Respiratory Patient Pathway
BWCCG – MOT’s Shortness of Breath Event
Thursday 5th November 2020 from 12:00pm – 14:00pm via Microsoft TEAMS
• Please note, the webinar will be recorded & by attending the session you are giving consent
• Kindly switch off your video & microphone to help avoid interruptions
• Lastly, kindly type in your questions clearly in the Chat box ( Symbol). A moderator will read them out at the end of each session. BWCCG – MOT’s Shortness of Breath Event Thursday 5th November 2020 from 12:00pm – 14:00pm Via Microsoft TEAMS
12:00 - Winter Respiratory Pathway Introduction (Dr Heike Veldtman, LTC GP Chair)
12:10 - SOB: Review and Management of Non COVID related Respiratory Conditions (Dr. Anne McGown, Respiratory Consultant – RBFT)
12:50 – Q & A session
13:00 - SOB: Review and management of Heart Failure (Dr Lindsey Tilling, Consultant Cardiologist – RBFT)
13:50 - Q & A Session
14:00 - CLOSE
Respiratory Patient Pathway
Patient Presents
NHS 111 OR GP
GP Triage Treat and Safetynet (Enquire about Covid Admit to Secondary Care test)
Need F2F MDT
Refer to BHFT Primary Care Review Community Respiratory Case Finding – CM input Seen in Primary Care Service Anticipatory Care Respiratory Hub (Care Planning, Planning Virtual Monitoring)
MDT Admit to Secondary Care
GP webinar – respiratory update
Anne McGown November 2020 Summary
• Managing exacerbations/deterioration in known respiratory disease – COPD – Asthma – Bronchiectasis – ILD • Other causes of chronic breathlessness • Pulse oximetry and exertional desaturation • CAP during COVID • Breathlessness following covid COPD – gradual deterioration -Deconditioning
• Unfit people get more breathless. • Early onset of lactic acidosis in unfit muscles stimulates chemoreceptors to increase ventilation. • One of the reasons pulmonary rehab works. • Unless accompanied by exercise; education or symptom management programs don’t help dyspnoea in COPD. Vicious circle 1
Deconditioni ng
Breathless ness on exertion
Reduce Perceived as exertion to potentially avoid harmful breathlessness Breathlessness in context Vicious circle
Sensations associated with breathlessne Interpret ss ed as dangero us Increased Increased physiological anxiety/distress awareness/aro usal Pulmonary rehab – RBH and community service Physios are accepting referrals for PR. Please complete the attached referral form and email to: [email protected] Patients are currently assessed face to face and enrolled onto a virtual programme (by telephone or via Microsoft TEAMS) Hoping to bring back face to face pulmonary rehabilitation in the New Year Community also up and running – refer through the hub. Takes place in Tilehurst and WBCH.
NICE 2019 summary COPD exacerbations – NICE 2018 - steroids • In the absence of significant contraindications, consider oral corticosteroids for people in the community who have an exacerbation with a significant increase in breathlessness that interferes with daily activities. [2004] • Encourage people who need corticosteroid therapy to present early to get maximum benefits. [2004] • Offer 30 mg oral prednisolone daily for 5 days. [2019] • Develop an individualised exacerbation action plan in collaboration with each person with COPD who is at risk of exacerbations. [2018]
COPD exacerbation – NICE 2019 - antibiotics COPD exacerbations – self management /rescue pack – NICE 2018
• Offer people rescue pack or steroids and antibiotics if -
they have had an exacerbation within the last year, and remain at risk of exacerbations
they understand and are confident about when and how to take these medicines, and the associated benefits and harms
they know to tell their healthcare professional when they have used the medicines, and to ask for replacements. [2018]
Action plan may include
adjusting their short-acting bronchodilator therapy to treat their symptoms
oral corticosteroids if increased breathlessness interferes with activities of daily living
oral antibiotics if their sputum changes colour and increases in volume or thickness beyond their normal day-to-day variation
telling their healthcare professional. [2018]
Community team contact details
• Referral through hub • Exacerbation of Spirometrically diagnosed COPD • Local ABX guidelines are amoxyl for infrequent exacerbators, doxy for frequent. 5 days with the steroids unless underlying bronchiectasis. • Only wean pred in those with v frequent courses – get community team involved in these. • Refer anyone to community team on second exacerbation.
