Download Welcome to the Cardiology Department - Dr Mark Dayer

Welcome to the Cardiology Department
Musgrove Park Hospital
Induction for Junior Doctors
We very much hope you will find your time with us interesting and enjoyable
MDS and DMZ 2012 (Updated TJM 2010)
Cardiology Induction for Junior Doctors
Welcome to the Cardiology Department
INDEX
2
Services provided and layout of the department
3
Who’s Who
4
What is expected of the junior doctors / how do the wards work
5
Consultant and registrar support
6
Annual leave and study leave arrangements
8
How to order cardiology investigations
8
Consent
9
Indications for complex devices
12
Preparing patients on the wards for procedures and post-procedure care
13
Specialist nurses
16
Cardiac Rehabilitation
Chest Pain
Arrhythmia
Audit
16
17
17
18
Discharge Policy
19
Care pathways / protocols and guidelines
20
NICE, ESC, DVLA
ACS (MPH Algorithm)
Anticoagulation in patients undergoing cardiology procedures
Bridging anticoagulation for patients with mechanical valves
Insertion of a TPW
20
20
23
24
28
Educational opportunities
Outpatients policy
Induction checklist
29
30
34
Appendix
37
Consent forms
Aspirin Desensitization protocol
39
45
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Cardiology Induction for Junior Doctors
Services provided and the layout of the department
The Cardiology Department at Musgrove Park provides a full set of secondary care cardiac
investigative and treatment options whilst also providing many services traditionally seen as
tertiary in nature, for example we have access to full out-patient facilities with specialist clinics for
Rapid-Access Chest Pain, Pacemaker\ICD follow up, Pre-operative assessment, Echo,
Angioplasty\DC cardioversion follow up and Adult Congenital Heart Disease.
We provide out-patient investigation with ECG, Exercise Testing, simple and complex
Echocardiography, heart rhythm and 24-hour BP monitoring, nuclear perfusion scanning and Tilt
testing.
For in-patients we provide a full emergency cardiac service via a 9-bedded CCU, a cardiology
ward (Fielding), and daily consultant review of patients on the MAU. We also provide nurse led
chest pain, heart failure, arrhythmia and rehabilitation services. We run 2 diagnostic\interventional
coronary laboratories providing full angiography and stenting services for routine, urgent and
emergency work, including a Primary PCI service for Acute MI.
We also run 1 separate pacemaker\ICD\resynchronisation therapy lab for device implantation. At
present we do not provide electrophysiology\ablation, interventional congenital nor cardiac surgical
services.
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Cardiology Induction for Junior Doctors
Who’s Who?
Consultants (SKW, DB, DHM, TJM, MXD, DMZ, MDS) and Associate Specialist (RK):
Stuart Walker
Mark Dayer
David Beacock
Dan McKenzie
David MacIver
Mike Seddon
Tom MacConnell
Richard Kilbey
Cardiology Clinical Management Team
This group has day to day responsibility for the smooth running of the department. It is held
responsible for the budget by the Medical Division Management team. It has a key role in setting
strategic direction for the Cardiology Department.
Clinical Services Lead
Matron
Clinical Investigation Manager
Dr David Beacock
Julia Hogg
Elaine Thompson
Catheter Laboratory User Group (CLUG)
This group is responsible for the day to day running of the catheter laboratory, creating a smooth,
high quality and timely patient journey within the strategic and budget parameters. This group is
responsible for governance standards in the laboratory and reports to the Cardiology
Multidisciplinary Team.
CLUG lead
Senior Nurse
Senior Radiographer
Senior Technician
Dr Mike Seddon
Diana Cooper
Gill Stapleton-Smith
Charlie Garland
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Cardiology Induction for Junior Doctors
Pacemaker User Group (PUG)
This group is responsible for the day to day running of the pacemaker/EPS laboratory, creating a
smooth, high quality and timely patient journey within the strategic and budget parameters. This
group is responsible for governance standards in the laboratory and reports to the Cardiology
Multidisciplinary Team.
