Cardiac Network Palpitations Pathway - Overview

                                                    

Presentation
  • Palpitations
  • Shortness of breath
  • Angina type symptoms
Primary Care Assessment/Investigations

Check history -

  • Family history of Sudden Adult Death syndrome/inherited Cardiac Condition … always ask!
  • Established Cardiovascular Disease e.g. CHD, Heart Failure, cardiomyopathy, value disease

Ensure that the following are assessed –

  • Pulse rate and rhythm
  • Heart auscultation – for rate and rhythm  (e.g. AF or ectopics) and murmurs
  • 12 lead- ECG
  • Where appropriate consider blood tests (FBC , TSH) and CXR

Adverse Clinical Features

  • Family history of Sudden Adult Death syndrome/inherited Cardiac Condition … always ask!
  • Syncope or pre-syncope
  • Established Cardiovascular Disease e.g. CHD, Heart Failure, cardiomyopathy, value disease
  • Significant findings on clinical assessment e.g. cardiac murmurs
  • Significant abnormalities on ECG e.g. LVH, heart block, left bundle branch block, previous MI
  • Palpitations triggered by or associated with exertion

If you need a Cardiologist Opinion follow this link for contact details.

Diagnosis
  • Family history
  • Syncope or pre-syncope
  • Significant findings on clinical assessment e.g. cardiac murmurs
  • Significant abnormalities on ECG e.g. LVH, heart block, left bundle branch block, previous MI
  • Palpitations triggered by or associated with exertion
Primary Care Management

No adverse features -No further investigation required -

  • Reassure, Advice on lifestyle, caffeine & alcohol, consider drug Rx

No adverse features but further assessment by ambulatory monitoring required  -

Please Note, a Direct Access Ambulatory Monitoring Service pilot is currently available in South Cotswolds only through Express Diagnostics, see the Services and Referrals section for further information.

Adverse Features -

If you need a Cardiologist Opinion follow this link for contact details.

Cardiac Physiologist Ambulatory Monitoring Service - Referral Guidance

Please refer to the guidance below prior to referring to GHFT's Ambulatory Monitoring Service.

YES must be ticked to all questions in order to access the TLPC

  1. Does the patient have a history of palpitations?
  2. Is the patient suitable for an Ambulatory Monitor?

Exclusion Criteria

Patients with current arrhythmias who are clinically/Haemodynically compromised should be admitted in the normal manor.

Patients with  known established/ diagnosed arrhythmias should only be referred as long as they are no longer under active follow-up for this arrhythmia and where there has been a significant change.

Please follow the resource link below to the referral form.

ICD Deactivation at End of Life

In order to ensure a peaceful death for a patient with an ICD who is reaching the end of their natural life, the clinician caring for the patient should consider deactivating the ICD. Where the patient has capacity this should be done after discussion and with their agreement.

Discussion with patients and their families introducing the subject of deactivation of their ICD in the final stages of their illness can be very difficult. Many patients will not be aware deactivation is necessary or may not recall earlier discussions held at other times.

The Arrhythmia Specialists in GHNHSFT and Heart Failure Service in Gloucestershire Care Services and Palliative Care can help to support patients in making this decision, documenting advanced care planning, completing Do Not Attempt Resuscitation (DNAR) and End of Life template is on System 1.

The Gloucestershire Care Services NHS multi-organisational interim documents 'shared care record' for the last days of life' include a prompt to clinicians to consider ICD deactivation.

Some clinicians may have concerns regarding deactivation of ICD's when capacity to consent is compromised and the following information may be useful:

  • When caring for a patient who lacks capacity to consent to deactivation of the ICD, clinicians have a duty to act in the patient's 'best interest' and 'where the determination relates to life-sustaining treatment (the clinician) must not, in considering whether the treatment is in the best interests of the person concerned, to motivated by a desire to bring about his death' (Mental Capacity Act 2005.
  • Where the patient lacks capacity to consent, the clinician may need to consider using an Independent Mental Capacity Advocate to support decision making in some circumstances.

Cardiology Investigations Department:

  • Gloucestershire Royal Hospital: 0300 422 8281
  • Cheltenham General Hospital: 0300 422 3561
  • Arrhythmia Nurse Specialist: 0300 422 8420
  • Gloucestershire Heart Failure Specialist: 0300 421 1212
  • Sue Ryder Hospice, Leckhampton: 01242 230199
  • Community Specialist Palliative Care Team- SPA 0300 422 5370
  • Specialist Palliative Care Out of Hours Advice Line: 0300 422 2222 (for professionals) 

Please follow the resource link below to the full Deactivation of ICD at End of Life Consensus Document - June 2019 revision.

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