Bronchiectasis
• UK data in 2013 revealed the prevalence in women was 566/100 000 and in men 486/100 000 • Usually an annoying condition which causes chronic cough and recurrent chest infections rather than progressive disability. May co-exist with asthma/COPD • A minority often with known cause have progressive infection and complications.
Microbiology
• Progressive bacterial colonisation of lower airways • Staph aureus • Haemophilus influenzae • Moraxella catarrhalis • Pseudomonas species • (AAFB) • Send regular samples for MC&S • Annual sputum AAFB Antimicrobial chemotherapy
• Short term, long term • Oral, nebulised, intra venous • Regular sputum surveillance • In vivo and in vitro sensitivity can be different • Need more prolonged antibiotic courses • Pseudomonas colonised patients have more exacerbations and a faster decline in lung function
Antibiotics
• Amoxycillin 1G TDS 10-14 days • Doxycycline 100mg OD 14 days • Ciprofloxacin 750mg BD 2-3 weeks if previous PsA
• First isolate of PsA needs eradication: 4-6 weeks ciprofloxacin with nebulised aminoglycoside • Long term nebulised colomycin reduces PsA exacerbations Refer if
• New PsA infection – treat with ciprofloxacin (even if lab resistance) and let us know • No response to 3-4 weeks of high dose oral antibiotics (ideally with known sensitivities) • Significant haemoptysis • Weight loss • Ventilatory failure • Please send sputums – multiple if required! Physiotherapy
• Regular, part of daily treatment • Active Cycle of Breathing Technique • Deep breathing, mobilise secretions • Regular exercise • Breathing control
• Pulmonary Rehabilitation Other Treatments
• Of underlying disease • Self management plan • Bronchodilators • Inhaled steroid – only if coexistent asthma • Nutrition, nutrition, nutrition • Vaccinations • Tranexamic acid • Surgery/transplant BTS 2019 Long term macrolides in bronchiectasis BTS April 2020 • Baseline ECG and LFT. If QTc is >450ms for men and >470ms macrolides contraindicated • Counsel patients about potential adverse effects including gastrointestinal upset, hearing and balance disturbance, cardiac effects and microbiological resistance. • Sputum culture for non tuberculous mycobacteria - avoid if present • Accurate assessment of baseline exacerbation rate should be determined before starting long-term macrolides for bronchiectasis. • Liver function tests should be checked one month after starting treatment and then every 6 months. • An ECG should be performed 1 month after starting treatment to check for new QTc prolongation. If present, treatment should be stopped. • Subsequent follow-up at 6 and 12 months should determine whether benefit is being derived from therapy. If there is no benefit, treatment should be stopped. • Even if benefit is seen, consideration should be given to stopping treatment for a period each year, for example over the summer. Asthma deterioration NICE 2017 – adults >17
1 If infrequent, short-lived wheeze and normal lung function, consider treatment with SABA reliever therapy alone. 2 Add low dose inhaled steroid ( if more than 3 SABA a week or waking at night 3. Add leukotriene receptor antagonist (LTRA) in addition to the ICS and review the response to treatment in 4 to 8 weeks.
4. Add a long-acting beta2 agonist (LABA) in combination with the ICS, and review LTRA 5. Convert to a MART regimen with a low maintenance ICS dose. 6. consider increasing the ICS to a moderate maintenance dose (either continuing on a MART regimen or changing to a fixed-dose of an ICS and a LABA, with a SABA as a reliever therapy). If asthma remains uncontrolled - options
• increasing the ICS to a high maintenance dose (this should only be offered as part of a fixed-dose regimen, with a SABA used as a reliever therapy) or
a trial of an additional drug (for example, a long-acting muscarinic receptor antagonist or theophylline) or
seeking advice from a healthcare professional with expertise in asthma. • Mepolizumab is possible add on for severe refractory eosinophilic asthma in adults (sc injection every 4weeks), only if:
the blood eosinophil count is 300 cells/microlitre or more in the previous 12 months, and
the person has agreed to and followed the optimised standard treatment plan and
has had 4 or more asthma exacerbations requiring systemic corticosteroids in the previous 12 months or had continuous oral corticosteroids of at least the equivalent of prednisolone 5 mg per day over the previous 6 months, - REFER (specialist commissioning)
Asthma deterioration/exacerbation NICE 2017 • Offer increased dose of ICS for 7 days in a self management plan (can quadruple dose if using ICS in single inhaler and within max licensed daily dose). • If not using ICS regularly explain regular use may enable them to regain control of asthma • Acute severe asthma – Prednisolone 40mg until better, minimum 5 days.
