New Routes to Integrated Care: Smart-phones and and changing GP roles

Transcription

1 New Routes to Integrated Care: Smart-phones and and changing GP roles Dr Matthew Fay GP Principal The Willows Medical Practice- Queensbury GPwSI and Co-Founder Westcliffe Cardiology Service GP Partner Westcliffe Medical Group Created 7/31/2016 Dr. Matthew Fay: Westcliffe Medical Group

2 Declaration of interests Funding has be variously given by: Abbot, Bayer, Boehringer-Ingelheim, Bristol Myers Squibb, Dawn 4S, INRStar, Medtronic, Oberoi Consulting, Pfizer, Roche, Sanofi-Aventis, Servier I am an advisor to: Anticoagulation Europe, AF Association, Arrhythmia Alliance, Heart Valve Voice, National Stroke Association, Syncope Trust I am a trustee of ThrombosisUK & AF Association

3 Who is this?

4 Willem Einthoven Who is this?

5 Patient Presents With palpitations Sees GP GP Refers Hospital Receives letter Negative Test 24hr ECG Outpatients Consultant receives letter Has 7 day ECG Outpatients and decision Has 7 day ECG Lost to system Put on waiting list Consider ILR Sees GP GP writes letter Outpatients and decision Hospital Receives letter

6 Insanity: doing the same thing over and over again and expecting different results. Albert Einstein

7 Vignette 28yr old female Presented age 14 with palpitations Investigated cardiology Poland Anxiety Presented age 22 with palpitations Investigated cardiology Leeds Anxiety Presented age 28 with palpitations Investigated GPwSI Shipley SVT with subsequent ablation of slow pathway

8 The history of the ECG Augustus Waller published first human ECG 1887 Willem Einthoven created PQRST system 1895, described ECG features of CV disorders

9 The history of the ECG 24hr ECG Invented by Dr. Norman J. Holter 1949 Initially contained within a 75 pound backpack Ambulatory ECG Circa 1976

10 Some evidence 24-hour ambulatory electrocardiographic monitoring is unhelpful in the investigation of older persons with recurrent falls Davison J, Brady S, Kenny RA Age and Ageing 2005; 34: Prospective case-control study

11 Methods Recruited patients age >64 presenting to A&E with fall, having sustained an additional fall in previous year Exclusions MMSE<24 or >1 previous syncopal episode or medical explanation for fall Controls matched for age and sex, no falls in 3 years or any previous syncope

12 Methods Both groups fitted with 24-hour monitors Instructed in using a symptom diary Type and duration of arrhythmia recorded major abnormalities e.g. VT, pauses, HR<30, Mobitz type II or complete heart block minor abnormalities e.g. multiple VEs, paroxysmal SVT, HR 30-39, Mobitz type I, PAF/flutter Symptoms and arrhythmias compared

13 Results - symptoms Fallers (n=128) Controls (n=100) Average age Mild symptoms 10% 13% Breathlessness 3% 7% Fatigue 1% 3% Chest pain 2% 2% Dizziness 5%?% Palpitations?% 5% Falls 1 patient none

14 Fallers Controls Any abnormality 49% 41% Pauses > 2s 6% 8% VT > 2 beats 4% 3% Mobitz II HB 1% 0% HR < 30 bpm 0% 1% Complete HB 0% 0% HR bpm 9% 5% Paroxysmal SVT 10% 13% Ventricular ectopy 34% 24% Paroxysmal AF 5% 4%

15 Summary of findings No significant difference between groups in prevalence of major or minor ECG abnormalities, or symptoms during recording Multiple abnormalities present in older people whether or not they have fallen 24-hour ECGs not helpful in investigation of recurrent falls

16 24-hour tapes Non-invasive Safe Low cost (approx. 70 per tape) Beat to beat acquisition High fidelity

17 However There may be intolerance to adhesive, or electrodes may become detached during recording Symptoms may not recur during recording Incidental abnormalities may be detected, unrelated to the fall

18 Diagnostic yield Results from studies vary widely Rhythm-symptom correlation in 4% 15% had symptoms but no arrhythmia (helpful in its own way) So yield is low, making cost per diagnosis higher (NB yield from history and exam)

19 Vignette 28yr old female Presented age 14 with palpitations Investigated cardiology Poland Anxiety Presented age 22 with palpitations Investigated cardiology Leeds Anxiety Presented age 28 with palpitations Investigated GPwSI Shipley SVT with subsequent ablation of slow pathway

20 iphone ECG

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23 iphone ECG

24 AliveCor Series Westcliffe Started 2014 Now over 80 recordings Females 54/Males 26 Age range 16-73yrs Indication Palpitations High suspicion AF Syncope

25 AliveCor fitted by Age

26 AliveCor Series Westcliffe Sinus rhythm 30 Dysrhythmia 35 SVT 10 Ectopy 8 AF 8 Atrial Flutter 1 Paroxysmal sinus tachycardia 1 Symptomatic sinus arrhythmia 1 AV disassociation 1 Majority detected on first trace

27 Palpitation

28 Vignette 35yr old female Presented age 30 with palpitations Investigated cardiology Bradford Uncertain Presented age 35 with palpitations Investigated cardiology GPwSI service Shipley Post traumatic stress due to childhood sexual abuse

29 Patient Presents With palpitations Sees GP GP Refers Hospital Receives letter Negative Test 24hr ECG Outpatients Consultant receives letter Has 7 day ECG Outpatients and decision Has 7 day ECG Lost to system Put on waiting list Consider ILR Sees GP GP writes letter Outpatients and decision Hospital Receives letter

