alternatively you may choose to refer the patient to the
anticoagulation
                       Clinic, possibly having given them a supply of 1, 3 and 5mg
tablets. They
                       will usually be seen in 1-2 weeks.

   Digoxin -    0.125mg daily, 0.0625 in the frail and very elderly. People
    needing more             rapid loading may require 0.5mg stat as first dose.




                                     Page 1.43
Bexhill & Rother PCG          Cardiology Guidelines                November 2000

Chapter 13

STROKE

Local Stroke Services

      Unlike the situation in Cardiology, where we are lucky to be well placed to meet the
       challenges of the NSF, we are perhaps less advanced locally when it comes to stroke.
       Despite discussions between the two local PCGS and Clinicians at the trust we do not
       have as yet any of the following:

          o   A Lead Consultant. (This should be Dr Strouthidis’s replacement)
          o   A Stroke Unit/Team (as defined by the Royal College of Physicians).
          o   A Community Rehabilitation team.
          o   An Integrated Care Pathway that has been accepted by all Clinicians involved.
          o   Effective ongoing audit of acute stroke care.
          o   A rehabilitation unit that is protected from admission of inappropriate patients.
          o   A fast track system for the Outpatient investigation of TIAs and CVAs.

      The PAMS (Professions allied to Medicine, ie Speech and Language therapy,
       Physiotherapy, Occupational therapy) did develop an integrated care pathway a few
       winters back, this is not currently implemented, and was not agreed by all other
       Clinicians.

      The PCGs and the Trust are working together on developing a Community Rehab.
       team, and new options for “intermediate care” . There are also continuing meetings of
       a Stroke Working Group which we hope will soon put forward a coherent plan of how
       Stroke Services will develop, and will work in future, to meet the expectations
       generated by the RCP report, and the forthcoming NSF for Elderly People.

      Dr McIntyre does Rehabilitation Ward Rounds on Egerton South, and a follow-up clinic.

      There is some form of Stroke Unit at both Eastbourne and Brighton.


The Royal College Stroke Guidelines

      In March 2000, the Royal College of Physicians published its National Clinical
       Guidelines for Stroke, based on the intercollegiate working party. The resulting
       document is shorter, but rather drier than the CHD NSF. Some of the recommendations
       of the RCP may find themselves in the forthcoming NSF for Elderly People.

      The guidelines cover management of patients with acute stroke from onset, through
       acute management and rehab. to the longer term. The guidelines follow on from the
       CSAG report (1998) and the National Sentinel Audit. The Scottish Intercollegiate
       Guidelines Network has developed a similar set of guidelines which are well worth
       looking at, and are one of many excellent guidelines available at their website.

      Perhaps the key take-home message is that following the work of Rudd et al (1999)
       and the Stroke Unit Triallists (1998) “it is now proven beyond doubt that patients
       managed by a specialist coordinated stroke team in a stroke unit have a lower
       mortality and morbidity”.

      The Guidelines lay out more specific details of what acute stroke care and rehab.
       should consist of, laying special emphasis on shared decision making involving patients
       and their carers, recognising physical, emotional and practical needs.

                                    Page 1.44
Bexhill & Rother PCG           Cardiology Guidelines                November 2000

What should happen when a patient has a stroke

The following derives from the RCP Guidelines, and Scottish Intercollegiate Guidelines.

   o   A Stroke is a “clinical syndrome typified by rapidly developing signs of focal or global
       disturbance of cerebral functions, lasting more than 24 hours or leading to death, with
       no apparent causes other than those of vascular origin”

   o   Patients should be admitted to hospital unless they refuse, unless you can be certain
       that you can arrange full stroke services for them at home, including:
           1. Facilities for diagnosis, including early CT scan, as an outpatient.
           2. Full Rehab. by a stroke rehab. team with links to the hospital team.
           3. Nursing, social and medical support without delay.

   o   Diagnosis is primarily clinical. Care is needed in the young, or if there is fever, gradual
       progression, severe headache or symptoms/signs of raised intracranial pressure. A CT
       scan should be done within 48hrs of onset unless there are good clinical reasons. MRI is
       only indicated if posterior fossa involvement is suspected.