• Mepolizumab - 45 patients locally – continue to use even if exacerbating
Interstitial lung disease – 2 main groups • Idiopathic pulmonary fibrosis – UIP (usual interstitial pneumonia) pattern (old cryptogenic fibrosing alveolitis) – limited treatment available with antifibrotics • Heterogeneous group of (usually) better prognosis conditions responding to steroids/immunosuppression including NSIP (non-specific interstitial pneumonia), HSP (hypersensitivity pneumonitis), COP (cryptogenic organizing pneumonia), sarcoid, connective tissue associated. • Asbestosis – no treatment but compensation UIP – deterioration/exacerbation
• No quick fix for ILD – particularly for UIP • Unpredictable course – a lot of people just have 6monthly monitoring until they hit the criteria for antifibrotics (FVC between 50% and 80%) or are shown to be deteriorating. Specialist commissioning. • Antifibrotics (pirfenidone, nintedanib) slow the rate of decline of lung function (but work very slowly – assessed for efficacy after a year and stopped if FVC fallen by >10%). Often stopped due to side effects. • Otherwise supportive care – morphine, oxygen • Chest infections common and treated with oral antibiotics • Acute exacerbation – sudden and often catastrophic – requires hospital admission - half of people with idiopathic pulmonary fibrosis who have an acute exacerbation will die within 30 days.
ILD COVID guidelines
• Before deciding to stop or adjust any treatment, if possible, contact the patient's hospital specialist team for advice. If a medicine is stopped, ask the hospital specialist team when and how to restart it. • Continue antifibrotics if blood monitoring parameters are in an acceptable range and there is no other reason to stop, such as significant adverse effects. • Think about temporarily stopping immunosuppressants (if covid diagnosed) unless the risk of aggravating their underlying lung condition outweighs the benefits of stopping. When deciding whether to stop treatment, discuss the risks and benefits with the patient. • Advise patients on maintenance oral prednisolone that if they are diagnosed with COVID-19, they should continue treatment because stopping it can be harmful.
Other causes of chronic breathlessness
• obesity hypoventilation with type 2 resp failure • Neuromuscular • Chest wall deformity (severe scoliosis) • Pulmonary hypertension • Pleural effusion • Anaemia • Upper airway obstruction • If examination, CXR and spiro normal – big causes are breathing pattern disorder and deconditioning ( after r/o asthma) Breathing pattern disorder
• New name for dysfunctional breathing, chronic hyperventilation • Often coexists with asthma, obesity. • Consider if anxiety overlay, or SOB does not get better with asthma treatments and objective tests normal at time of SOB (PEFR/spiro) and associated symptoms of metabolic alkalosis • Try to diagnose positively (not a diagnosis of exclusion but is a clinical diagnosis in most cases) • Treated with physio for breathing retraining and this works well. • www.physiotherapyforbpd.org.uk
Pulse oximetry
• Non-invasive way to monitor percentage of haemoglobin that is saturated with oxygen. • Works because oxygenated haemoglobin is a different colour from deoxygenated haemoglobin. • Selects out pulsatile flow. • Accurate above a saturation of 70%. Pulse oximetry - practical points
• Not accurate if signal poor - always need to check signal – probe position – hypovolaemia/shock – peripheral vasoconstriction - cold – shivering – nail varnish
– If it can’t pick up the pulse, remember venous saturation is around 70% – Also need to ignore results when coughing Exertional desaturation
• Proxy measurement for gas transfer • Found in any cause of breathlessness with alveolar involvement – Emphysema – ILD – PCP pneumonia – COVID pneumonia – Pulmonary hypertension – Big PE
Very useful to distinguish well from ill, does not really help with diagnosis. Chronic exertional desaturation in chronic lung disease may be an indication for ambulatory oxygen assessment, but as long as sats improve with rest does not need acute action.