PUG lead
Senior Nurse
Senior Technicians
Dr Mark Dayer
Alison Witcher
Helen Kavanagh and Jess Osman
Cardiology Multidisciplinary Team
This group is in place to ensure the patients and their optimal care is at the centre of our activity. It
is the forum where information is exchanged, strategic direction ratified and governance standards
set, acted upon, delivered and responsibility taken for. The MDT is led by the Lead Clinician but to
be at its most effective it requires contributions from all members of the Team, secretaries to
consultants, senior technicians to HCAs.
What is expected of the junior doctors in Cardiology?
How do the wards work?
The junior doctors are responsible for the day to day care of the patients on CCU, Fielding ward,
and the medical patients on Blake ward (our “buddy” ward). Generally, one junior will cover CCU
and Blake, as well as ad hoc cover on the “cardiac day unit”, whilst the others will look after the
patients on Fielding. However, it is expected that the juniors will work as a team and share the
work during times of uneven workload. Division of labour on Fielding ward may depend on the skill
and seniority mix – some groups have split the wards by individually covering bays, other groups
have looked after all the patients together. It is up to you how you feel best to cover the work, but
we expect the more experienced juniors to support those less experienced.
Patients are admitted to the Cardiology Beds via ED, MAU, other wards, or from Outpatients
electively. CCU patients are generally stepped down to Fielding.
All new admissions to the hospital should be clerked in by a member of the team (F1, F2, ST1 or
ST2) and a summary with problem list and management plan generated. Internal transfers to the
Cardiology beds should have a new problem list and management plan generated.
Please request old notes ASAP, but if these are not immediately available please gather
information from:
(i) Previous Cardiology letters from the cardiology secretaries (or on the shared S: drive)
(ii) Echo reports on TOMCAT (CVIS) (please ask DHM for a password)
(iii) PACs for previous relevant radiology results
A typical summary might read/ be presented to the consultant/registrar as follows:
68F
Background: T2DM, HT, moderate AS, ulcerative colitis, mild CKD (baseline creat 156)
Last echo 1 yr ago (Normal LV, AS gradient 45 AVA 1.3cm2, mild AR)
Admitted with SOB…treated as pulmonary oedema
Relevant results… (bloods, troponin, radiology, ECG, echo etc)
Current issues / problems…
Plan…
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Cardiology Induction for Junior Doctors
Ward Rounds
Please ensure that your entries in the notes record date/time/person leading the ward round and
that you sign off with your name and bleep number legibly. Include the key thoughts and
management plan and record any issues discussed with patients/ relatives. Complete/update a
current problem list. Please ensure cumulative results sheets are up to date each day. Review
prescription charts, write legibly, review date stops for antibiotics, steroids, nebulisers, oxygen.
Communication
We like to know what is happening with our patients. Do not hesitate to contact us or phone us if
you have any concerns or problems or unusual developments. Communication is crucial to good
patient care and poor communication is the origin of most complaints.
Ask a senior if you are unsure
Keep your seniors and consultant well-informed of significant changes in your patients’ progress
Communicate well and courteously with GPs
Ring the GP about difficult cases and complex discharges and record this
Relatives
Courtesy at all times and keep them well informed. Do not hesitate to ask for help with relatives
when there is bad news to be given or you sense dissatisfaction. Record any discussions you have
with them.
Consultant and Registrar support
The care of inpatients across the trust is increasingly consultant-led and delivered. New patients
must be seen within 24 hours of their admission by a senior member of medical staff and the
management plan ratified. If there are immediate concerns about a patient the Consultant
Cardiologist on call (or if the patient is on a Cardiology ward already, one of the consultants
covering the wards – see below) should be contacted. We hope that you will find us all very
approachable.
Six of the consultants contribute to regular inpatient care (with Dr Walker exempt due to his
workload as Clinical Director). Three consultants will cover the wards at any time on a 5 week
cycle currently in the groups of 3 below:
Dr Beacock (DB)
Dr MacIver (DHM)
Dr McKenzie (DMZ)
Dr MacConnell (TJM)
Dr Dayer (MXD)
Dr Seddon (MDS)
Each week, one of the ward consultants will be responsible for CCU. They will perform regular
CCU ward rounds and will see new patients on Blake ward. Any problems on CCU should be
addressed with this consultant.
