Cardiology Preceptorship for GPs
ORGANISED BY THE CARDIAC UNIT OF ALTNAGELVIN HOSPITAL
Tuesday, 09 December 2008
W ELCOME TO A LTNAGELVIN C ARDIAC U NIT
Thursday, 4th December 2008 saw the first Cardiac Faculty
Cardiology Preceptorship for family doctors
held in Altnagelvin Hospital, part of the Dr. Albert McNeill
Western HSC Trust.
A full day programme was organised com- Dr. John Purvis
prising a morning of lectures in key topics
Dr. Sinead Hughes
and demonstrations of the latest Cardiologi-
cal techniques. After lunch, the delegates, Dr. John Riddell
visited the unit’s catheter lab, echocardio-
gram labs and treadmill rooms and saw live Dr. Stephen Barr
Six family doctors were able to avail of a Sr. Shirley McGaffin
kind sponsorship grant from Pfizer UK to
leave their practice for the day and attend.
The delegates enjoyed both lectures and
practical demonstrations with Chronic Heart
A new initiative
Dr. Albert McNeill, Clinical Lead in Cardi-
Failure, Acute Coronary Syndrome and Atrial
ology, Western HSC Trust, welcomes Mr. Fibrillation lectures provoking a lot of ques-
Richard Kelly from Pfizer UK to the first tions related to problems that occur daily in
Cardiology Preceptorship in Altnagelvin primary care.
Dr. Frank Johnston
9.30 – 9.45 am Welcome & Introduction
An Overview of Cardiology Services Within the Trust - Dr A McNeill
9.45 – 10.30 am Overview of Non-invasive Cardiac Investigations – Dr S Hughes and Dr J Purvis Dr. John O’Donnell
10.30 – 11.00 am Management of Acute Coronary Syndromes – Dr A McNeill
Dr. Ian McGinley
11.15 – 11.45 am Atrial Fibrillation – Dr J Riddell Waterside HC
11.45 – 12.15 pm Heart Failure – Dr S Barr
12.15 – 12.45 pm Invasive & Interventional Cardiology – Dr J Riddell
Dr. Deirdre Donnelly
12.45 – 1.15 pm Secondary Prevention – Sister S McGaffin Out of Hours Centre
2.00 pm 3 Rotating Groups x 3 Workshops (45 mins each):
Dr. Brian Quigley
Echo Labs Dr. Gerry Watson
Exercise Stress Testing Strabane HC
4.15 pm Summary & Close Mr. Richard Kelly
We Hope to Hold the Preceptorship Course Twice Yearly!
Rapid Access Chest Pain Clinic
Dr. John Purvis presented information from tests show that coronary heart disease is
the RACPC database. The service has as- NOT present in 64%
sessed 1147 patients since it was first Patients with positive treadmills are re-
launched in April 2007. Over 74% of ferred for cardiac catheterization as soon
treadmills are negative with patients being as possible and a substantial number of
reassured that day that all is well. these need percutaneous coronary interven-
Some 11% of patients have treadmill tion or coronary by-pass graft operations.
tests that are equivocal and for these pa- Patients who cant do a treadmill are risk
Coronary CT Angiogram tients, further tests are required. Altnagelvin assessed using a chest pain and risk factor
The latest generation of CT scan- has the widest range of intermediate tests in score and prioritized on that basis.
ners are capable of examining the Province and patients can be referred Altnagelvin is the first hospital in the Prov-
coronary arteries in close detail. for Dobutamine Stress Echoes, Myocardial ince to use this approach for patients unable
The technique is useful for out- Perfusion Scans or Cardiac CT scans to help to treadmill and this is now being adopted
ruling coronary disease and ex- clarify results. throughout NI via the province-wide Cardiac
amining coronary artery by-pass
grafts as in this case In these equivocal patients, the additional Network
Advanced Cardiac Imaging
Dr Sinead Hughes presented the latest able at regional level such as cardiac
non-invasive cardiac imaging techniques Magnetic Resonance imaging.
available at Altnagelvin such as Tissue Delegates were impressed at the ad-
Doppler, 3D echo and Trans Oesophag- vances in cardiac imaging over the last
eal Echo as well as discussing tests avail- few years
Cardiac MR 3D Echo
High resolution imaging of cardiac Using an advanced triplanar echo
anatomy including right heart probe, ventricular volumes can be
structure and function is possible calculated in multiple planes and
with cMR. This technique is particu- a 3D image of the ventricle con-
larly useful in cardiomyopathies structed—here a constriction can
be seen in mid LV in this patient
with Tako-tsubo syndrome
Acute Coronary Syndromes
Dr. Albert McNeill presented management Dr. McNeill updated delegates on plans
of acute coronary syndromes including the to bring PCI to Altnagelvin in the near fu-
latest guidance from European Cardiac So- ture.
ciety on management of ST and non-ST seg- The role of primary PCI for acute MI was
ment myocardial infarction. also discussed in the light of the new ECS
Aspirin and Clopidogrel are key agents in guidance.
prevention of clot formation in the acute For the time being the best and most
coronary syndromes, with the CURE study rapid treatment for most patients in our
giving evidence that patients with non ST mostly rural area is pre-hospital thromboly-
elevation MI benefit for up to 12 months sis
post event, whilst the CHARISMA study The delay times involved for transfer to a
yielded similar data for ST elevation MI primary PCI centre that offers round the
with Altnagelvin being a key UK centre for clock access remain prohibitive.
