British Cardiac Society

Guidance for cardiology patient clinic follow-up for junior staff in cardiology Prepared by Dr Ranjit More on behalf of the British Cardiac Society Guidelines and Medical Practice Committee First published: June 2002

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Introduction

The idea for this guidance was prompted by the repeated request of local senior house officers (SHOs) and specialist registrars (SpRs) for written guidance on the management of cardiac patients that they encountered in the outpatient setting. The British Cardiac Society (BCS) Guidelines and Medical Practice Committee felt that this guidance, with further development, would be an important and worthwhile concept. The cardiologists at Portsmouth NHS Trust initially developed this guidance, with input from junior medical staff and nursing staff. Further input and a consensus opinion were received from members of the BCS Guidelines and Medical Practice Committee and from the Primary Care Cardiovascular Society. The contents are based on an extensive literature search, including other published guidelines. This guidance covers areas such as the possible need for further investigations, changes in medication, whom to discharge, whom to discuss further with the Consultant and the time period for subsequent follow-up. The intention was to produce a concise document, which we would regularly update, that would act as a template or guide to these issues, rather than be prescriptive. We fully appreciate that interpretation of some of the areas covered is open to genuine differences of opinion and therefore local variations in management strategies. We intend to update this guidance every 6-12 months. Any feedback would be helpful and greatly appreciated (via BCS e-mail: guidelines@bcs.com or website: http://www.bcs.com/) We refer frequently to the Driver and Vehicle Licensing Authority (DVLA) medical standards and fitness to drive. These are intended for use by doctors and are frequently updated. The most recent guidelines can be obtained on the internet: http://www.dvla.gov.uk/at_a_glance/ch2_cardiovascular.htm.

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Contents Page 1. Coronary artery disease 4 2. Valvular heart disease 6 3. Heart failure 10 4. Hypertension 11 5. Arrhythmias 13 6. Congenital heart disease 17 7. Pacemakers 18 8. Others 19 Appendix A: Patients discharged to GPs 20 Appendix B: Useful websites 21

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1. Coronary artery disease a. Stable angina: Check if patient has had or been considered for coronary angiography. Discharge if : • Symptoms stable • Risk factors documented and treated (lipids (T.cholesterol < 5mmol/l), hypertension, DM, smoking) and • Further investigation (eg cardiac catheter) not being considered. Ensure all patients are on aspirin 75mg od or an alternative. Driving: Not to drive if angina occurs during driving (patients should notify DVLA in this instance). Vocational (LGV/PCV) driving: Permanent refusal whether or not maintained symptom free by use of medication unless angina has definitely ceased. Patients should have notified and been advised by DVLA. If free of angina for at least 6 weeks then for relicensing need to fulfill exercise test criteria (completion of stage 3 of Bruce protocol (off cardioactive drugs for 48hrs), without any ST segment changes, arrhythmias or BP drop) b. Recent change in anginal symptoms:

(i) If “new” onset of angina: • Early stress testing (usually treadmill) - ideally these patients should be seen in the setting of a fast

access chest pain clinic • Risk factor assessment and management (lipids, diabetes etc) • Commence on aspirin and beta blockers (if no contraindications) • Early coronary angiography may be required – dependent on stress test result

(ii) If stable angina symptoms have deteriorated recently then:

• Consider increasing anti-anginals • Ensure on aspirin and • Discuss need for cardiac catheterisation with consultant.

1. Early followup needed (4-6 weeks). 2. If rest symptoms may need admission. 3. Educate patient on what to do if severe, prolonged episode of pain ie call ambulance rather than GP.

c. Recent MI: • Chase lipid profile (if checked > 24hrs to < 6 weeks post MI – obtain repeat profile at > 6 weeks post MI)

and stress test result • Check on secondary preventative measures (Are patients on aspirin, and if appropriate ACEI (heart failure

or impaired LV), beta blockers, statins (elevated cholesterol: T.chol > 5mmol/l)). • Discuss the benefits of cardiac rehabilitation and ensure referral has been made for cardiac rehabilitation.

• In the case of “younger” MI patients discuss with consultant whether to list for coronary angiography If asymptomatic and above measures have been resolved then discharge.

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If symptomatic or positive exercise test at low workload then : • Consider increasing antianginal medication and • Discuss need for cardiac catheterisation with consultant.

d. Recent CABG:

• Check wound sites • Check risk factor profile (lipids, hypertension, DM, smoking) • Check whether on appropriate medication:

(i) Check that ACEI, diuretics, statins and beta blockers have not been inappropriately

stopped post surgery, or (ii) Patients have not been left on too much therapy - eg digoxin/amiodarone for transient AF

post surgery, or several antianginal agents after complete revascularisation). • Assess functional status, discuss benefits of and refer for cardiac rehabilitation

If patient progressing well and asymptomatic then discharge.

