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Remote consulting: cardiology



Continuing our series, GP specialist Dr Matthew Molloy advises on remote management of common cardiology presentations

The Covid-19 pandemic has meant we have had to significantly change the way we assess and manage cardiology cases. In our primary care cardiology service, traditional face-to-face appointments have been replaced by telephone and video consultations, where appropriate, and we have increased the amount of information we relay to patients via text message services.  

Despite the return to more face-to-face consultations, we have found some benefits from managing cases remotely and we are embedding these systems for the future. 

Based on our experience, these are my tips for managing some common cardiology presentations using remote consultations.

POORLY CONTROLLED BLOOD PRESSURE
This tends to fall into two groups: younger patients (usually under 35 years) with potential secondary hypertension; and older patients whose blood pressure remains above target despite treatment. 

Key pointers in the history
Explore these factors by reviewing the notes and phone assessment:

  • Weight.
  • Salt intake.  
  • Physical exercise.  
  • Smoking and alcohol intake.
  • Medications that may increase blood pressure such as NSAIDs, steroids, oral contraceptives, tricyclic antidepressants.
  • Adherence to antihypertensive medications.
  • Discrepancies in home blood pressure monitoring recordings. Check the patient’s technique, which can be done by video consultation (see box 1). Check blood pressure monitor accuracy against clinic standard machines.

Box 1: Advice on home blood pressure monitoring

  • At each recording, take two consecutive measurements, at least one minute apart while seated
  • Record blood pressure twice daily, ideally in the morning and evening
  • Record twice daily for seven days
  • Discard the measurements taken on the first day and use the average value of the remaining measurements to guide treatment

The following pointers should suggest referral to appropriate secondary care services or further investigations:

  • Brady or tachycardia, constipation, diarrhoea, menstrual disturbance and cold or heat intolerance – may indicate underlying thyroid disease.
  • Hypokalaemia (potassium below 4.0mmol/l) – may indicate Conn’s syndrome.
  • Buffalo hump, central obesity, Moon facies, striae – linked to Cushing’s syndrome.
  • High Epworth Sleepiness Scale score – indicates obstructive sleep apnoea.
  • Increase in serum creatinine after starting ACE inhibitors or angiotensin receptor blockers (ARBs) – may be due to renal artery stenosis.
  • Flushing, headaches, labile blood pressure, palpitations, sweating or syncope – may indicate phaeochromocytoma.  

Remote management
For patients whose blood pressure is not responding despite treatment, telephone and text advice should include:

  • Addressing lifestyle factors that may be contributing to the hypertension and signposting to local services. 
  • Offering education on the importance of medication adherence and support to optimise dosing, timings and regimens, including to address any drug interactions.   
  • Medication review and optimisation to target a blood pressure of below 130/80mmHg, with a minimum of side-effects.1 After each dose adjustment the patient’s blood pressure readings should be reviewed within four to six weeks and medications uptitrated or added accordingly.2

Red flag
The following situation requires referral for suspected malignant hypertension: blood pressure consistently above 180/110mmHg and new onset symptoms such as confusion, chest pain, signs of heart failure, acute kidney injury.

PALPITATIONS
Palpitations are a common presenting symptom in primary care, with or without associated cardiac symptoms.
A careful history via telephone can help to identify if there is likely to be serious underlying pathology and guide further investigation. 

Key pointers in the history

  • Onset of palpitations – what was the patient doing, were the palpitations of sudden onset?
  • Trigger factors and relieving factors such as exertion, anxiety or caffeine.  
  • Rate and rhythm – fast or slow, regular or irregular?
  • Frequency and duration of the palpitations.
  • Associated symptoms, such as chest pain, fatigue, breathlessness, dizziness
    or syncope. 

For further investigation of a possible cardiac cause, arrange heart rhythm monitoring. The decision on whether to use a daily or weekly Holter monitor or a portable ECG depends on the frequency and severity of symptoms. Patients reporting daily episodes can be monitored by 24-hour ECG, while those with episodes every few days should undergo Holter monitoring for up to one week. Patients experiencing less frequent episodes will need longer-term monitoring with a device such as the AliveCor Kardiamobile.