Between them, the three ward consultants will see new patients on Fielding each day. Ward round
times are not cast in stone since they have to be flexible around the consultant on call rota and
other commitments. When consultants are away on leave, the other ward consultants will crosscover ward patients.
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Cardiology Induction for Junior Doctors
Separately, we have a responsibility to see patients on the Post-Take Ward Round (PTWR) list
each morning – this list resides on CCU and should consist of patients referred by the senior MAU
team for specialist Cardiology review. We operate a 1 in 8 rota for the PTWR (all 7 consultants and
Richard Kilbey) – the designated person will either go down to MAU themselves or will take a
junior with them. This system is separate from the “red top referral” system which should be used
by other teams throughout the hospital for inpatients requiring specialist cardiology input.
There is always a consultant crdiologist on call, the rota is available on CCU. Dr Seddon currently
produces this rota. If you have an immediate concern about any consultant’s patient you should
initially try to contact that consultant directly.
Dr Beacock
Dr Dayer
Dr MacConnell
Dr MacIver
Dr McKenzie
Dr Seddon
Dr Walker
07731 627055
07428 690564
07968 275745
07887 743705
07801 562183
07765 872874
07977 508077
If that consultant is unavailable contact one of the other consultants, or out of hours the on call
Consultant Cardiologist.
Registrars:
There are 2 Cardiology registrars. They have a range of commitments and training requirements
including general medical on call, outpatient clinics and training lists (echo, pacing, angiography).
They are also responsible for seeing the red-top referrals (and discussing with consultants if
necessary). They have a commitment to do a formal ward round (Fielding and Blake) each
Wednesday morning (when the consultants often have other commitments/ departmental meetings
at that time) but are also available for advice and support / supervision of procedures at other
times during the week – they can be contacted via bleep. The registrars’ office is to the side of the
3 bed bay in CCU. Their individual timetables are as below.
Nitin Kumar (ST5) – Bleep 2105
Phoebe Sun (ST5) – Bleep 2358
Tuesday
NITIN KUMAR
AM
Angio/
Admin
Pacing
Wednesday
Wards
Thursday
Echo
Friday
Admin/
Ad hoc lab
DAY
Monday
PM
Ad hoc Lab/
Referrals
Ad hoc Lab/
Referrals
Clinic/
Referrals
Clinic/
Referrals
Angio
PHOEBE SUN
AM
PM
Admin
Angio
Clinic
Echo
Wards
Pacing
Clinic/
Referrals
Angio
Angio/
Pacing
Admin/
Referrals
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Cardiology Induction for Junior Doctors
Annual Leave and Study Leave Arrangements
Your leave must be ratified by the Lead Clinician (DB). Registrars – only 1 of 2 away at any time;
Juniors – 2 cardiology juniors from the Fielding and CCU grouping may be on leave at any one
time.
Arranging Cardiology Investigations
In Patients
ECG
HCA on ward
Exercise ECG
Bleep Chest pain nurse 9am-8pm Mon-Sun (Bleep 2473) or
Clinical investigation by arrangement ext 2953
Echocardiogram
Echo request form to reception (Cardiology outpatients) ext 2953
IP to be signed by consultant Cardiologist
Please give as much relevant information as possible on the form
If an inpatient echo needs to be done urgently then discuss with
one of the echocardiographers.
Stress Echocardiogram
By arrangement with senior echocardiographer
Transoesophageal Echo
By arrangement with senior echocardiographer
Myocardial Perfusion Scan
Not routinely available. As outpatient only by consultant request.
Coronary angiogram
Patients name, ward, consultant, clinical problem with expected
findings and whether or not ? proceed to be put on white board in
cathlab. Cath lab will assign slot
See coronary angiogram protocol for bloods etc
See consent
Cardiac MRI
Very limited slots – to be arranged via consultants through DB
Cardiac CT
Cardiac gated CT – not yet locally available
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Cardiology Induction for Junior Doctors
Consent for cardiological procedures – general principles

Consent is a process, not an isolated event. Patients should receive advice and
the appropriate leaflet with time to digest the information before being asked to
sign the form.

For consent to be informed, a competent patient needs to understand their
medical condition, the proposed treatment of it, the risks, consequences of, and
alternatives to that treatment.