Target cholesterol for all patients with established IHD: T.cholesterol < 5mmol/l (LDL < 3mmol/l) but for those who have undergone CABG T.cholesterol < 4.5mmol/l (LDL < 2.5mmol/l) Driving: Not to drive for 4 weeks post MI/UA/CABG. Not to drive for 1 week post PCI Vocational (LGV/PCV)driving: At least not for 6 weeks post event. Relicensing if exercise testing shows completion of stage 3 of Bruce protocol (off cardioactive drugs for 48hrs), without any ST segment changes, arrhythmias or BP drop. Driver reassessed every 3 years.

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2. Valvular heart disease • All patients should be advised about antibiotic prophylaxis (for eg major dental, or other procedures) and

teeth should be checked and patients advised on dental hygiene.

• Educate patients to seek early medical assessment and treatment if they: • Become more short of breath • Develop chest pain • Palpitations or syncope • Unexplained or prolonged pyrexia or flu-like symptoms

Vocational (LGV/PCV) driving: Recommended refusal of license if in past 5 years history of cerebral ischaemia, embolism, arrhythmias, persisting LV/RV hypertrophy or dilatation. a. Mitral stenosis: Follow-up period dependent on echo severity, symptoms and co-existent problems:

(i) Mild (MVA > 1.5cm2) : Follow-up 12 -18 months with echo before

If stable for a number of years ? discharge (discuss with consultant)

(ii) Moderate (MVA 1-1.5cm2): Follow-up 6-12 months with echo before.

May require further investigation depending on symptoms (TOE, cardiac catheter - discuss with consultant)

(iii) Severe (MVA < 1cm2): Follow-up 4-6 months with echo before.

Will require further investigation depending on symptoms (TOE, cardiac catheter - discuss with consultant).

Early TOE for symptomatic patients with moderate/severe mitral stenosis will help to clarify whether these individuals may be suitable for balloon mitral valvuloplasty (eg no calcification of subvalvular apparatus, MR absent or minimal, etc) – discuss with consultant. Ensure that patients with AF (chronic/paroxysmal) are on oral anticoagulants, unless contra-indicated. If patients are in sinus rhythm anticoagulation may not be necessary unless spontaneous contrast or left atrial thrombus found on TOE, previous history of systemic thromboembolism or LA > 5.5cm (in moderate/severe MS). b. Mitral regurgitation: Follow-up dependent on echo features and symptoms:

(i) Mild MR and normal LV • may not require long term follow-up

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• discuss with consultant

(ii) Moderate MR - follow-up 9-12 months with echo.

• Shorter follow-up period (and further assessment with TOE, cardiac catheter, before referral for surgical intervention) if: • Symptomatic • In asymptomatic cases if :

• LV is starting to dilate and LV systolic diameter close to 4.5cm or • Ejection fraction (EF) close to 60% (ie not entirely normal).

(iii) Severe MR

follow-up 4-6 months with echo

• Further assessment with TOE, cardiac catheter necessary , especially if symptomatic or in asymptomatic cases if LV is starting to dilate and LV systolic diameter close to 4.5cm or EF close to 60%. Discuss all these cases with consultant since patients with severe MR need aggressive management and early surgical referral for optimal outcome.

NB. If EF < 60% early investigation is warranted. Symptomatic MR patients may require diuretics. The role of vasodilators such as ACE inhibitors is unclear, especially in those with preserved LV systolic function. Surgery is usually the most appropriate intervention in symptomatic individuals. c. Aortic regurgitation Follow-up dependent on echo features and symptoms:

(i) Mild - • If asymptomatic and normal LV systolic function then for yearly review, with echocardiography every

2-3 years to monitor for any progression in AR.

(ii) Moderate

6-12 month follow-up with echo if relatively asymptomatic. • Shorter follow-up if symptomatic or LV starting to dilate on echo

(if LV systolic diameter >5.0cm) - discuss with consultant, since further investigation (cardiac catheterisation etc) warranted.

• Consider ACEI or other vasodilator therapy (calcium antagonist) especially if symptomatic, LV dilatation present or hypertension also present.

(iii) Severe

4-6 month follow-up with echo. • Consider ACEI or other vasodilator therapy (calcium antagonist) especially if symptomatic, LV

dilatation present or hypertension also present.

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• Need further investigation (cardiac catheterisation etc, prior to surgical referral), especially if symptomatic or LV starting to dilate - discuss all these cases with consultant.

d. Aortic stenosis Follow-up dependent on clinical symptoms and echocardiographic features. Patients who become symptomatic need rapid clinic assessment.

(i) Mild/sclerosis (no gradient):

• Probably no follow-up necessary (depending on age of patient) • Discuss with consultant.

(ii) Moderate (gradient < 50mmHg, AV area 1.0 - 1.5cm2):

Follow-up dependent on symptoms.