   o   Aspirin 300mgs should be given as soon as possible once a haemorrhage as been
       excluded. Thrombolysis should only be given as part of research trials. Anticoagulation
       should be started 2 weeks later for those in AF.

   o   Blood pressure should not be lowered in the first week unless there is accelerated
       hypertension. Continue existing anti-hypertensive medication. Monitor hydration,
       glucose, temperature and look for development of hydrocephalus.

   o   There should be an initial multi-disciplinary team assessment within five working days
       of admission. A Speech & Language Therapist should see any patient with a swallowing
       problem. The gag reflex is not an adequate test. Other assessments should include
       consciousness level at admission, pressure sore risk, nutritional status, handling needs
       and assessment of cognitive impairment within 48hrs of regaining consciousness.

   o   All patients should be referred to a specialist rehab. team as soon as possible,
       preferably within 7 days of admission.

   o   Naso-gastric or PEG tubes may be necessary, as may modified foods and dietetic
       advice. Compression stockings and/or Aspirin may be necessary in immobile patients
       and those with leg paralysis.

   o   Most patients with moderate to severe stroke are incontinent at admission. Many are
       incontinent at discharge. There should be unit protocols for urinary and faecal
       continence and constipation management. Catheters should not be used routinely.
       Incontinent patients should not be discharged until adequate continence aids and
       services have been arranged at home.

   o   All these measures should be delivered in a hospital ward or ward area with adequate
       expertise and staffing. There should be an organised team, with a lead Clinician
       responsible for organisation, education and implementing advances in treatment as
       evidence becomes available. Staff need to be trained in communication and cognition
       problems, and avoiding contractures and pressure sores. This means we have to decide
       who is the lead clinician.

   o   Rehabilitation should involve:
          1. Speech & Language assessment with therapy as necessary.
          2. Physiotherapy from a therapist with expertise in neurodisability.
          3. Assessment of Activities of Daily Living (ADLs) , with OT support and training.
          4. Help with walking aids and orthoses as necessary. Aids at home where needed.
          5. Psychiatric/psychologist input where depression, or cognitive impairment.

                                     Page 1.45
Bexhill & Rother PCG           Cardiology Guidelines                November 2000

   o   Emotionalism (emotional lability) can be a big difficulty, and may respond to anti-
       depressants if severe.

   o   Discharge needs to be planned, with involvement of carers, and social, nursing and
       medical services in the community. All necessary aids and appliances should be in place
       at home already. Continuing outpatient or day hospital appointments should be
       available with delay. Information about statutory and voluntary agencies should be
       given.

   o   Rehab. can be effectively delivered in the community, or in day hospital, providing the
       patient is able to transfer from bed to chair, and that a full rehab. team is available in
       these settings.

   o   Secondary prevention is important, as the risk of further problems is high.( further
       stroke 7%/year, other vascular events 7%/yr, epilepsy 5%/2 years). Hypertension
       should be controlled as per BHS guidelines. If not on Warfarin, patients should be on
       aspirin or an aspirin-dipyridamole combination. Clopidrogel may be needed if Aspirin is
       contraindicated.

   o   Patients should be anticoagulated. if they are in AF, or in sinus rhythm with ischaemic
       stroke associated with Mitral Valve Disease/prosthetic heart valves/within 3 months of
       an MI. This should not be started until CT scan has excluded haemorrhage, and not
       until 14 days have passed from the onset of an ischaemic stroke.

   o   Patients should have all the Secondary Prevention measures discussed in Chapter 5,
       including Statins and smoking cessation advice.

   o   Carotid endarterectomy may be indicated in patients with carotid area strokes with
       minor residual disability. This may mean ultrasound assessment. The surgery should be
       only considered if the Stenosis is >70%.

   o   Audit and a stroke register, should be implemented. Carers and patients views should e
       sought.

   o   If evidence becomes available that early thrombolysis is of significant benefit in
       ischaemic stroke, this would have major implications for how we organise stroke
       services.


It can be seen that doing all this, in a timely and organised fashion will be a challenge. Various
tools such as integrated care pathways and “stroke clerking sheets” have been used
elsewhere.