If you or your patient are unhappy about the process you should not complete
(sign the form) the process and refer the matter to the consultant in charge of the
patients care

A patient cannot give informed consent if sedated

Generally, a person capable of performing the procedure should obtain consent.
Preferably the person performing the procedure should obtain consent.
Foundation year doctors should not obtain consent.
Ethical guidance on consent can be obtained from the trust intranet site as well as
http://www.gmc-uk.org/guidance/ethical_guidance/consent_guidance_index.asp
http://www.bma.org.uk
http://www.bma.org.uk/ethics/consent_and_capacity/consenttoolkit.jsp
SEE APPENDIX FOR PROCEDURE-SPECIFIC CONSENT FORMS
Consent - Pacemaker Implantation
Reasons for implantation
To prevent/ treat symptomatic bradycardia / syncope / high grade AV block
To control arrhythmias
To improvement symptoms of heart failure
The Risks – see consent form in Appendix
Consequences
Long term follow up in technician-led pacing clinic
Generator will need replacement after 5-10 years depending on how much it is used/needed.
Complications of the procedure.
The Alternatives
For a patient with cardiac syncope/ pre-syncope due to conduction tissue disease there is no
alternative treatment. For patients with AF and heart failure, pacemakers are one of many
treatment modalities.
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Cardiology Induction for Junior Doctors
See www.markdayer.com/guidance/pacing/
Consent - Coronary Angiography
Procedure involving injection of radiographic contrast into coronary arteries having passed a tube
from the artery in the groin (femoral puncture) or arm (radial puncture).
Reasons for procedure
To gain diagnostic information about coronary anatomy and or heart valves.
The Risks – see consent form in Appendix
Consequences
The information gained from the test will inform the consultant’s advice about whether the patient’s
condition should be treated medically, with percutaneous coronary intervention (PCI) or with
bypass surgery
The Alternatives
Non invasive testing (Exercise testing, stress echo, myocardial perfusion scanning, stress MRI)
are physiological tests looking at regional perfusion and ischaemia rather than anatomy. Cardiac
gated multislice CT can be used in subsets of patients to demonstrate coronary and cardiac
anatomy non-invasively but this service is not yet available locally and image/data quality is not yet
comparable to the gold standard, invasive angiography.
Consent – Percutaneous Coronary Intervention
Reasons for procedureEmergency procedureSTEMINSTE-ACS patients with on going
pain and ECG changes/ haemodynamic instabilityUrgent procedure - Most NSTE-ACS
patients - reduces the likelihood of a further major adverse cardiac event (heart attack/
death) when performed within 72 hours.
Elective procedure - reduces anginal symptoms effectively, improves quality of life
The Risks – see consent form in Appendix
Consequences
Small annual risk ~1% of stent thrombosis (particularly if patient stops antiplatelet agents
prematurely)
Small risk of late renarrowing (restenosis): 5-10% risk with a bare metal stent
2-3% risk with a drug eluting stent
The Alternatives
Symptoms can be treated with tablets (but may not be as effective in controlling symptoms)
Bypass surgery could be considered but potentially greater immediate risks for no prognostic
advantage. In some patients there may be a lower risk of recurrence of symptoms of angina (eg
diabetics with complex lesions)
Consent - Cardioversion
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Cardiology Induction for Junior Doctors
Reasons For Procedure
Restoration of normal heart rhythm
May result in improved exercise capacity
Possible reduction in the need for long term anticoagulation
The Risks – see consent form in Appendix
Consequences
Improved exercise capacity (in 60-70% of people)
Reduced need for anticoagulation if sinus rhythm maintained
May require long term antiarrhythmic drugs to maintain sinus rhythm
The Alternatives
Control rate of atrial fibrillation with drugs
Invasive ablation procedures
Treat risk of embolic event with aspirin or warfarin
Consent – (Automated) Implantable Cardioverter-Defibrillator (A) ICD
Reasons For Procedure
Protective therapy for recurrent VT/VF in patients who have already had VT/VF in the past
Protective therapy for VT/VF in patients who have not had VT/VF but are at high risk (see below)