• If asymptomatic then follow-up 12 monthly with echo. • Much shorter period if patient becomes symptomatic. Patients should be advised to promptly

report the development of exertional chest pain, dyspnoea, lightheadness or syncope. These individuals will require further investigations including repeat echocardiography and cardiac catheterisation – discuss with consultant.

(iii) Severe (gradient > 50mmHg, AV area < 1.0cm2):

Follow-up 6 monthly with echo

Much shorter follow-up if symptomatic

• Urgent investigations (cardiac catheter) required if symptomatic (angina, dyspnoea, syncope) –

since early surgical intervention beneficial - discuss with consultant.

• Also consider early investigation if patient asymptomatic but transvalvular gradient > 100mmHg NB. If LV systolic function is impaired then the echo doppler calculated valvular stenosis severity may be an underestimate – discuss these cases with consultant.

e. Valve repair/replacement

• In all patients who have had valve replacement ensure that a “baseline” post valve replacement echocardiogram has been carried out.

• All patients should be advised about antibiotic prophylaxis (for eg major dental, or other procedures) and teeth should be checked and patients advised on dental hygiene.

• Ensure that therapies for AF, hypertension, CCF etc have not been inadvertently stopped post surgery.

(i) Prosthetic mechanical valves:

All patients with prosthetic mechanical valves will be on warfarin.

a. Patient stable (asymptomatic), no paravalvular leak:

• Yearly follow-up until discharge at 3 years post procedure (some centres however may prefer to continue long-term follow-up)

b. Patient still symptomatic, some paravalvular leak:

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• Follow-up 3-12 months +/- echo depending on severity of symptoms and severity of

paravalvular leak.

TOE may be necessary for adequate assessment of paravalvular leak.

Urgent investigation (including admission and TOE) necessary if :

• Bacterial endocarditis or • Significant worsening of paravalvular leak suspected

(ii) Tissue valve:

a. If no paraprosthetic or prosthetic leak:

• 12-18 month follow-up for first 5 years, then 6-12 month follow-up

b. If paraprosthetic leak present from time of operation:

• 6-9 months follow-up +/- echo (depending on severity of leak and symptoms)

c. If valvular deterioration (stenosis or regurgitation):

• 4-6 months follow-up + echo • Discuss all these cases with consultant since the tissue valve in these cases will at some stage

need replacing

N.B. Discuss with consultant if patient has deterioration in symptoms and/or significant deterioration in echo findings.

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3. Heart failure: • Ensure aetiology (IHD, hypertension, valvular heart disease, thyroid etc) has been investigated and treated • Check echo has been carried out • Check patient is on an ACE inhibitor (or an angiotensin II receptor antagonists if side-effects such as dry

persistent cough with ACEI), diuretics (including for NYHA grade 3 / 4 patients spironolactone , provided serum K+ < 5mmol/l) and that beta blockers (start at low doses with slow dose uptitration) have been considered

• Check that serum electrolytes are stable

• May be appropriate for patients to be on nitrates, digoxin, amiodarone.

• If in sinus rhythm consider aspirin; if in AF or have a dilated, very poorly contractile LV consider warfarin

• If underlying problem is hypertension ensure blood pressure is well controlled

• If underlying problem is IHD check anginal symptoms are well controlled. • Myocardial ischaemia may also be a major factor in impaired LV function (ie “hibernating” myocardium) –

discuss with consultant whether stress echo, radionuclide study or cardiac catheter may be appropriate.

• If valvular heart disease is thought to be a major factor underlying heart failure discuss with consultant re: possible valve repair/replacement

• Consider referral to local Heart Failure Specialist nurse, if this service is available locally

If significant deterioration in symptoms since last clinic visit discuss with consultant. If symptoms well controlled and all of the above measures have been considered patient could be discharged. • Ensure all patients have been advised about simple beneficial measures eg:

1. Weighing themselves regularly 2. Seeking medical advice early if:

• Weight increases or • Worsening of peripheral oedema or shortness of breath

3. Mild regular exercise 4. Reduced salt intake, limit fluid intake (1-1.5litres/day in those with severe symptoms) 5. Avoidance of NSAIDs, if possible (eg consider using colchicine for acute flare-ups of

gout) 6. Prevention of infection – vaccination to be recommended against pneumococcal

infection and influenza (annual vaccination for the later) 7. Alcohol intake to be kept moderate (none if alcohol induced heart failure)

Vocational (LGV/PCV) driving: Disqualification if symptomatic. Relicesing possible if symptom free and ejection fraction > 0.4 and exercise test requirements are met.

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4. Hypertension: • Check if any FH • Check for clinical features of secondary hypertension (flushing symptoms, radiofemoral delay etc.) • Check for “target-organ” effects: microscopic haematuria, proteinuria, retinal changes, LVH (ECG, echo)

and check U and Es. If these are present, patient requires additional investigations (renal ultrasound, echocardiogram etc).