Post covid breathlessness
• No evidence basis for any treatment except time and exercise • Rule out other causes. • Trust website/patients and visitors/ patient information leaflets/respiratory • Respiratory (physio): Pulmonary Rehabilitation - Recovering from COVID-19 useful resources October 2020 • Respiratory (physio): Pulmonary Rehabilitation - recovering from post-acute Covid-19 (long Covid) October 2020
Resources for covid recovery (breathlessness)
• https://www.yourcovidrecovery.nhs.uk/
• Exercise videos: • British Lung Foundation: • • https://www.blf.org.uk/support-for-you/keep-active/exercise- video • • https://www.blf.org.uk/support-for-you/keep-active/how-to-stay- motivated
• Breathlessness: • Association of Chartered Physiotherapists in Respiratory Care: • • www.acprc.org.uk
• Physiotherapy for breathing pattern disorder: • • www.physiotherapyforbpd.org.uk
NICE – 2020 – distinguishing covid from bacterial pneumonia • COVID-19 viral pneumonia may be more likely if the patient: • presents with a history of typical COVID-19 symptoms for about a week • has severe muscle pain (myalgia) • has loss of sense of smell (anosmia) • is breathless but has no pleuritic pain • has a history of exposure to known or suspected COVID-19, such as a household or workplace contact. • A bacterial cause of pneumonia may be more likely if the patient: • becomes rapidly unwell after only a few days of symptoms • does not have a history of typical COVID-19 symptoms • has pleuritic pain • has purulent sputum. Give antibiotics if patient unwell anyway – doxycycline first choice, no steroids unless hypoxic
NICE 2020 – hospital admission in covid pneumonia • Be aware that older people, or those with comorbidities, frailty, impaired immunity or a reduced ability to cough and clear secretions, are more likely to develop severe pneumonia. Because this can lead to respiratory failure and death, hospital admission would have been the usual recommendation for these people before the COVID-19 pandemic. Explain that: • the benefits of hospital admission include improved diagnostic tests (chest X-ray, microbiological tests and blood tests) and respiratory support • the risks and disadvantages of hospital admission may include spreading or catching COVID-19 and loss of contact with families. [amended 19 August 2020]
Any questions?
• Please ask for advice and guidance via C and B • Or [email protected] • Or CAT11 – [email protected] • CAT 11 - 0118 322 6676 and ask to be rung back
Breathlessness and Heart Failure
Dr Lindsey Tilling Cardiology Consultant Royal Berkshire Hospital • Symptoms and Signs • Tests • Medications- diuretics • How do you contact us?
BACKGROUND Is it heart failure?
Undetermined (no angiographic data) 13 (10%)
Results based on full investigation (including Idiopathic (no CAD) 17 (13%) coronary angiography) in new patients aged <75 years identified in a UK population-based study
Other 7 (5%)
AF alone 4 (3%)
Coronary artery Alcohol 5 (4%) disease 71 (52%)
Valve disease 13 (10%)
Hypertension alone 6 (4%) Fox et al, Eur. Heart J., 2001 Other relevant history Cardiovascular: o chest pain o Palpitations
Respiratory: o known lung disease o Cough, wheeze, o Smoking history
Gastrointestinal o Weight loss o Malaena
Thyroid Renal
Symptoms
• Dyspnoea • Orthopnea • Reduced exercise tolerance • Paroxysmal nocturnal dyspnoea • Oedema • Lethargy, fatigue, anorexia • Depression
Signs
Left heart failure Right heart failure
• Pulmonary congestion • Systemic congestion – tachypnoea – raised JVP – basal inspiratory crackles/wheeze – abdominal ascites – wheeze – peripheral pitting – dull to percussion oedema • Auscultatory signs – sacral oedema – third or fourth heart sounds – dull to percussion • Systemic hypoperfusion – cold clammy peripheries – feeble pulses, tachycardia – hypotension
Investigations
NICE AHF 2014
• In people presenting with new suspected HF use BNP or NTproBNP to rule out HF: • BNP <100ng/L • NTpro BNP<400ng/L
• With raised NP level perform a transthoracic echo to establish presence or absence of cardiac abnormalities. Other Factors affecting NTproBNP
• Increased in: – Age (automatic lab correction) – Female gender (automatic lab correction) – Atrial fibrillation – Left ventricular hypertrophy – Renal failure – Some respiratory disase, PE
• Reduced in: – obesity
NP and Prognosis in HF
• Falling NP correlates with improved haemodynamic measurements