The Future

We hope that there will be news in the near future of local developments in stroke
management and services. However, the financial and management implications, and cultural
changes involved are huge. We may need to see what the NSF for Elderly People says, and
whether the Government will put some money where its mouth is…

What follows is a simple flowchart of what might happen to patients diagnosed with Stroke, if
an Integrated Stroke Care Pathway conforming to the RCP Guidelines was implemented. This
does not pretend to represent the views of the DME Consultants, but is just a discussion
document tabled at the local Stroke Working Group.




                                     Page 1.46
Bexhill & Rother PCG          Cardiology Guidelines                November 2000


An example of a possible future framework for stroke:-


                          GP diagnoses
                              Patient with
                                  CVA



                            ? admit Conquest             No      Can stay at home or admit
                                                                 to Intermediate care or
                                                                 Bexhill Hospital if the
                            Yes
                                                                 following can be arranged.
                                                                  Early CT scan
   Brief assessment on Assessment ward before                     Appropriate Nursing and
   transfer to one of a few designated wards where                   social care without delay
   staff are skilled in dealing with:                             Full team assessment
    Cognitive/communication problems                             Full rehab.
    Nutrition and bedsore risk assessment                       Patients at home, unless
    Continence and posture management.                          dying, should be able to
    Swallowing and consciousness assessment                     manage bed-chair transfer.
    Protocols for BP/glucose/temp. control.                     Carers should be happy with
   Staff should be part of stroke team.                          this, and all aids provided.




   Early Medical Management: Diagnosis. CT scan in <48hrs. Aspirin then, unless
   haemorrhage. Monitor hydration, temp., glucose. Look for ICP^. May need PEG.
   Early team assessment:          Assessment and management of consciousness, posture,
   thromboembolic and bedsore risk, continence, communication, cognition and swallowing
   and nutrition. All by properly trained staff linked to stroke team.
   Rehab assessment: Within first 7 days, decision on goals, suitability and location of
   rehab. ( ie Egerton, Day Hosp, Community). Joint plan with patient/carers.
   A stroke clerking sheet/record incorporating care pathways is the logical way to do
   this in an organised way across disciplines, analogous to Obstetric notes, incorporating
   flow-charts, protocols and all request/nursing process/PAMS paperwork.




            Inpatient/Day Hosp Rehab.                                Home Rehab
      Rehab. beds ring-fenced from non CVA/Rehab.                      Team led rehab.
      Team led rehab as per RCP guidelines.                            2 prevention
      Initiation of 2 prevention (anticoag. If AF)                    May need “step-up”




   Discharge and Follow-up
      Planned discharge, discussed with carers, aids/incont aids ready at home. Social and
       Nursing care ready to support. No more Friday pm with no summary/drugs/notice.
      Prompt discharge/rehab summary > GPs/DNs/SS, (preferably on day of discharge).
      2 prevention started. FU clinic ready. Local organisation info. Carer support/respite.


         Audit of process, outcomes, user’s views. Team Education

                                    Page 1.47
Bexhill & Rother PCG          Cardiology Guidelines              November 2000
Chapter 14

Transient Ischaemic Attacks (TIAs)


This chapter includes information and guidelines supplied by Dr Chowdhury. There is
necessarily an overlap between information in this chapter, and that dealing with Stroke. The
risk factors and secondary prevention measures for TIA and Ischaemic stroke are similar.

TIAs may frequently be the precursor to ischaemic stroke. Appropriate
     prompt diagnosis and treatment of TIAs may therefore allow
   prevention of Stroke and death and disability following Stroke.

TIAs increase the risk of CVA by perhaps up to 10 times. Up to 20% of patients will have a
Stoke within 12 months of their first TIA, and 35% within four years. The annual death rate
from CHD + CVA + other Vascular causes, is 9% following a TIA. This explains why Patients
with TIAs are considered an important group for Secondary Prevention in the CHD NSF.


Symptoms

   Sudden onset of neurological deficit or monocular loss of vision with complete
    resolution within 24 hours, which after adequate investigation is presumed to e
    of thrombotic or embolic origin. Most resolve within 30 minutes.