• If “white coat” effect suspected or patient has borderline hypertension and unsure whether drug treatment is

necessary then for 24 hr BP monitoring. • If difficult to control BP then for:

• renal ultrasound • urinary metanephrines and 5HIAAs • blood glucose • 24hr ambulatory BP monitoring (NB Average difference cf “conventional” BP

readings is 12-16mmHg systolic and 6-10mmHg diastolic). Check whether there is or not a night time “dip” in BP.

• Advise all patients on simple measures (as appropriate) :

1. Increase regular exercise 2. Reduce salt intake 3. Reduce weight 4. Stop smoking, reduce alcohol intake 5. Aspirin 75mg od if BP well controlled and additional risk factors present eg CHD, diabetes

• Choice of antihypertensive dependent on patient profile and severity of hypertension eg:

1. Mild hypertension: Elderly – thiazides, beta blockers Younger patients – ACE inhibitor (or angiotension II receptor antagonist), beta blockers, calcium antagonist Black patients – diuretic, calcium antagonist, alpha blocker Diabetics with microalbuminuria or LVH - ACE inhibitors, AIIRAs.

2. Combination therapy may be necessary in a sizable proportion of patients whose

hypertension is more than mild at baseline (diastolic BP > 100mmHg). Use “AB/CD rule” ie if initial agent is an Ace inhibitor or beta blocker add a calcium antagonist or diuretic and vice versa. In some patients more than two agents may be required – consider alpha blockers and centrally acting agents such as methyldopa and moxonidone.

3. In pregnancy suitable agents limited – methyldopa or beta blockers.

• Target BP levels

• < 150/90 (British Hypertension Society) – BUT best to use assessment of absolute cardiovascular risk to determine when to start drug treatment (Joint British recommendations)

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BP >160/100 140-159/90-99 <140/<90 Lifestyle and drug therapy CHD risk > 15% or TOD CHD <15% Lifestyle and reassess 5 yrs Lifestyle and drug therapy Lifestyle and annual reassessment

TOD = Target organ damage CHD risk is calculated as a probability (%) of developing CHD (non-fatal MI or coronary death) over 10 years. Calculated using age of patient, sex, BP, smoking status, total cholesterol, HDL cholesterol, diabetes status, LVH on ECG (Cardiac Risk Assessor computer program). Adjust risk upwards by factor of 1.5 if there is a first degree male relative who developed CHD before 55years or female relative before 65 years.

• < 140/85 – if patient has established CHD (Joint British recommendations)

• < 130/80 – if patient is Diabetic (JNC VI recommendations) Vocational driving: Refusal/revocation in established hypertension if BP > 180 systolic or > 100 diastolic or medication causes symptoms which may affect driving ability.

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5. Arrhythmias a. Ectopic beats (with normal echo):

• Once diagnosis made and appropriate investigations carried out (24hr ECG, echocardiogram) patient can be discharged to GP.

• Low dose beta blockers can be suggested for those who are very symptomatic.

NB. If the echo is abnormal then further investigation is required. b. “Palpitations”: Ensure some attempt has been made to record “palpitations”

• 24hr ECG, cardiomemo

• If these are normal or only a few ectopic beats detected and echocardiogram is normal discharge

If echocardiogram is abnormal further investigation is required c. Supraventricular tachycardias:

• Very occasional symptoms - Advice on simple physiological manoeuvres eg Valsava and discharge.

• Regular symptoms – if symptoms occur only occasionally use AV blockers eg beta blockers, verapamil,

diltiazem. If these are unhelpful could consider other antiarrhythmics – discuss with consultant. If symptoms occur on a regular basis or tachycardias occur in setting of Wolf Parkinson White Syndrome then discuss with consultant referral for radiofrequency (RF) ablation of accessory pathway.

Once symptoms well controlled discharge.

• Poorly controlled symptoms - discuss with consultant referral for RF ablation.

d. (i) Atrial Fibrillation:

• Check aetiology has been determined:

- Hypertension, IHD, thyrotoxicosis, valvular heart disease, pericarditis, heavy alcohol intake, PE, COPD etc.

• Ensure LFTs (include GGT), TFTs, Echo have been carried out • Assess whether rate control is adequate (by use of 24hr ambulatory ECG monitoring):

- Beta blockers, diltiazem or verapamil if good LV systolic function - Digoxin if poor LV systolic function

- If rate control remains a problem discuss with consultant (further measures such as addition of amiodarone, consideration of AV node ablation + Pacemaker etc may be required).

• Has cardioversion been considered in patient ?