The Risks – see consent form in Appendix
Consequences
Reduces the risk of sudden cardiac death (SCD) in appropriately selected patients (see NICE
guidance below)
Can cardiovert sustained VT
The Alternatives
Antiarrhythmics – beta blockers or amiodarone, but mortality improved with ICDs in appropriately
selected patients
Consent – Cardiac Resynchronisation Therapy (CRT) or Biventricular Pacing without
defibrillator (CRT-P)
Reasons For Procedure
Symptom improvement in a well-defined subset of patients with heart failure (see below)
Prognostic benefit in the same group
The Risks – see consent form in Appendix
Consequences
May improve symptoms in appropriately selected patients (see NICE guidance)
Reduces mortality in randomised controlled studies of appropriately selected patients
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Cardiology Induction for Junior Doctors
The Alternatives
Optimal medical management (diuretics, ACE, beta-blockers +/- an aldosterone antagonist,
ivabridine and digoxin)
Consent – Cardiac Resynchronisation Therapy (CRT) or Biventricular Pacing with
defibrillator (CRT-D)
CRT-D devices are implanted for patients who fit the NICE criteria for ICD as well as those for
CRT-P
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Cardiology Induction for Junior Doctors
Preparing patients on the ward for procedures:
Once a Consultant has decided / agreed that a patient should have a procedure they must be
listed (by you) on the appropriate board in the Cardiac Day Unit (CDU). This can be discussed with
the Co-ordinator on the unit in the week. Out of hours you need to put the: patients name, ward,
procedure, date listed, ensuring cathlab and ward know
Angiogram ?proceed
Ensure the patient has had recent bloods – highlight anaemia or any drop in haemoglobin, as well
as renal dysfunction (patients with creatinine >150 or eGFR <60 should be pre-hydrated with oral
+/- IV fluids)
Patients for angiogram ?proceed should be taking aspirin and clopidogrel. Please highlight any
patients who are not taking both. What is the indication for the procedure (perhaps it is only an
angiogram with no plan to proceed eg pre-operative assessment for Aortic Stenosis), and are
there any issues with aspirin or clopidogrel. Please highlight any patients who have aspirin
“allergy” (this does not include GI tract irritation related to aspirin) since we have an aspirin
desensitization protocol (See Appendix).
Metformin should be withheld peri-procedure
All patients having angiogram ?proceed need a cannula – this should be a pink or green
cannula ideally in a vein at the antecubital fossa and on the left side (in case angiography
via right wrist)
Patients on anticoagulants, see Appendix
No food for 6 hrs, No fluids for 2 hrs
Pacemaker
Ensure the patient has had recent bloods including inflammatory markers. Highlight any concerns
regarding active infection. Ensure patient can lie flat for an hour.
All patients should be screened for MRSA and MSSA (do this even if there is a possibility they
won’t need the pacemaker to prevent delays). If they are positive, the patient should be
decolonised
All patients should have a cannula on the same side to the planned implant side
No food for 6 hrs, No fluids for 2 hrs
Patients on anticoagulants, see Appendix
Write up prophylactic antibiotics
http://intranet.tsft.nhs.uk/Prophylaxis/Cardiovascularimplantabledevices/tabid/7299/language/enGB/Default.aspx
Pre-procedure 1g Flucloxacillin IV + 3mg/kg Gentamicin IV (2mg/kg if eGFR <20)
Afterwards 500mg qds Flucloxacillin PO for 7 doses
If penicillin allergic
Pre-procedure 400mg IV Teicoplanin and Gentamicin as above
Afterwards 500mg bd Clarithromycin for 4 doses
ICD
As per pacemaker. All patients due to undergo ICD implantation should be seen by the arrhythmia
nurses.
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Cardiology Induction for Junior Doctors
TPW
These should be covered with Teicoplanin and Gentamicin from the time of implant until time of
removal or insertion of a permanent system. Threshold and stability should be checked daily.
D/C Cardioversions
The Cardioversion Service is led by Sr. Dee Eaton & Sr. Ruth Hacker, based on Cardiac Cath Lab
(direct line Ex 3068 with answerphone). Refer elective DCC patients on an ECG form and send to
Cath Lab. Inpatients can sometimes be accommodated on the elective list on Thursday morning,
contact Dee or Ruth to arrange. Patient to be NBM for 2 hours, clear fluids only for 4 hours before
that.