• Useful for follow up and assessing disease progression; very high NP (>10 000) indicates very poor prognosis if no intervention
CXR signs
• Cardiomegaly • Upper lobe diversion of the vasculature • Batwing perihilar shadowing • Septal lines (Kerley B lines) • Fluid in the horizontal fissure • Pleural effusion
ECG findings
• Rhythm? AF may be clue to etiology • Rate? Tachycardic in decompensated HF • Ischaemia/Infarct? • Cardiomyopathy • Hypertension (LVH with strain pattern)
• Interventricular conduction delay: BBB
Echocardiography
• Diagnosis of heart failure – detection of LV and/or RV systolic and/or diastolic impairment • Assessment of severity – assessment of LV and RV systolic function, diastolic function and dimensions • Determining aetiology – valvular pathology – regional wall motion abnormalities – cardiomyopathies
HFrEF vs HFpEF
• Heart failure with reduced ejection fraction vs heart failure with preserved ejection fraction • HFrEF: EF <50%, HFpEF: EF>50%
• Fairly equal distribution of hospitalisation • Both carry comparable morbidity/mortality • Elevated NTproBNP in both, similar CXR findings • Much more therapeutic interventions for HFrEF
Diuretics
• For relief of symptoms and signs of congestion – no mortality benefit • Not contraindicated by renal failure, hyponatraemia or hypotension • Two classes: – loop (first-line) e.g. furosemide, bumetanide: – thiazide e.g. bendroflumethiazide, metolazone – can be combined for maximum effect Diuretics
• Don’t be afraid to increase the dose • Massive doses given in the large trials, with no long-term sequelae (CARESS HF trial)
• Patients with CKD or chronic diuretic use require higher doses to be effective • Evidence that diuretic-induced renal deterioration is transient (DOSE trial)
• In end-stage HF: what matters most to the patient? Diuretics in elderly
• If >85years old – no previous cardiac history – symptoms/signs of HF – elevated NTpBNP …it is almost certainly HFpEF
• In my opinion these patients do not need an echo, nor a hospital appointment, particularly with the current Covid risk • Start low dose diuretic, titrate up slowly, don’t worry too much about some degree of renal function deterioration Treatment: Heart failure with reduced ejection fraction (HFrEF) SNS β-blockers
Adrenaline α1, β1, β2 Noradrenaline receptors Vasoconstriction RAAS activity Natriuretic peptide Vasopressin system HFrEF Heart rate SYMPTOMS & Contractility PROGRESSION NPRs NPs Vasodilation Blood pressure RAAS inhibitors Sympathetic tone RAAS (ACEI, ARB, MRA) Natriuresis/diuresis Vasopressin Ang II AT1R Aldosterone Fibrosis Vasoconstriction Hypertrophy Blood pressure Sympathetic tone Aldosterone Hypertrophy Fibrosis
ACE Inhibitors
• Inhibit ACE, which converts angiotensin I to angiotensin II • Indicated in all stages of HFrEF mortality and morbidity benefit • Adverse effects: cough (5-15%), hypotension, hyperkalaemia, renal failure, angio-oedema.
• Evidence base: enalapril, ramipril, lisinopril, perindopril • Dose: start low, titrate up to maximum tolerated • Renal issues: NICE state allow ≤20% reduction in creatinine Angiotensin Receptor Blockers
• Antagonists at AT1 receptors (block action of angiotensin II) • Indicated in patients with HFrEF who are intolerant of ACE inhibitors (morbidity benefit, debatable mortality benefit) • Adverse effects: same as ACE inhibitors except no cough
• Evidence base is not as strong as for ACEI. Candesartan, valsartan (not losartan) Beta Blockers
• Competitive beta adrenoceptor antagonists • Indicated in all stages of HFrEF mortality and morbidity benefit • Adverse effects: bradycardia, hypotension, fatigue, impotence, sleep disturbance
• Evidence base: carvedilol, metoprolol, bisoprolol, nebivolol • Dose: maximum tolerated • NOT contraindicated in COPD, PVD Mineralocorticoid Receptor Antagonists
• Competitive aldosterone receptor antagonists • Indicated in severe HFrEF (LVEF 35%) mortality and morbidity benefit • Adverse effects: hyperkalaemia, renal failure, gynaecomastia and impotence with spironolactone, GI upset
• Evidence base: spironolactone, eplerenone • Dose: 25mg od. If concern over renal function/K+ start with 12.5mg
Sacubitril/Valsartan (Entresto) • Angiotensin receptor neprilysin inhibitor (ARNI) • PARADIGM-HF trial – Chronic HF NYHA II–IV with LVEF ≤35, optimally managed. Entresto vs enalapril.