   Anterior Circulation TIAs: (80%) Hemiparesis, Monoparesis, Hemianaesthesia,
    Monoanaesthesia, Hemifacial paresis or anaesthesia, Dysphasia, Dysarthria, Homonymous
    Hemianopia, Amaurosis Fugax.

   Posterior Circulation TIAs: (20%)         Paraparesis, Tetraparesis, Bilateral sensory
    impairment, Lower Motor Neurone hemifacial palsy, Dysarthria, Homonymous Hemianopia,
    Diplopia, Oscillopia, Vertigo and ataxia.

   Vaguer Symptoms like dizziness, syncope and unsteadiness are less likely to be a TIA.

   Alternative Diagnoses include: Temporal Arteritis, Migrainous Aura, Focal Epilepsy, MS,
    Intracranial lesions, Retinal/Vitreous haemorrhage, Labyrinthine problems, Transient
    Global Amnesia, Psycholgical problems, and Metabolic problems (eg hypoglycaemia).


Risk Factors For TIA and CVA

   Age. - 75% of all CVAs are in those over 65. Men are 25% more at risk than women.
   Ethnicity – increased rates in Asians and Afro-Caribbean patients.
   Smoking. - doubles the risk of CVA even without other risk factors.
   Hypertension. – increases risk of CVA 3-5 fold.
   Previous TIAs. – as above, increases risk of CVA by up to 10 fold.
   Carotid Stenosis.
   Atrial Fibrillation. – increases risk of CVA by 3-5 fold, especially as age increases.
   Diabetes - increases CVA risk by 1.8-3 fold.
   CHD and LVF.
   Thrombophilia
   Raised Blood Lipids

It can be seen that many of the risk factors are similar to those for CHD, and that lifestyle
measures like Smoking Cessation, low fat diet, Weight Loss and moderation of alcohol intake
may be important in CVA and TIA, just as in CHD and Hypertension.

                                    Page 1.48
Bexhill & Rother PCG           Cardiology Guidelines                  November 2000

Investigation and Management of TIAs

   Patients should be referred as soon as possible for investigation.

   Patients should be seen in hospital within 4 weeks of referral.

   Unless there are concerns that haemorrhage might have caused the symptoms, Aspirin
    should be started immediately. (results of Oxford Community Stroke Project).

   GP tests should include:

       o   BP, Cardiac and Neurological examination. Remember visual fields.
       o   ECG (if possible AF or Hypertension).
       o   FBC, ESR, Lipids and Glucose, Clotting.
       o   Presence or absence of Carotid Bruits is not necessarily significant.

   Hospital tests should include:

       o   The tests above, if not done yet.
       o   CT brain.
       o   Doppler USS of Carotids if anterior circulation TIA.
       o   Echocardiogram if AF or murmur present.
       o   Young patients, those with recurrent thrombosis, or a strong FHx of thrombosis
           should have a thrombophillia screen done.

   Hypertension, Hyperlipidaemia and Diabetes need investigation and treatment.

   Lifestyle advice eg Smoking, Exercise, moderate alcohol, Diet etc. should be given.

   Patients with 70% or greater Carotid Artery Stenosis (on the relevant side) on Doppler
    USS need Carotid Angiography. If this confirms stenosis, and they are fit for Anaesthesia,
    they should be referred for urgent surgery. Angioplasty and Stenting might be considered
    if not fit for G.A.

   Patients in AF should be anti-coagulated. If AF is of recent onset, consider referral for
    Conversion to Sinus Rhythm. Patients with Valve disease or Cardiomyopathy should also
    see a Cardiologist, and be considered for anticoagulation.

   All other patients should be on Aspirin (75-300mg), or on Asantin if on Aspirin at time of
    TIA, or Clopidrogel if Aspirin contraindicated.

   Treatments which are not indicated include

       o   Aspirin at doses above 300mg daily.
       o   Anticoagulation in patients with no Cardiac source of embolism.
       o   Carotid Endarterectomy if Internal Carotid Stenosis <70%.

   Patients with a genuine TIA qualify for all the Secondary Prevention interventions of the
    CHD NSF, as discussed in chapter 5.

   As audit of TIA management and secondary prevention may follow in the future,
    appropriate Diagnostic Coding may save you time in the future, and allow you to see how
    well you are doing.