For emergency cardioversions, check availability of Cardiology Registrar, contact Anaesthetic
office Ex 2114 to arrange Anaesthetist, and secure a bed on CCU (where procedure usually takes
place).
Note: Patients taking Dabigatran can proceed to D/C Cardioversion but need to sign a specific
consent form confirming that they have taken their Dabigatran in the run up to their cardioversion.
There is currently limited safety data concerning D/C Cardioversion for patients taking
Rivaroxaban, and therefore we will not cardiovert patients taking this drug – if cardioversion is
deemed necessary, their anticoagulant agent will need to be changed.
Post cathlab procedures
Following all the above procedures
Check patient is comfortable and enough analgesia is written up.
Check access site/ wound OK
In case of persistent hypotension…consider BLEEDING from access site (particularly with
angiograms performed from the leg, significant retroperitoneal blood can accumulate before
clinically apparent) and exclude compromising PERICARDIAL EFFUSION with echo. Alert
operator who performed procedure.
After device implantation (including PPM, CRT, ICD), check CXR PA and Lateral 4 hours post
procedure (Ensure leads appropriately placed…and pointing forward on lateral film, no
pneumothorax, haemothorax). After TPW, check CXR (no lateral required) for lead position and
exclude pneumothorax.
After device implantation ensure antibiotics written up as above.
AFTER STENTS
Aspirin 75mg od for life, in combination with clopidogrel or prasugrel as below
Clopidogrel
1 year in all ACS regardless of stent type;
1 year in elective cases with Drug-Eluting Stents (DES)
1 month in elective cases with Bare Metal Stents (BMS)
Prasugrel
Only used here for STEMI and stent thrombosis – no elective indication
1 year in STEMI
Operator discretion for stent thrombosis
TOE
All patients should have a cannula
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Cardiology Induction for Junior Doctors
No food for 6 hrs, No fluids for 2 hrs
Cardiac Surgery
Patients awaiting cardiac surgery should be seen by the Cardiac Rehabilitation team who will coordinate referral to Bristol. Please notify them ASAP of any patients awaiting cardiac surgery. A
consultant letter of referral will also be dictated after the patient has had their angiogram.
Patients awaiting inpatient CABG
Stop clopidogrel after angiogram (ideally >5 days before CABG) unless unstable (discuss with
consultant).
Stop Tirofiban 8 hrs before; Warfarin 2 days before; Enoxaparin night before; IV heparin can
continue.
Notify registrar / consultant of any significant chest pain episodes particularly if associated with
ECG changes (may necessitate IABP insertion or liaison for expedition of surgery)
Carotid dopplers if previous TIA/stroke/bruit
PFTs if significant lung disease
Patients awaiting inpatient Valve surgery
Max fax assessment if they have teeth (no need if all dentures!)
Carotid dopplers if previous TIA/stroke/bruit
PFTs if significant lung disease
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Cardiology Induction for Junior Doctors
Specialist Nurses
Cardiac Rehabilitation
All patients admitted with Acute Coronary Syndromes (STEMI and NSTE-ACS) should be referred
to cardiac rehabilitation
Referral protocol for the identification and invitation of patients admitted with CHD to
participate in a multidisciplinary programme of secondary prevention and cardiac
rehabilitation.
Purpose Statement
For health professionals and others responsible for caring for patients with Coronary Heart
Disease to be able to identify and refer patients for secondary prevention and cardiac rehabilitation
services.
Rationale
Secondary Prevention and Cardiac Rehabilitation is effective at reducing the risk of a subsequent
cardiac event.
Policy Criteria
All patients with a diagnosis of Coronary Heart Disease (CHD) and those admitted to hospital with
chest pain and risk factors associated with CHD are eligible to access the service regardless of
age, sex, ethnic origin or physical ability.
Priority will be given to those who have had a Myocardial Infarction or revascularisation procedure
in the six months prior to the date of referral
A comprehensive, menu based service will be available.
Individuals will be assessed to identify their needs.