Factors from the history combined with findings from rhythm monitoring can then help to stratify the risk and determine whether the symptoms represent significant pathology.

Low risk factors and symptoms

  • Skipped beats.
  • Thumping beats. 
  • Short fluttering. 
  • Slow pounding. 
  • Normal ECG.  
  • No family history.
  • No structural heart disease.

Possible diagnoses include atrial and ventricular ectopy; in most cases GPs can offer reassurance and follow-up if symptoms worsen.

Medium risk factors and symptoms

  • History suggesting recurrent tachyarrhythmia – a fast heart rate (more than 100bpm) with sudden onset or offset lasting minutes to days.
  • Palpitations with associated symptoms (breathlessness, dizziness, fatigue).
  • Structural heart disease. 

Possible diagnoses include supraventricular tachycardia and atrial fibrillation (AF) or flutter. Patients will almost always require referral to cardiology for further investigation.

High risk factors and symptoms 

  • Abnormal ECG (see below). 
  • Palpitations during exercise. 
  • Palpitations with syncope or near syncope.
  • High risk structural heart disease. 
  • Family history of ischaemic heart disease. 
  • High degree atrioventricular (AV) block.

ECG appearances that require urgent attention are:

  • Bradycardia: pauses of more than three seconds.
  • Mobitz type II second or third-degree AV block. 
  • Alternating right or left bundle branch block. 
  • Rapid supraventricular tachycardia. 
  • Ventricular tachycardia. 
  • Cardiac ischaemia. 
  • Myocardial infarction. 
  • Wolff-Parkinson-White syndrome
  • Long QT.
  • Brugada syndrome

Possible diagnoses include significant ischaemic heart disease, cardiomyopathy, complete heart block. The presence of any of the above necessitates an urgent referral to cardiology for further assessment and management.

POSSIBLE HEART FAILURE

Key pointers in the history  
Patients commonly present with:

  • Exertional breathlessness.
  • Orthopnoea.
  • Nocturia.
  • Paroxysmal nocturnal dyspnoea.

Ankle swelling may accompany the above symptoms, but in isolation does not warrant further investigation for heart failure.

Arrange initial testing for FBC, U&Es, LFTs, HbA1c, lipids, TFT, NT-proBNP and chest X-ray, as well as ECG and ambulatory or home blood pressure monitoring. 

The following are key signs of heart failure if examination is possible, but are not essential for diagnosis:

  • Tachycardia
  • Basal crepitations

If the patient has ischaemic heart disease or AF, refer for echocardiography.  

NT-proBNP levels should be interpreted as follows:

  • NT-proBNP >2000pg/ml – two-week urgent echocardiogram referral.
  • NT-proBNP 400–2,000pg/ml – six-week echocardiogram referral.
  • NT-proBNP <400pg/ml – consider alternative diagnosis.

A normal ECG and low NT-proBNP precludes heart failure with reduced ejection fraction (HFrEF) or HF with preserved ejection fraction as the cause of breathlessness. There may be symptoms and signs of heart failure syndrome, but the cause will not be pump failure. If symptomatic heart failure is confirmed following echocardiography, the patient should undergo an in-person review and follow-up by video or phone, or in person if required. 

Remote management
Following diagnosis, initiate treatment in line with NICE guidance (see box 2) with the option of support from
a specialist service. 

Refer early to cardiology services if:

  • Direct access to echocardiography services is not available.
  • Clinician is unsure how to proceed. 
  • HFrEF aetiology is uncertain. 
  • There are issues with symptom management.
  • Left ventricular systolic dysfunction is due to cardiomyopathy or AF.
  • There is hypotension due to pump failure or an iatrogenic cause. 
  • There is resting bradycardia. 
  • There are complex comorbidities, in particular chronic kidney disease stage 3 or higher.
  • There are complex emotional or social issues.