Atrial Fibrillation and PCI
Dr. John Riddell presented these two sub- over 75 (high risk of stroke) and those
jects. between 65 and 75 who have significant
Definitions are important when considering risk factors such as hypertension..
how to treat AF:
Blood thinning drugs also featured
Paroxysmal AF prominently in John’s second talk on Percu- Vulnerable Plaque
Brief duration usually reverts spontaneously taneous Coronary Intervention.
Persistant AF The arrow points to a haemor-
May last some days, usually needs some Drug Eluting Stents (DES) release rhage in a plaque in the proximal
Left Anterior Descending coronary
form of cardioversion to restore SR. agents into the surrounding blood vessel to artery
Permenant AF help prevent coronary artery restenosis.
Will last indefinitely, might respond to car- This technique can half the rate of in-stent
dioversion, may need rate control. restenosis from 10% down to 5%., but the
lining of the vessel can remain raw and
Warfarin is superior to aspirin as an antico- vulnerable to clotting so sometimes the use
agulant and is recommended for AF in asso- of aspirin and plavix needs to be ex-
ciation with valvular disease as well as those tended beyond one year. If in doubt, ask
Chronic Heart Failure
Dr. Stephen Barr presented, in laconic CARDIAC
fashion, a summary of chronic heart failure Beta-blockers are almost as important and
management with emphasis on drug therapy need to be considered in all patients. Lipid CATHETER
and practical tips. soluble beta-blockers such as Nebivolol and
Bisoprolol have the best trial evidence. Side- PROCEDURES
BNP effects such as hypotension and exacerba- ARE
Now available to GPs and an excellent aid tion of asthma/COPD need to be watched
to prompt recognition of CHF carefully and therapy should not be initiated PERFORMED IN
in the acute, wet, patient. Start low and go
Life Saving Drugs: slow is the best up-titration advice.
ACE inhibitors are the cornerstone of CHF Aldosterone antagonists such as Spironolac-
management and should be initiated in all tone are life-saving in the more severe cases
cases unless there are significant problems. but care must be taken in the elderly and
Angiotensin Receptor Blockers are a useful those with poor renal function.
alternative if ACE inhibitors not tolerated.
Sr. Shirley McGaffin presented guidelines tion drugs, all efforts should be made to up-
on secondary prevention. Patients admitted titrate towards top doses.
to the cardiology unit with a diagnosis of Overall patients enjoy the secondary pre-
acute coronary syndrome are now followed
up by the secondary prevention and reha-
Priorities include ensuring patients are on:
Lipid targets for secondary pre-
Aspirin vention are 4mmol/l for total
Beta-blockers cholesterol and 2mmol/l for LDL
vention experience and the opportunity to
Omacor as per NICE talk to clinical psychology, dietitians, phar-
Plavix as per ACS guidelines macists as well as doctors and nurses about
To get full benefit from secondary preven-
Cardiology Preceptorship for GPs
THURSDAY 4TH DECEMBER 2008
Left Ventr owing an egg-
gram sh of a
Echocardio in the left ventricle
shaped cl recent heart attack solve
pa tient with be required to dis
ABOVE Cath Lab Visit
Echo Lab s Mr. Richa m A severe stenosis
enna show ra of
auline McK lysis of echocardiog to able for a stent pr the right coronary artery suit-
siologist P na sis ocedure.
Clinical Phy perform offline a ws detailed analy BELOW
w to allo ent
a workst ation, this and speeds up pati Dr. John Riddell de
images on the patient has left sheath used to ca monstrates a radial artery
occ ur after diac catheterisat ulate the wrist artery for car-
The consultant staff of Altnagelvin Cardiac Unit wish to tre for the day.
thank all those who made the Preceptorship a success. We hope that the delegates enjoyed the series of
We are sorry that Dr. Paul McGlinchey was unable to lectures and practical demonstrations and can take the
join us on this occasion due to PCI commitments in Belfast experience forward into daily life in practice.
City Hospital but we hope to have the benefit of Paul’s We wish to thank Pfizer UK for making the day possi-
experience in the future. ble and supporting the delegates’ attendance.
We are especially grateful to the staff of the Tread-
mill, Echo and Cath Labs who welcomed our guests for We hope to hold further courses in the future—if you
the day and went out of their way to explain and dem- would like to attend please contact the editor, Dr John
onstrate the technology involved. Purvis:
We are grateful to hospital site management for use
of the old Boardroom which made an ideal lecture thea- email@example.com
Our Thanks to Pfizer UK for sponsoring the event