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- Discuss with consultant if the answer is no (may be particularly relevant if the AF is of short

(<3 months) duration or poorly tolerated by patient) - If referred for cardioversion ensure on warfarin for at least 3 weeks before and 4 weeks after

successful cardioversion

• If AF is paroxysmal :

- Consider antiarrhythmics if symptoms frequent, long lasting or distressing - If LV is good and no evidence of IHD consider flecainide, propafenone or sotalol - If LV is impaired then opt for amiodarone - Digoxin is not useful in these patients - If pharmacological measures are unsuccessful or PAF occurs as part of sick sinus syndrome

then discuss with consultant (mode switching dual chamber rate responsive pacing (DDDR) may be appropriate +/- AV node ablation)

- Consider referral for catheter ablation of ectopic foci that may trigger initiation of AF – this particular group of PAF patients are identified by frequent atrial ectopy and/or short runs of AF on 24hr ECG recordings.

• Has anticoagulation been considered?

- Low risk group = “lone AF” (normal echo, <65yrs, no hypertension or DM etc): aspirin 300mg od - Otherwise for warfarin unless contraindication

Once patient stable and all above measures have been considered then could be discharged.

d. (ii) Atrial flutter:

• Similar underlying aetiology to AF (sinus node dysfunction, chronic obstructive pulmonary disease, mitral/tricuspid valve disease, thyrotoxicosis, atrial enlargement etc).

• Atrial flutter and fibrillation can often co-exist in the same individual. • Atrial flutter is typically paroxysmal but can occasionally be a persistent rhythm • A rapid ventricular rate can occur in some instances (in the presence of WPW it may be associated with 1:1

AV conduction) • Ensure LFTs (include GGT), TFTs, Echo have been carried out • Acute Treatment: Options to restore sinus rhythm are:

• Antiarrhythmics eg flecainide, amiodarone - antiarrhythmics may paradoxically accelerate ventricular rate in certain individuals during atrial flutter by allowing 1:1 AV conduction of a slowed down atrial flutter rate

• DC cardioversion – especially if haemodynamically compromised • Rapid atrial pacing • Rate control until spontaneous restoration of sinus rhythm: beta blockers, diltiazem or

verapamil if good LV systolic function , digoxin if poor LV systolic function

• Chronic treatment: • Antiarrhythmics: flecainide and propafenone can be used in patients with no structural heart

disease, and amiodarone if LV function is impaired • Atrial flutter however is quite difficult to suppress with drugs • Catheter ablation may be curative and therefore should be considered in all symptomatic cases

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• Anticoagulation: As for AF, since thromboembolic problems also occur with atrial flutter.

e. Ventricular Tachycardia : All patients with recurrent ventricular tachycardia should have had specialist input to their management. These patients should have had appropriate investigations to assess for structural heart disease (echocardiogram, coronary angiography etc)

• In the context of a “normal” heart, prognosis is good. If well tolerated and medical therapy (eg beta blockers, amiodarone) is effective then these patients could be discharged after discussion with consultant

• If symptoms are not well controlled with antiarrhythmics then refer for electrophysiological

assessment (catheter ablation etc) – discuss with consultant

• If LV systolic function is also impaired then the patient should be referred for electrophysiological assessment (catheter ablation, implantable defibrillator) – discuss with consultant

• If patient has implantable defibrillator then check with patient how many times it may have

discharged, ensure that they are also being followed up in a defibrillator clinic

• If on amiodarone ensure that LFTs and TFTs are checked every 9-12 months. f. Unexplained Syncope If cardiac cause suspected then ensure

• Arrhythmias have been excluded – 24-72 hr Holter monitoring, event recorder or implanted device recorder eg Reveal device (Device choice dependent on frequency of symptoms – discuss with consultant)

• Echocardiogram has excluded structural heart disease eg HCM

• Vasodepressor cause has been excluded – tilt table test

Driving and ventricular arrhythmias: Not to drive and to notify DVLA if incapacity due to arrhythmia. Patients whose underlying cause of arrhythmia has been identified and who remain symptom free with their arrhythmia controlled for at least 4 weeks may be allowed to resume driving subject to regular medical review. Patients with implantable defibrillators are not allowed to drive and should notify DVLA.They may be allowed to drive 6 months after implantation provided there is freedom from incapacity during discharge, the device has not delivered 3 or more treatments, regular review by implant interrogation and 1 month off driving following any revision. Vocational (LGV/PCV): Disqualified from driving if arrhythmia has caused or is likely to cause incapacity (including systemic embolism). Driving may be permitted when arrhythmia has been controlled for at least 3 months, provided the LV EF is >0.4 and ETT requirements are met. Permanent refusal for ICD implant patients. Successful catheter ablation: Driving to cease for 1 week ( 6 weeks for vocational (LGV/PCV)driving)

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6. Congenital heart disease This guidance only refer to adult patients with congenital heart disease: a. Successful repaired ASD/VSD:

• If no significant arrhythmias, right heart failure or pulmonary hypertension then can be discharged. b. Unrepaired ASD/VSD:

• Follow-up period will dependent on symptoms (3-24 months) and echo features. • Check “plan of action” has been sorted for each individual. • Small VSD and lack of right heart strain (ie normal size right ventricle) do not usually need followup – BUT ensure that all these patients have been advised about antibiotic prophylaxis.

c. Other congenital heart disease:

• Discuss individual cases with consultant • Ideally these individuals should be followed up in a GUCH clinic

Ensure that all patients have been advised about antibiotic prophylaxis.

d. Eisenmenger’s syndrome:

• Follow-up every 6-12 months

• Any deterioration in condition discuss with consultant. • Important to advise all patients about antibiotic prophylaxis, avoidance of dehydration and the need to seek

medical advice early with any suspected infection. • Anticoagulation long-term may be appropriate especially if polycythaemia is present (discuss with

consultant) • Venesection may need to be considered but only in those with symptoms of hyperviscosity (eg headache,

dizziness, blurred vision, amaurosis fugax, muscle weakness, fatigue, depressed mentation, chest and abdominal pains, paraesthesia) and haematocrit > 65 (and provided the patient is not dehydrated) – discuss with consultant

Vocational (LGV/PCV) driving: Uncomplicated cases of congenital HD will be licenced. Complex cases are likely to be disqualified.

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7. Pacemakers

• Temporary pacing indications for patients undergoing surgery with general anaesthesia:

1. Second degree or complete heart block*

2. Trifascicular block ie alternating LBBB and RBBB, or fixed RBBB with alternating left anterior hemiblock (left axis deviation) and left posterior hemiblock (right axis deviation)*

3. Bifascicular block with 1o block

4. Symptomatic patients with sick sinus syndrome where bradycardia is the major component*

NOT: Asymptomatic patients with bifascicular block alone

* These patients require permanent pacing; temporary pacing can cover the perioperative period but a permanent system implant is subsequently needed.

• Permanent Pacing

• Ensure patient has attended for pacing check 4-6 weeks after new unit implantation

• Ensure patient has yearly follow-up at pacing clinic • Ensure other medical conditions are managed

Driving: Not to drive for 1 week post implantation (must notify DVLA). Not necessary to stop driving after pacemaker box change. Will be allowed to hold license until the age of 70 years provided they undergo regular medical supervision by a cardiologist. Vocational (LGV/PCV) driving: Disqualified from driving for 3 months. Relicensing may be permitted after this period unless there is another disqualifying condition

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8. Others a. Hypertrophic cardiomyopathy: • Ensure diagnosis is clear cut (on basis of echo) • Check if any history of :

- Syncopal/presyncopal episodes - Palpitations (need 24 hr ECG to exclude significant ventricular arrhythmias or fast AF) - FH of early sudden death • Ensure an exercise test has been carried out (to assess for any exercise related

hypotension - adverse prognostic indicator) • If significant (>50mmHg) LV outflow tract gradient on echo:

- Beta blockers or verapamil - If these agents are unhelpful or side-effects occur:

- May need dual chamber permanent pacing, septal artery ablation or surgery (myomectomy) (Dependent on symptoms - discuss with consultant)

• If in AF good rate control necessary (see AF section)

- if PAF present consider amiodarone • If nonsustained runs of VT present consider amiodarone, • If sustained or long runs of VT then discuss with consultant (implantable defibrillator may be appropriate). • Check whether any genetic sampling and family screening (using echo) has been carried out.

Vocational (LGV/PCV) driving: Disqualified if symptomatic. Relicensing possible if asymptomatic, no FH of sudden cardiomyopathic death, HCM anatomically mild, no serious rhythm disturbance, no hypotension during exercise b. Marfan’s:

• Check for any murmurs • Check echo for any aortic root dilatation, MR or AR • If aortic root dilatation present:

- aortic root > 4cm for beta blockers plus if : - aortic root > 4.5cm – close review with repeated echos (every 4-8 months)

- aortic root > 5cm – referral for aortic root replacement

• If AR or MR present (see above sections) • Check whether family screening (including genetic counselling) has been carried out.

Vocational (LGV/PCV) driving: Disqualified if aortic root dilatation present

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Appendix A: General notes on patients discharged to GPs: 1. Ensure that the patient is content to be discharged to the GP for continued management. 2. Ensure that the GP is notified promptly about patients discharged from clinic. 3. Ensure that in the discharge letter a continued management plan is clearly defined including any changes in

medication, any elements that need continued monitoring (eg BP, cholesterol) and when to refer patients back to the cardiology clinic.

