The Arrhythmia Pathway

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The Arrhythmia Pathway
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Background

• Palpitation is a common symptom affecting 4 of
  people aged over 65 years
• Most patients with palpitation do no have a
  significant problem with their heart rhythm
• BUT
• Patients with serious arrhythmias are at risk of
  sudden death
• Patients with benign arrhythmia may require
  drug treatment or a procedure

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Background

• The most important points in evaluating a patient
  with palpitation are
• assessing risk of serious arrhythmia
• obtaining a recording of the heart rhythm during
  an episode

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Who is at risk ?

• Patients with
• blackouts or collapses
• recent heart attack
• recent heart surgery or PCI (balloon) treatment
• previous history of malignant arrhythmia
• recent pacemaker implant

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The Current Problem

• We have no quick route for patients with
  suspected rhythm problems to be assessed
• Most patients with palpitation dont have a
  serious rhythm problem
• The tests needed are hospital based and not
  available to GPs

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• As a result
• its slow to identify the small number of at
  risk patients
• many patients who dont have anything wrong with
  their heart attend our clinics
• But
• identifying high risk patients is simple
• the tests needed are simple

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Suspected new arrhythmia
yes
Any high risk features ?
Referral to consultant who will assess need for
urgent clinic appointment
no
yes
Is request simply to confirm benign diagnosis,
e.g. ectopic beats, non-arrhythmic cause ?
Are episodes frequent gt3 x per week ?
no
yes
no
Consider routine O/P referral
DIRECT ACCESS AMBULATORY MONITORING
Consider routine O/P referral
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Potential Problems

• would such a system generate significant extra
  pressure on cardiology services ? (i.e. a lot of
  unnecessary tests being carried out)
• Depends what is meant by unnecessary. A
  negative test isnt an unhelpful test and will
  provide reassurance.
• would such a system really reduce unnecessary
  clinic referrals or would it simply delay them ?

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We did a survey..

• Leith Community Treatment Centre has offered
  these tests to GPs in East Edinburgh
• in 85 of cases patient would not be referred on
  to hospital clinic
• if the service were not available, only 16 of
  patients would not have been referred to hospital
  clinic
• we dont know how many patients with a negative
  ambulatory ECG would eventually be referred to
  our clinics

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Initial Implementation

• Referral guidelines on RefHelp
• 5 x ambulatory ECG slots made available per week
  each at SJH, RIE and WGH sites
• Additional monitors purchased
• Normal ambulatory ECGs so be sent direct to GPs
• Abnormal ECGs to be consultant reported
• Audit of what happens of all patients referred
  through this system

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