It can be seen from the above that GPs are probably not as good at investigating and
managing TIAs, as they are at investigating and managing Angina and CHD. The Conquest
Hospital may also have some way to go before it is ready to deliver rapid investigation of
patients with TIAs who have been referred.

                                     Page 1.49
Bexhill & Rother PCG          Cardiology Guidelines                  November 2000
Chapter 15

VASCULAR REFERRAL GUIDELINES


1) VARICOSE VEINS

Refer:

         Ulceration
         Skin changes – eczema, pigmentation, liposclerosis
         Thrombophlebitis
         Bleeding

Can be referred:

         Itching or discomfort localised to the varicosities usually respond to treatment.

Comments:

         Symptoms of aching legs, swelling, cramps, restless legs respond poorly.
         Asymptomatic varicose veins and thread veins do not require treatment, however
          extensive they may be.



2) LEG ULCERS

Refer:

         Ulcers with evidence of untreated venous or arterial disease (skin grafting may be
          effective in large, recent ulcers with good granulation).
         Diabetic foot ulcers to diabetic foot clinic. Refer to surgeons if critically ischaemic.
          NB Doppler pressure readings often unreliable.
         If evidence of other systemic disease that may be contributing, e.g. Rheumatoid
          Arthritis or Crohn’s disease.

Comments:

         Surgery has no part to play in chronic end-stage ulcers with little or no granulation
          tissue, unless for debridement or amputation.



3) LYMPHOEDEMA:

Refer:

         For confirmation of diagnosis and advice to patient on management.

Comments:

         Surgery only indicated for gross incapacitating lymphoedema. Most treated by
          compression hosiery, elevation + or – external compression devices e.g. Flotron.




                                     Page 1.50
Bexhill & Rother PCG           Cardiology Guidelines                November 2000
4) ASYMPTOMATIC AORTIC ANEURYSM

Refer:

      If age <80 and aorta >4cms. If less than 4cms, can be followed up by 6 monthly
       ultrasound scans by GP.
      When >4cm or grows by >1cm a year.
      All if tender, back pain or raised ESR, or evidence of embolus.


Comments:

      Check popliteal pulses and refer if prominent. Popliteal aneurysms are often associated
       with AAA.
      Age over 80 is not necessarily a bar to elective surgery.



5) LOWER LIMB ARTERIAL DISEASE
Urgent referral if any of the following:

      Rest pain
      Ulcer
      Gangrene
      Ankle pressure <70mmHg


Intermittent Claudication, refer if:

      Diagnosis uncertain or patient needs reassurance
      Socially debilitating
      Absent or diminished femoral pulses
      Progressive deterioration
      Popliteal aneurysm

Comments:

      Stable claudicants with palpable femoral pulses but no distal pulses and no symptoms
       of critical limb ischaemia do not have to be referred.
      Encourage to stop smoking, and to walk as much as possible. This is proven to improve
       claudication distance. Put on Aspirin. No other drug treatment is of proven benefit.



6) CAROTID DISEASE

Refer Urgently for Carotid Duplex Scanning if:

      Carotid territory TIA
      Amaurosis fugax
      Carotid territory stroke with good functional recovery.
      If stenosis is >70%, then urgent surgical referral is indicated.

Comments:

      Presence or absence of carotid bruit is NOT significant.


                                     Page 1.51
Bexhill & Rother PCG            Cardiology Guidelines                  November 2000



Chapter 16

Management of Deep Venous Thrombosis
   Deep Venous Thrombosis (DVT) is an important cause of illness and death. A blood clot
    forms within the deep veins of the leg. The clot may progressively extend. The chief risk to
    life comes from the possibility of migration of clots from leg and pelvic veins to the lungs,
    causing Pulmonary Embolism (PE) which can be difficult to diagnose, and can be fatal.