30 Patient Presents With palpitations Sees GP GP supplies AliveCor GP Symptomatic trace Advice and management

31 How to help the GP Palpitations: an abnormally perceived heart beat

32 What does the patient mean? Palpitations: an abnormally perceived heart beat

33 History, history, history How long How fast How often Onset / offset Triggers Circumstances Known structural heart dise

34 Any associated symptoms? Dizziness Blackout Breathlessness Chest pain

35 Family history 1 st degree relatives Sudden ( cardiac ) death under age of 40 Fatal drowning /RTA Epiletic death Family members with inheritable heart disease

36 Risk stratification Skipped beats Thumping beats Short fluttering Slow pounding AND Normal ECG AND No FHx AND No structural heart disease Hx suggests recurrent tachyarrhythmia Palpitations with associated symptoms AND / OR Abnormal ECG AND / OR Structural heart disease Palpitation during exercise Palpitations with syncope / near syncope High risk structural heart disease FHx of inheritable heart disease High degree AV block Low risk Manage in Primary Care Refer to cardiology / Arrhythmia care Co-ordinator Refer to cardiology with urgency

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39 Screening for AF

40 Wilson and Jungner Criteria for Screening UK National Screening Committee: Criteria for appraising the viability, effectiveness and appropriateness of a screening programme Ideally all the following criteria should be met before screening for a condition is initiated:

41 The Condition The condition should be an important health problem The epidemiology and natural history of the condition, including development from latent to declared disease, should be adequately understood and there should be a detectable risk factor, disease marker, latent period or early symptomatic stage. All the cost-effective primary prevention interventions should have been implemented as far as practicable.

42 The Test There should be a simple, safe, precise and validated screening test. The distribution of test values in the target population should be known and a suitable cut-off level defined and agreed. The test should be acceptable to the population. There should be an agreed policy on the further diagnostic investigation of individuals with a positive test result and on the choices available to those individuals.

43 The Treatment There should be an effective treatment or intervention for patients identified through early detection, with evidence of early treatment leading to better outcomes than late treatment. There should be agreed evidence based policies covering which individuals should be offered treatment and the appropriate treatment to be offered. Clinical management of the condition and patient outcomes should be optimised in all health care providers prior to participation in a screening programme.

44 The Screening Programme There should be evidence from high quality Randomised Controlled Trials that the screening programme is effective in reducing mortality or morbidity. There should be evidence that the complete screening programme (test, diagnostic procedures, treatment/ intervention) is clinically, socially and ethically acceptable to health professionals and the public. The benefit from the screening programme should outweigh the physical and psychological harm (caused by the test, diagnostic procedures and treatment). The opportunity cost of the screening programme (including testing, diagnosis and treatment, administration, training and quality assurance) should be economically balanced in relation to expenditure on medical care as a whole.

45 Screening for Atrial Fibrillation The Condition Why AF is important The Test Find patients with AF Confirm the diagnosis of AF The Treatment Assess risk of thromboembolic event Decide on treatment and initiate anticoagulation

46 Take the Opportunity

47 Prevalence of Unknown AF Patients with Risk Factors 132 adult patients (76 male; age: 64 ± 14, mean ± SD) without known AF Screened in diabetes, hypertension, and dyslipidemia clinics 76 outpatients and 56 stroke survivors Simple patient-operated, single-channel ECG recorder (Omron hcg-801-e). Samol A et al. Europace 2013;15: % of patients screened Hypertension 2 risk factors or stroke Stroke hypertension and diabetes

48 AF Detection with Modified BP Monitor ECG Sensitivity (%) Specificity (%) Comparison of individual device readings to the ECG rhythm Device reading AF Non-AF Irregular Regular ( ) ( Comparison of the three-sequential device readings to the ECG rhythm Device reading AF Non-AF Irregular Regular (91 99) (85 92) An oscillometric automatic blood pressure monitor (model BP3MQ1-2D; Microlife USA) Wiesel J, et al. Am J Hypertens 2009; 22:848-52

49 AF Detection on iphone ECG Learning set (n = 109) Sensitivity Specificity Accuracy Kappa Cardiologist A 100% 90% 94% 0.87 Cardiologist B 95% 94% 95% 0.88 Original algorithm 87% 97% 94% 0.86 Optimized algorithm 100% 96% 97% 0.94 Validation set (n = 204) Algorithm was optimized by increasing weighting of absence of P waves Optimized algorithm 98% 97% 97% 0.92 Lau JK, et al. International Journal of Cardiology 2013;165:193-4

50 Action in the Community Take the pulse Record ECG

51 MyDiagnostick Acquires a one minute ECG (Lead I) Performs ECG analysis and provides diagnostic outcome directly after ECG acquisition Diagnostic outcome is simply red (AF) or green (No AF) easy interpreted by physician and patient Web-portal for ECG viewing, storage and management 573 patients 65 years old attending flu clinic and 95 patients had an irregular pulse 21 had prior AF, 68 were invited for ECG and 39 attended 2 new cases of AF were diagnosed Rhys GC, et al. Keele University, UK 61 pts (age 70.1±5.2 years) of 676 pts (age 74±7.1 years) attending for flu vaccine had AF Correct diagnosis in 55 pts (prevalence 8.1%) 44 pts (6.5%) were known with AF, but 11 pts (1.6%) were not Mean CHA 2 DS 2 -VASc-score of 3 Tieleman R et al, Europace 2014 in press

52 Thank you for your