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Appendix B: Useful Websites Websites have been divided into general useful sites and those of particular value to patients/general public. We have assessed each of the sites for:

C Content E Ease of use CS Connectivity to other sites

We have graded the sites using the following scoring system: 0 Poor 1 Adequate 2 Good 3 Excellent

General Useful Sites: http://www.heartforum.org.uk Alliance of over 40 national organisations for reduction

of CHD including BHF, BMA, BDA. Role of organisation is to provide a forum for exchange of information and ideas on CHD prevention (eg role of exercise, diet, tobacco control measures etc). The site has limited content but provides good links. C1 E1 CS3

http://www.bhf.org.uk British Heart Foundation: Charitable organisation involved in funding of

research on heart disease, providing support and information to patients and families, educating the public and health professionals about heart disease, and providing training in emergency life support skills for the public and health professionals. The site provides access to educational materials, publications, ongoing research and has reasonable links to mother sites. Particularly good for patients and relatives: information on heart disease, fund raising, life support training etc: C2 E2 CS1

http://www.hda-online.org.uk Health Development Agency: Aims to reduce health inequalities and

improve general health of people. Gathers evidence and advises on standards. Provides health promotion and public health advice. Site has limited cardiovascular content.

C1 E1 CS1 http://www.doh.gov.uk Department of Health: Good site providing access to latest news (eg NHS

Plan) and information on the Department. This includes access to previous DoH publications, in particular the National Service Frameworks. Links limited.

C3 E2 CS1 http://www.doh.gov.uk/pub/docs/doh/coronary.pdf DoH National Service Framework for CHD (guidelines, 7 chapters on :

prevention, patients, MI, Angina, revascularisation, rehab). Most important government document on cardiovascular disease management in recent years C3 E2 CS1

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http://www.dhsspsni.gov.uk Dept of Health, Social Services, Public Health: Responsible for policy and legislation for hospitals, family practitioners, community health, social services, public health and public safety eg review of cardiology services in

Northern Ireland. Useful for health care professionals but very limited for general public. C2 E1 CS1

http://www.acc.org American College of Cardiology: Excellent site for health care professionals

providing access to ACC/AHA guidelines, continuing education, data registry, fellows in training, and acc journals. Limited content for general public – AHA website better in this respect. Excellent links. C3 E3 CS3

http://www.americanheart.org American Heart Association: Good site with extensive access to AHA

journals, AHA/ACC guidelines, conferences, publications, healthy lifestyles, CPR, national programmes. Has good section for general public including cookbooks, patient education notes (MyHeartwatch programme). Not as easy to access contents as ACC website. C3 E2 CS2

http://www.hyp.ac.uk/bhs

British Hypertension Society: Provides hypertension guidelines, publications, and information on courses and meetings. Does have a limited information service for patients (eg validated BP monitoring devices). Site easy to use. C2 E2 CS1

http://www.bma.org.uk British Medical Association: Good site for health care professionals with easy access to medline, library, BMA publications (eg BMJ), publications on ethics, policy, science and international links. Has good links to other sites. Limited content for general public. C2 E2 CS2

http://ccad3.biomed.gla.ac.uk/ccad Central Cardiac Audit Database: national system for centralised confidential

data collection, rapid online comparative reporting, data quality reporting, mortality tracking. At present covers MI patients (MINAP), adult cardiac surgery and intervention, paediatric cardiac surgery 7 intervention, heart valve surgery, pacemakers. Has links to eg NSF for CHD. C2 E1 CS1

http://www.escardio.org European Society of Cardiology: Good site for medical professionals, with

information on journals, education, ESC guidelines, committees, working groups and meetings. Also has a virtual press office. Excellent link to other societies. Has limited content for general public, mainly in the form of press releases. C2 E2 CS3

http://www.gmc-uk.org General Medical Council: Body charged with promoting high standards of

good medical practice. Site contents include register of qualified doctors, information on revalidation, standards of practice, complaints procedures etc. C2 E1 CS1

http://www.medical-devices.gov.uk/mda Medical Devices Agency: Aim is to safeguard interests of patients by

ensuring medical devices and equipment meet appropriate standards of safety, quality and performance. Contents include UK implant registers (eg stents), reports on wheelchairs, reducing needlestick and sharps injuries etc. C1 E1 CS1

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http://www.mrc.ac.uk Medical Research Council: Aims to improve health by promoting

research into all areas of medical and related science, through its research establishments, grants to individual scientist and support for postgraduate students. Site includes ethics guides, press releases and also has a schools resource section. C1 E1 CS1

http://www.pccs.org.uk Primary Care Cardiovascular Society : Aims to improve care and

outcome of patients with cardiovascular disease through exchange of knowledge and promotion amongst clinical practitioners of research, education and development relating to cardiovascular disease in general and community cardiovascular disease in particular. Society’s journal is British Journal of Cardiology. Site is limited, has details on meetings, members etc.