   Recent advances have revolutionised the treatment of DVT, which used to be dependent
    on clinical diagnosis +/- Venography, followed by inpatient continuous heparin infusion
    until oral anticoagulation had been achieved. These advances include:

       o   Ultrasonography (USS) of leg veins, which is good at detecting clots above the
           knee.

       o   D-Dimer testing. D-Dimer is a breakdown product of fibrin produced within blood
           clots. The test is not specific enough to diagnose the presence of DVT or PE, but it
           is sensitive enough for a low level to be helpful in ruling out DVT or PE.

       o   Injectable Low Molecular Weight Heparins (LMWH) such as Tinzaparin, which, given
           as once daily injections, are as effective in preventing progression of DVT or
           migration of clot to form PE, as continuous Heparin infusion. These can be given at
           home.

       o   Increased knowledge of thrombophillic conditions that can lead to DVTs, such as
           deficiencies of Antithrombin III and Proteins C & S, Lupus anticoagulant syndrome,
           and the Factor V Leiden mutation. These are especially important in deciding how
           to reduce DVT risk and prophylaxis in women who might become pregnant in the
           future.

   Understanding these advances allows the possibility of a more accurate and rapid
    diagnostic service for DVT, in which the majority of patients will be seen in A&E, and their
    management continued without the need for expensive and inconvenient admission. This
    should not lead to a great increase in primary care workload, and should make diagnosing
    DVT easier for GPs. The new rapid access DVT service will be available in A&E from
    February 18th 2002.

   There are some patients who are not suitable for outpatient management of DVT, and who
    therefore need to be admitted.



           PATIENTS WHO NEED
           ADMISSION
           1. Suspected PE or massive DVT
           2. Increased bleeding risk or contraindication to anticoagulation. (active bleeding, recent
               surgery, active peptic ulcer, advanced liver disease, bleeding disorder).
           3. Pregnant women (who may come home on regular LMWH, rather than Warfarin).
          that remain limited to veins below including may be asymptomatic, and are
    DVTs 4. Co-existing severe medical problems, the knee,malignancy.
           5. Poor social circumstances/mobility be treatable with compression stockings only,
    relatively unlikely to lead to PE. They may
           6. Difficult to stabilise on LMWH, e.g. Under 18, Weight <45 or >100kg. Significant
                                        Page 1.52
               renal impairment.
Bexhill & Rother PCG           Cardiology Guidelines              November 2000
   but there is a risk that the clot extends proximally and can then lead to PE. Monitoring to
   ensure the clot does not extend may be necessary. Some patients may need a further USS
   despite a negative initial USS.

    It is important to remember that DVT is sometimes the first presentation of a cancer that has not yet
     been discovered. This is why the following clinical pathway lays particular importance on GPs examining
     patients and considering investigations for hidden malignancy when there is no immediately obvious
     reason why a patient has had a DVT.

                Protocol for management of possible DVT by GPs and A&E Department


                GP sees patient with ? DVT


                                                         No               Admit Medics or DME
                Suitable for Outpatient
                          Rx ?
                         Yes
                                                                                Assess Clinically. If
                                                         No                medium/high risk, send now to
                Between 0800 & 2400 ?
                                                                            A&E for LMWH injection.
                                                                           Otherwise A&E 0900 next day
                         Yes

                  Patient sent to A&E with referral letter, where clinical evaluation
                        carried out by A&E Registrar or Staff Grade Doctor


        No DVT, other
        diagnosis found
                                              Low/medium risk of
                                              DVT
                                                                                            High

                                                                                            risk
                                                                                            1st USS of leg, *
               GP
            Follow-up
                                   -ve         D-dimer test
                                                                                  USS +ve   of
                                                                                            A&E reg. review
                                                                                                     USS -ve



                                                                                            DVT
                                                   +ve
                                                                                            2nd USS of leg
                                                                                             two days later
                                                                                            ? LMWH till then
* = after 17:00 & at weekends
     LMWH started, INR sent
     USS next working day
                                              USS of leg,                     USS +ve                USS -ve


            USS –ve
                                              *
                                              USS +ve                                        D-dimer Test

                                               A&E reg. review                                +ve           -
     GP follow-up.                       DVT
ve                                       A&E team then ensures
                                           LMWH & Warfarin started,
   If clinically                               Baseline INR sent.                 +ve
  DVT 5-7 days           USS +ve          Referred to Anticoag. Team
   later, refer                             UECs/LFTs/FBC/ESR
N back to A&E,
                                                                                   Venogram -ve
  where 2nd USS
     may be
    arranged                                             (copies of all results
                                                         to GP. Significantly
                                                                                            Veno
                                                                                            GP Follow-up

                                            Page 1.53
                                                                                            gram
Bexhill & Rother PCG   Cardiology Guidelines                November 2000
                                          abnormal results phoned)




          Patient returns to GP
          follow-up, with
          report from A&E.
          If no obvious
          precipitant for
          proven DVT,
          consider
          USS/PSA/CXR etc. to
          look for occult
          malignancy. GP
          refers as necessary.




