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Palpitation guidelines and referral criteria for primary care practices in the University Hospitals of Leicester Trust. Abbreviation = Echo, transoesophageal echocardiogram. Based on guidelines set by the National Institute of Clinical Excellence in the UK (16).
Source publication
Background and aims
Palpitations are a common presentation in primary care. Guidelines have been developed to identify patients with palpitations who require further assessment by a cardiologist in secondary care. However, patients that do not meet guideline thresholds for referrals are still referred to secondary care services. This audit evaluate...
Contexts in source publication
Context 1
... can be risk stratified by their clinical history, examination and routine investigations available to many primary care services, such as an electrocardiogram (ECG) or blood tests (7,(10)(11)(12)(13)(14)(15). In our trust, local guidelines are provided to primary care to aid with referrals ( Fig. 1) based on national guidelines set out by the National Institute of Clinical Excellence (16). This flow chart is aimed at patients who are clinically stable at presentation and not requiring urgent emergency admission. The flow chart (Fig. 1) initially encourages the identification and treatment of reversible key risk factors, including ...
Context 2
... In our trust, local guidelines are provided to primary care to aid with referrals ( Fig. 1) based on national guidelines set out by the National Institute of Clinical Excellence (16). This flow chart is aimed at patients who are clinically stable at presentation and not requiring urgent emergency admission. The flow chart (Fig. 1) initially encourages the identification and treatment of reversible key risk factors, including caffeine and alcohol intake, obesity management, sleep apnoea and hypertension. Those with palpitations that cannot be explained by the previous risk factors are grouped into two categories: those with high-risk features, ECG changes or ...
Context 3
... this flow chart guideline is available to primary care providers, referrals still come through that do not meet the clinical thresholds for referral. The exact rates of inappropriate referral are not fully understood. In this clinical audit, we aimed to evaluate cardiology referrals from primary care by assessing adherence to these guidelines (Fig. 1). The audit then aimed to assess the differences between patients that were referred appropriately versus those referred who had not met the guideline ...
Context 4
... were assessed for adherence to the local guidelines through the evaluation of clinical letters. Patients that did not meet the criteria for referral, as shown by Figure 1, were deemed to have been referred inappropriately. The following data was also extracted from the clinical letters and medical records: investigations the patient had and final diagnosis. ...
Context 5
... referred patients may make up a significant proportion being referred to secondary care services for palpitations. Over half of the patients referred to our clinic were referred inappropriately (Fig. 1). Patients that can be managed in primary care are occupying secondary care outpatient clinics time. This may serve as early evidence that there are efficiency savings to be made with palpitation referrals. Trusts and future studies may wish to explore the financial implications and possible ...
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Citations
... In our study, 9.8% of the population experienced palpitations, which is similar to the 11.7% reported in a UK cardiology clinic [15]. Palpitations pose a challenge for primary care services, as patients may be referred due to concerns about missing potential heart issues. ...
Background: The stress electrocardiographic (ECG), is a dependable method for evaluating cardiovascular health and examining potential heart conditions like myocardial ischemia and arrhythmia. EST is rare in cardiac settings with limited data on diagnosis in the developing worlds. Our main goal was to determine the clinical characteristics of patients referred to our cardiac center. Methods: A retrospective cross-sectional study of adult patients aged (>18 years old) with low or intermediate pretest symptoms referred for EST to GoodHeart Medical consultant hospital between October 2019 and January 2023. Data included medication, smoking, alcohol, medical history, and symptoms. Results: In a study with 102 subjects (mean age: 49±16 years), 57.8% were aged 41-60, and 72.5% were males. Routine medical fitness and chest pain were common indications for EST. 80% of subjects with positive arrhythmia and 50% with positive ischemia had chest pain. None of the patient presenting for routine medical fitness had arrhythmia while 14.3% had ischemia. Arrhythmia correlated significantly with chest pain. Among those with positive ischemia, 71.4% were hypertensive and 64.2% were obese; none smoked or consumed alcohol. For positive arrhythmia cases, 70% were hypertensive and 80% were obese; 40%, 20%, and 10% smoked, consumed alcohol, and were diabetic, respectively. Conclusion: Majority of subjects that underwent the EST has normal result and the few that had positive ischemia 13.7% were referred for angiography and angioplasty while subject with positive arrhythmia 9.8% were recommended for Holter ECG and electrophysiology studies. The occurrence of major cardiovascular events was rare.
... This referral to cardiologist care rate is similar to that of other studies, confirmed by the literature, with a typical range of 30%-50%. [17][18][19][20] Referral decision results The GP decision referral performance was based on either the ECG or CHART reports, presented in table 2. ...
Purpose
In a comparator study, designed with assistance from the Food and Drug Administration, a State-of-the-Art (SOTA) ECG device augmented with automated analysis, the comparator, was compared with a breakthrough technology, Cardio-HART (CHART).
Methods
The referral decision defined by physician reading biosignal-based ECG or CHART report were compared for 550 patients, where its performance is calculated against the ground truth referral decision. The ground truth was established by cardiologist consensus based on all the available measurements and findings including echocardiography (ECHO).
Results
The results confirmed that CHART analysis was far more effective than ECG only analysis: CHART reduced false negative rates 15.8% and false positive (FP) rates by 5%, when compared with SOTA ECG devices. General physicians (GP’s) using CHART saw their positive diagnosis rate significantly increased, from ~10% to ~26% (260% increase), and the uncertainty rate significantly decreased, from ~31% to ~1.9% (94% decrease). For cardiology, the study showed that in 98% of the cases, the CHART report was found to be a good indicator as to what kind of heart problems can be expected (the ‘start-point’) in the ECHO examination.
Conclusions
The study revealed that GP use of CHART resulted in more accurate referrals for cardiology, resulting in fewer true negative or FP—healthy or mildly abnormal patients not in need of ECHO confirmation. The indirect benefit is the reduction in wait-times and in unnecessary and costly testing in secondary care. Moreover, when used as a start-point, CHART can shorten the echocardiograph examination time.
