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