cardiology services · outpatient cardiology services • general cardiology – new and follow-up...
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Cardiology Services Getting to the heart of the matter
Mark Connaughton MD, FRCP
Consultant Cardiologist
Associate Medical Director
Medicine for Members
July 2017
St Mary’s Cardiology in 2001
• Predominantly outpatient service
• No routine cardiology input to Coronary Care
• No cardiology inpatients
• No cardiology junior medical staff
• No pacemaker service on site
• Only basic echo service on site
• Patchy access to specialist services on mainland
Cardiovascular disease
• Is the Isle of Wight a
“black hole” for all
cardiovascular disease?
• Only Hastings, Tameside and
Manchester have worse death
rates in England
• IoW 345 deaths/100,000
• East Hampshire 211/100,000
• Portsmouth 304/100,000
• England average 258/100,000
Lies, damned lies and statistics
Mortality rates per 100,000 England average Isle of Wight
Cardiovascular disease – all ages 258 345
Cardiovascular disease – under 75 67 66.5
Coronary heart disease – all ages 115 108
Coronary heart disease – under 75 36 31.5
Stroke – all ages 64 56
Stroke – under 75 11 9
Figures suggest a disproportionate number of
Island residents die of cardiovascular disease,
but NOT specifically of heart attacks or stroke,
...and they die aged over 75
Cardiology personnel
• Dr Dallas Price and myself – should be 3
At full strength for 7 months since April 2013
• 1 specialist registrar from Wessex Deanery
• 5 cardiac physiologists
1 part-time, 1 due to leave, 1 due to retire
• 1 Rehabilitation nurse; part-time rehab physio
• 2 secretarial staff; 2 faculty clerks; 1 HCA
• 1x full-time, 2x job-share community HF nurses
Cardiology services
• Inpatient Coronary Care Unit
• Inpatient Cardiology (Stepdown) ward
• Cardiology Department for non-invasive tests
(outpatient and inpatient)
• Cardiology outpatient clinics
• Teaching and training
• Research
Coronary Care Unit
• Building opened in 2005
• 5 cubicles, 1 room, 1 bed space
• Central ECG and vital sign monitoring
• Dedicated pacing theatre
• DC cardioversions
• Will accept patients for non-invasive ventilation,
and hyperacute stroke patients for thrombolysis
Coronary Care Unit
Coronary Care Unit
• Typically patients with heart attacks,
serious disturbances of cardiac rhythm
or acute heart failure
• Consultant rounds 5 days/week
• All rounds are teaching rounds
• Full medical team is 1 specialist registrar,
1 Core Medical trainee, and 1 Foundation doctor
Cardiology training
• Postgraduate medical – on cardiology team 6x Foundation Year 1 doctors/year – 4 months
2x Foundation Year 2 doctors/year – 6 months
2x Core Medical doctors/year – 6 months
1-2x Cardiology specialist registrar – variable
2x Acute medicine specialist registrar – 6 months
• Postgraduate medical – via Education Centre Regular clinical and didactic presentations
• Undergraduate medical Southampton year 4 or year 5 medical students
Elective students e.g. Dublin
Cardiology (Stepdown) ward
• 12 beds total – 4 side rooms, 2x 4 bed bays
• Dedicated procedure room, used principally
for trans-oesophageal echocardiography
• Invariable use by “medical outliers” or for
isolating patients with likely bowel infections
• ECG monitoring via telemetry
Cardiology Department
• 24hr ambulatory ECG
• Cardiomemo
• Exercise treadmill test
• Echocardiography
(trans-thoracic, trans-oesophageal)
• 24hr ambulatory blood pressure
• Loop recorder implant
• Permanent pacemaker implant
Cardiomemo
Good for intermittent symptoms
29 studies in 2016-17
24hr ECG
Good for near daily symptoms
975 studies in 2016-17
Exercise treadmill test
Useful dynamic test
Mainstay of investigation in
Rapid Access Chest Pain clinic
Long experience with good
predictive value
281 tests in 2015-16
Trans-thoracic echocardiography
Echocardiography – cardiac ultrasound
Painless, non-invasive, many indications
1969 outpatient studies in 2016-17
1451 inpatient studies in 2016-17
Consultant reporting to GPs of investigations
• Echocardiograms
• 24hr ambulatory ECGs
• Cardiomemos
• Exercise tests
• 24hr ambulatory blood pressure
Procedures performed at St Mary’s
• DC cardioversion
• Trans-oesophageal echocardiography
• Pericardiocentesis
• Permanent pacemaker implantation
DC (direct current) cardioversion
• Treatment for atrial fibrillation or atrial flutter, which
are irregular heart rhythms
• External electrode pads
• General anaesthetic or unconscious sedation
• Day case procedure
DC (direct current) cardioversion
Trans-oesophageal echocardiography
• Performed under sedation, similar to upper GI
fibre-optic endoscopy
• Day case
• Routine work-up of valve function pre-surgery
• Useful on Intensive Care Unit
• Shows up intra-cardiac clot and other masses
• Detailed examination of shunts from e.g. Right heart