• Primary outcome – 20% reduction in CV death or HF hospitalisation – 20% reduction in CV mortality – 21% reduction in HF hospitalisation
Sacubitril/Valsartan (Entresto)
NICE June 2016 • Indicated in severe HFrEF (EF<35%), NYHA II-IV, previous ACEI/ARB
• Adverse effects: hypotension, renal impairment, hyperkalemia. • Contraindications: concurrent ACEI, angioedema with ACEI, eGFR<30 • Dose:24mg/26mg bd, 49mg/51mg bd, target 97mg/103mg bd
Other Treatment: Devices
• Cardiac resynchronisation therapy (CRT) = biventricular pacemaker – severe heart failure and bundle branch block on ECG, optimal medical therapy.
Other Treatment: Devices
Implantable cardioverter defibrillator (ICD) – as primary prevention of arrythmic death in selected patients
Devices
EF< 35%: consider referral for device
European Society Cardiology 2017
…and more soon to come
• GLP1 RA: reduce major adverse cardiac events • SGLT2i: reduce MACE and HF hospitalization ….in diabetics and non-diabetics
Community HF team
• 7 nurses working in West Berks • Have regular hub clinics, can visit patients at home too • Monitoring, blood tests, medication review, RBH MDT and close liaison with me • Ideally need to have had an echo before referral accepted
What can we offer at RBH? Urgent HF assessment clinic
• Patient seen within 2 weeks of referral • TTE (& NP) if not had previously • Other investigations as necessary • Medication optimisation • Consideration of • Device therapy • Advanced HF management • Gateway to Ambulatory HF unit • Involvement of community team • Involvement of Palliative care team
What can we offer at RBH? Ambulatory HF unit • Day case unit (JSU) • Ambulatory diuretic service – Long iv line – High dose diuretics, short stay – Paracentesis – Daily blood tests
– Ambulent; transport; committed
– Avoidance of admission, great patient feedback!
Contacts
• For Urgent HF clinic/Ambulatory HF unit referrals: 0118 3226638/ [email protected]
• General HF enquiries: • Cardiology Advice and Guidance line • CAT11 0118 3226676/ [email protected]
Thank you
Dr Katrin Balkhausen Consultant Cardiologist Royal Berkshire Hospital % increase of echo referrals 2015-
12000 2019 >11%
10000
> 16% 8000
< 16% 6000 2015 >2.3% 2016 2017 4000 2018 > 79% > 20% > 51% 2019 2000
0 % total of GP echo referrals 2015- 2019
Total echo Total GP % GP 2015 8842 882 10 2016 9043 1199 13 2017 9487 1422 15 2018 9616 1693 17 2019 9806 1576 16 reasons for GP echo referrals
> 40% of all GP referrals - suspected heart failure over 70 % of GP referrals for heart failure had prior NTproBNP • 70% HAD NO CONSIDER LV DYSFUNCTION ALTERNATIVE DIAGNOSIS
DIRECT REFERRAL TO URGENT HEART FUNCTION CLINIC reasons for GP echo referrals no routine echo indicated …
… in patients with … in patients without change in clinical status with • controlled hypertension known structural heart disease • isolated incidental ventricular or atrial ectopics • sinus brady- or tachycardia … in patients presenting with non- cardiac chest pain • 1st degree AV block
• right bundle branch block … in patients with significant illness • left axis deviation whose management would not be affected by echocardiographic abnormalities … in patients with normal ECG/no murmur/no clinical signs of heart failure and • radiographic cardiomegaly • palpitations without proof of relevant dysrhythmia • classic vaso-vagal syncope
direct cardiology referral (no OP echo)… • NTproBNP >2000 ng/l, please initiate treatment and refer for urgent Heart Function Clinic review • change in clinical status of patients known with • cardiomyopathy / valve disease • suspected cardiomyopathy • 1st degree family member with cardiomyopathy • complex dysrhythmia on Holter monitor • known congenital heart disease
routine echo for …
• Suspected heart failure with NTproBNP > 400ng/l - <2000ng/l Please provide recent NTproBNP level Please initiate therapy
• New murmur
• Screening for Bicuspid Aortic Valve (BAV) in 1st degree family members please contact us!
If your patient does not fit into any of the categories above but you feel might require an echocardiogram, please discuss directly via our Advice & Guidance Service or write with a generic referral to the Cardiology Department
Thank you!