Box 2: Principles of treating heart failure

  • Prescribe diuretic to relieve congestive symptoms and fluid retention; titrate up or down following the addition of further medication
  • Commence ACEi/ARB and up-titrate
  • Commence ß-blocker licensed for heart failure – bisoprolol, carvedilol or (in people aged 70 and over) nebivolol – and up-titrate 

Further treatment options under specialist direction

  • Consider adding spironolactone/eplenerone if HFrEF patients remain symptomatic
  • Switch from ACEi/ARB to angiotensin-receptor-neprilysin inhibitor (Entresto) in HFrEF (EF <35%) patients who remain symptomatic 
  • Consider addition of dapagliflozin 
  • Consider adding ivabradine in patients in sinus rhythm with heart rate above 70bpm
  • Refer for consideration of automated implantable cardioverter defibrillator if severe HFrEF (EF <30% on echocardiogram)
  • Consider referral for cardiac resynchronisation if sinus rhythm with QRS duration >130ms

Source: NICE guidance NG106

Syncope and pre-syncope
Patients typically present with isolated or recurrent episodes of syncope, or dizziness/pre-syncopal symptoms. The main types of syncope and their characteristics are outlined in Box 3. Possible diagnoses include atrial and ventricular ectopy; in most cases GPs can offer reassurance and follow up if symptoms worsen. Working out whether the symptoms are of cardiac or neurological nature is key to diagnosis and management.

GPs should carry out an initial telephone consultation to help establish a possible underlying cause and guide further investigation. The work-up will then usually require a period of rhythm monitoring and an echocardiogram to assess cardiac structure and function. 

Key pointers in the history
Feature suggestive of a cardiac cause:

  • Syncope develops when supine. 
  • Develops during exertion. 
  • Onset preceded by palpitations.Presence of severe heart disease. 
  • ECG abnormalities such as wide QRS (>0.12 sec), AV conduction abnormalities, sinus bradycardia (<50bpm), pauses, long QT.

Features suggestive of a neurally mediated cause:

  • Syncope occurs after sudden unexpected unpleasant sight, sound or smell. 
  • Develops after prolonged standing at attention or crowded warm place. 
  • Nausea, vomiting associated with syncope. 
  • Onset within one hour of a meal. 
  • Develops after exertion. 
  • Temporal relationship with start of medication or changes of dosage.

Drugs predisposing to syncope 

  • Vasodilators: nitrates, calcium channel blockers, ACE inhibitors. 
  • Antihypertensives: alpha blockers, ß-blockers. 
  • Drugs that prolong QT: antiarrhythmic agents; antibiotics including macrolides such as erythromycin, Bactrim (sulfamethoxazole/trimethoprim); terfenadine; TCAs.

Red flags 
The following require urgent referral to specialist cardiology services:

  • Suspected or known significant cardiac disease. 
  • Chest pain. 
  • Cardiac murmur. 
  • ECG abnormalities suggesting arrhythmias, such as long QT.
  • Syncope during exercise. 
  • Syncope causing severe injury. 
  • Family history of sudden death. 
  • Sudden onset of palpitations in the absence of heart disease. 
  • Frequent recurrent episodes.

Box 3: Types of syncope and their characteristics

Vasovagal syncope
Precipitating events such as fear, severe pain, emotional stress, instrumentation or prolonged standing are associated with typical prodromal symptoms (although prodrome is not always present, the precipitating factors still have diagnostic significance) 

Situational syncope
Syncope occurs during or immediately after urination, defaecation, coughing or swallowing 

Orthostatic syncope
Documented orthostatic hypotension (decrease in SBP of 20mmHg to 90mmHg) associated with syncope or pre-syncope

Features strongly suggestive of vasovagal syncope
Occurs when standing, extreme pallor, random limb jerks, always collapse to floor, quick recovery 

Syncope due to cardiac ischaemia
Symptoms present with ECG evidence of acute ischaemia with or without myocardial infarction

Syncope due to cardiac arrhythmia
ECG changes showing sinus bradycardia, pauses of more than three seconds, AV block, alternating left and right bundle branch block, rapid paroxysmal supraventricular tachycardia or ventricular tachycardia, pacemaker malfunction with cardiac pauses

Dr Matthew Molloy is a GPSI in cardiology at the Westcliffe Health Innovations primary care cardiology service in Bradford, West Yorkshire

References

  1. Williams B et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J 2018;39:3021-3104
  2. NICE guidance NG136. Hypertension in adults: diagnosis and management. 2019
  3. NICE guidance NG106. Chronic heart failure in adults: diagnosis and management. 2018

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