C1 E1 CS1 http://www.resus.org.uk/SiteIndx.htm Resuscitation Council UK: Provides education and reference material to

healthcare professionals and general public in most effective methods of resuscitation including guidelines. Site includes publications, guidelines, legal ramifications etc. C2 E2 CS1

http://www.rcplondon.ac.uk Royal College of Physicians (London): Good site covering

conferences at RCP, education issues, audit issues, committee reports and minutes, library services, Membership examination, SHO and specialist registrar training, publications. C2 E2 CS1

http://www.scts.org/ Society of Cardiothoracic Surgeons of GB and Ireland: Responsible

for setting, monitoring and raising standards in cardiac and thoracic surgery and improving standard of education and training for cardiothoracic surgeons. Site includes guidelines, committees, surgical audit and outcomes and link to journal. There is a patient information glossary, with information on a number of surgical procedures. C2 E2 CS1

http://www.socpharmed.org Society of Pharmaceutical Medicine: Multidisciplinary agency which

aims to promote acquisition and dissemination of knowledge concerning action and development of medicinal agents. Limited site covering meetings and archive reports. C1 E1 CS1

http://www.show.scot.nhs.uk/sign/index.html

Scottish Intercollegiate Guidelines Network: Set up to improve quality of healthcare in Scotland by reducing variation in practice and outcome, through development of and dissemination of national clinical guidelines for effective practice (eg secondary prevention following MI etc). Over 60 evidence based guidelines available on this site. SIGN council includes patient representatives. C2 E2 CS1

http://www.who.int/home-page/ World Health Organisation: Site includes international statistical

classification of diseases, disease surveillance, library of public health, publications, directory of medical schools. Site has limited coverage for general public. C2 E1 CS1

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http://www.worldheart.org/main.asp World Heart Federation: Aim is to provide international strategies and

programmes for prevention of cardiovascular disease, with numerous countries represented. Site however is limited (covers meetings and organisation publications only). C1 E1 CS1

http://www.doh.gov.uk/wfprconsult/ Developing the NHS Workforce report http://www.chi.nhs.uk/ Commission for Health Improvement: Aim is to improve quality of

patient care in NHS. Responsible for assessing every NHS organisation and making findings public, investigating where serious failures have occurred, advising NHS on best practice, and checking NHS is following national guidelines. Site provides access to clinical governance reviews, commission meeting dates, reports.

C2 E2 CS1 http://www.dataprotection.gov.uk Data Protection Agency: Responsible for keeping register of data

controllers. Site also has access to freedom of information act, education and training issues. C1 E1 CS1

http://www.nelh.nhs.uk/ National Electronic Library for Health: Digital library for NHS staff,

patients and public. Site has good links to NHS Direct, nhs.uk, Department of Health, Medline, Cochrane library, BNF, and information on NSF for CHD, Care pathways, databases, guidelines (including NICE guidelines). Also has access to a electronic library for social care. Includes a frequently asked questions section and headline news. Easy to use site and helpful for general public. C3 E3 CS3

http://www.nice.org.uk/ National Institute for Clinical Excellence: Role is to provide patients,

health professionals and public with authorative, robust and reliable guidance on current best practice. Site has various appraisals available (eg glycoprotein IIb/IIIa antagonists, stents, defibrillators). C2 E2 CS1

http://www.doh.gov.uk/research/ NHS Research and Development: reports available on ongoing funded

research and covers opportunities for bidding for research monies. C1 E2 CS1

http://www.oft.gov.uk/ Office of Fair Trading: Promotes and protects public health by helping

safe and effective products reach market and monitoring products for continued safety after they are in use. Site provides access to press releases, meetings, “hot” topics (eg BSE, bioterrorism), safety alerts, comments on drugs, medical devices, food etc. C2 E1 CS1

www.nhlbi.nih.gov/nhlbi/nhlbi.htm US National Heart, Lung and Blood Institute: Part of NIH. Provides

leadership for a national program in diseases of the heart, blood vessels, lung and blood, blood resource and sleep disorders. Institute plans, conducts and coordinates program of basic research, clinical and observational trials, and educational projects. Site provides access to publications, studies seeking patients, committees, forthcoming meetings, research funding, events etc. Useful information available for patients on heart and vascular disorders as well as blood and lung diseases. C2 E2 CS1

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http://www.nih.gov/ US National Institutes of Health: Responsible for conducting research in own labs and supporting research in non-Federal labs and training of investigators. Site provides access to resources such as human embryo stem cell registry. Site also has news and events, grants , health information and a Healthwise newsletter for patients. C2 E2 CS1

http://www.acponline.org/journals/ebm/ebmmenu.htm American College of Physicians/American Society of Internal

Medicine: Good site providing access to journals, CME, guidelines and evidence-based medicine. C2 E2 CS2

http://www.cochranelibrary.com/enter/ Cochrane Library: Provides high quality evidence to inform people

providing and receiving care. Site provides access to abstracts of reviews. Need to subscribe to library to gain access to full reports. C2 E1 CS1

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