to left heart, and other structural abnormalities
• Suspected valve infections
Trans-oesophageal echo (TOE)
TOE probe Probe in oesophagus behind heart
Trans-oesophageal echo (TOE)
Pericardiocentesis
Treatment for fluid build-up in pericardial space,
between layers of the pericardial sac around the heart
Permanent pacemakers
• Service started January 2007
• 55 new implants in 2015 (last national audit)
• Dedicated pacing theatre
Dual chamber, single chamber, loop recorders
• Technician-led follow up and full data
supplied to national audit
773 follow-ups in 2015-16
Single chamber pacemaker
Dual chamber pacemaker
St Mary’s 393
UK 615
Western Europe 739
Implant rates
per million
2015
Other low number centres
• University Hospital, Lewisham
• North Middlesex Hospital
• Whipps Cross Hospital
• North Manchester General Hospital
• Sandwell Hospital
• Horton Hospital, Banbury
Outpatient cardiology services
• General cardiology – new and follow-up clinics
• Rapid Access Chest Pain clinic
• Rapid Access Heart Failure clinic
• Cardiac Rehabilitation clinics (Nurse and Physio)
• Community Heart Failure Nurse clinic
• Angiogram/angioplasty pre-assessment clinic
• Permanent pacemaker follow-up clinic
• Paediatric cardiology outreach clinic (Southampton)
Outpatient cardiology services
• General cardiology – new and follow-up clinics
• Rapid Access Chest Pain clinic
• Rapid Access Heart Failure clinic
• ~100% of cardiac surgical follow-ups now come to
St Mary’s for their only follow-up
• ~100% of heart attack follow-ups come to St Mary’s,
whether or not they were previously treated here
• Follow-up straightforward Grown Up Congenital heart
disease patients in liaison with GUCH at Southampton
• One of the lowest follow-up:new ratios of any service
• Minimise clinic requirement by arranging tests
independent of clinic assessment
Heart failure
196 hospital discharges
from St Mary’s in 2014-15
with primary diagnosis
of heart failure
Typical admission may
be 2-3 weeks
Mean age is ~78 yrs
Heart failure
Some 150 patients form the
caseload of 1 full-time and
2 job-sharing Community
Heart Failure Specialist nurses
Coronary artery disease
Coronary artery pathology
Coronary angioplasty/stenting
Heart attacks in 2008
National Infarct Angioplasty Project
• Pilot study to look at primary PCI (PPCI) as
initial reperfusion treatment for
ST elevation myocardial infarction (STEMI)
• Feasibility study rather than controlled trial
• Overall mortality for PPCI 5.2%
Thrombolysis was 7.1% (identical to MINAP)
Overall conclusions
Quickest call-to-balloon (CTB) times when transfer was direct to cath lab (not to A and E or CCU or more local hospital)
Better outcomes if CTB time was <120 min
PPCI declared cost-effective compared to lytic
The gamechanger
Patient flow
CCU Pre-hospital (P)PCI
Direct transfer to PCI centre
?CCU lysis
optimised
medical Rx
?Pre-hospital
lysis
Angio within
24 hr
Outside of flying hours
When Air Ambulance flying
24/7 PPCI started Sept 2010
Relations with mainland units
• Queen Alexandra, Portsmouth
– Invasive coronary angiography
– CT coronary angiography
– Coronary angioplasty/stenting
– 24/7 Primary angioplasty for ST elevation MI (heart attack)
– Cardiac electrophysiology
– Biventricular pacemaker and ICD implant
– Complex heart failure
– Pulmonary hypertension service
(outreach from Hammersmith)
• IoW consultants have developed and contributed to
these services for more than 15 years
Relations with mainland units
• Southampton General
– Cardiac MRI
– Cardiac surgery – coronary arteries, valves
– Acute aortic dissection
– Trans-aortic valve implant (TAVI)
– Grown up congenital
• National units
– Royal Free, London (Amyloid heart disease)
– Harefield, London (Transplant assessment)
– Royal Brompton; St George’s (Cardiac surgery)
2002 to 2017
2002 2017
Coronary Care Unit Old, cramped unit Purpose built unit
Cardiac ward None Purpose built
Cardiology trainees None Up to 6 trainees
Echocardiography No ward cover 2 portable machines
Trans-oesophageal echo None – via SGH Weekly session
Permanent pacing None – via SGH Full service on site
Pacing follow-up None – via SGH ~800 patients in clinic
Surgery follow-up Via SGH At St Mary’s
Heart attacks Treatment by
physicians
24/7 access to
primary angioplasty
Cardiac rehabilitation Community led Senior nurse, physio,
integrated with HCC
How do we see our future role?
• The obvious – providing high quality cardiac
care to inpatients and outpatients
• Develop services to allow easier access
e.g. Pacing, TOE, follow-up after surgery
• Working to minimise disadvantage of being
geographically separated from some services
• Trying to anticipate the challenges of an
uncertain future
British Heart Foundation
Support organisations - national
• bhf.org
• Arrhythmia Alliance
• Atrial fibrillation Association
Support organisations - local
Thank you