                            Page 1.54
Bexhill & Rother PCG               Cardiology Guidelines                      November 2000

   Much of the work will be done by “middle grade” medical staff in A&E. Including:
       o Diagnosis and initial management 0800 – 2400, 7 days a week
       o Organising D-dimer tests, leg Ultrasound Scans and venograms.
       o Making sure patients are started on Warfarin and referred to the anticoagulant clinic.
       o Ordering initial blood tests to look for occult malignancy, such as LFTs/ESR/FBC and PSA.

   GPs should review their patients who have a confirmed DVT with no precipitating cause, to
    consider, after examination, whether any further investigations (such as CXR or USS of
    abdo/pelvis) are indicated to look for occult malignancy.

   Patients who are low/medium risk with a +ve D-dimer but a negative USS, will be referred back to their
    GP who should review them a week later, to see if symptoms persist or are worse. If the patient still
    clinically has a possible DVT, the GP should refer the Patient back to A&E, in case the patient has had a
    DVT below the knee (which might not show up on the first USS) which has now extended above the
    knee. The patient can be sent up with a letter, or Mr Underhill’s secretary phoned to get an appointment
    in the next few days. The A&E team may then get a repeat USS.

   Thrombophillia Screening should be considered in patients with an unexplained DVT only if they are a
    woman of child-bearing age, or have a first-degree female relative of child-bearing age (for whom a
    diagnosis of hereditary thrombophillia might be important). It is unlikely to alter clinical management in
    other patients. Blood tests will be done by the A&E middle grade staff.

   LMWH injections will usually be given as Tinzaprin once daily SC injections, and be supplied by A&E or
    the Hospital Pharmacy, not on GPs prescriptions. The initial injection will be done in A&E. Subsequent
    injections could be done by one of: practice nurse, district nurse, self-administration, anti-coag. Clinic or
    the anti-coag. Nurse practitioner. No APTT monitoring is needed.

   LMWH is stopped when the INR is > 2. Warfarin is normally continued for 3 months after a typical DVT.
    Uncomplicated post-operative DVTs may require less.

   GPs can still refer direct for leg USS if they wish. If they run in-house anticoagulation clinics, they can
    mention this in the referral to the A&E team, who can then refer the patient back to them.

   The risk assessment tool used by the A&E team is this:

            Clinical Feature                                                                                 Score

            Active Cancer (treated in last 6 months, or palliative care)                                        1
            Paralysis. Paresis, recent POP on leg                                                               1
            Recently Bedridden > 3 days, or Surgery in last 4 weeks                                             1
            Localised tenderness over distribution of deep venous system                                        1
            Entire leg swollen                                                                                  1
            Calf swelling >3cm compared with other leg (10cm below tibial tuberosity)                           1
            Pitting oedema greater in symptomatic leg                                                           1
            Collateral superficial veins prominent (non-varicose)                                               1
            Previous DVT or PE                                                                                  1
            Oral Contraceptive or HRT                                                                           1
            Recent long distance travel, especially flight > 4hours                                             1
            History of DVT in a first degree relative                                                           1
            Alternative diagnosis as likely, or more likely than DVT                                           -2

           Low Risk = -2 to 0, Medium Risk = 1 to 2, High Risk = 3 or more.
           In patients with symptoms in both legs, the more symptomatic leg is scored.


      In summary: from 18th February 2002, if you see a patient who you think might have a DVT, you can
     send them to A&E directly, with a letter addressed to the A&E Registrar, unless you think the likelihood
           is low and it is between 2400 and 0800, in which case you can wait till 0900 the next day.




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