A plan of care including education, exercise and psychosocial support will be agreed with the
individual.
MINAP data and TNI results will be used to help identify suitable patients.
In patients
A purple referral form will be completed and signed and retained on Coronary Care Unit, Fielding
and Eliot ward. These will be collected by the Cardiac Rehabilitation team.
All other areas will send referrals to Cardiac Rehabilitation office via internal postal system.
Patients who have had an angioplasty will be referred by the Catheter Laboratory nurses.
Out patients
Referrals can be received in writing, via fax system or by telephone.
Patients who have had Coronary Artery Bypass grafting will be referred by the tertiary centre.
Patients living in other localities where there are community rehabilitation programmes will be
referred from the Cardiac Rehabilitation Team at the hospital to that programme by fax.
In addition Cardiac Rehabilitation Teams will review all referrals and establish that they are
appropriate and fulfil the criteria as detailed above.
Cardiac Rehabilitation Nurses may discuss the referral with the West of Somerset Cardiac
Rehabilitation Nurse Specialist if referral appears to be inappropriate.
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Cardiology Induction for Junior Doctors
Following an individualised assessment a plan for Cardiac Rehabilitation will be agreed with the
patient and documented in the Cardiac Rehabilitation notes.
Chest pain nurses
Andria Haffenden (lead), Dawn Giblett, Bridget Capewell and Debbie Gray.
The Chest Pain Assessment Team is based in the Emergency Department and covers Monday –
Friday 08.00-20.00, weekends 08.00-16.30. They are responsible for assessing and treating
emergency admissions to the Department with chest pain, and the day-to-day running of the
Chest Pain Unit (CPU). The CPU is nominally based on Jowett ward, but is more a system of
care rather than a physical entity.
For suitable patients, the protocol includes routine haematology/biochemistry tests, serial ECGs,
Chest X-ray and cardiac enzymes, including baseline CKMB, which is repeated at 6 hours after
the worst episode of pain, along with Troponin. If all the results are within normal limits, the
patient goes on to perform an Exercise Treadmill Test either the same day, or next working day
possible. In order to try and put as many appropriate patients through this accelerated protocol,
Chest Pain Nurses accept referrals from Somerset Primary Link, or direct from GPs, rather than
automatically admit to MAU for a twelve hour troponin. The team has a treadmill in the
Emergency Department which can also be used to treadmill in-patients when required, and
workload allows. The team also does a daily trawl of Troponin results on patients throughout the
hospital, will review patients/notes, and transfer patients to CCU/Fielding when needed, or add
patients to the consultant PTWR if they fit the criteria. They are also now performing rapid access
chest pain clinics in the Cardiology department.
Arrhythmia nurses
Janice Bailey and Jackie Kemp.
The Arrhythmia Nurses see in-patients with ICD/CRTD implants who have any issues
surrounding therapy from their device, home monitoring and end of life care, where deactivation
may be considered. We also see survivors of out of hospital cardiac arrest due to inherited
conditions and, if appropriate, their families. Patients who are awaiting ablation or EP studies are
also seen. Please refer patients with syncope who require Reveal implant in order that we can
set up home monitoring and provide driving and insurance advice even if they do not require
support.
In out patients’ clinic we see patients and their families with inherited conditions for support and
screening, GP referrals of new AF, patients for or with ICD/CRTD for long term support. Patients
requiring reveal implant. We also run a support group for patients with an ICD.
Patients with an arrhythmia requiring longer term support or education can be referred for outpatient follow up.
Leaflets have been supplied to all Cardiology areas but we also keep a large and varied stock.
Referrals can be made by any member of the health care, social or chaplaincy team, we also
accept self referrals. Please refer in person (our office is 1st on the right in the CCU link corridor),
by email [email protected] or leave a message on ext 3595.
When referring please include patients name, MRN, preferred method of contact (if being seen
post discharge) ward and reason for referral. The service is available Monday to Friday 8.304.30.
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Cardiology Induction for Junior Doctors
Audit Nurse
The Cardiology Department participates in four of the national cardiac audits as required by the
Department of Health & Care & Quality Commission. These four audits are MINAP (Myocardial
Ischaemia National Audit Project), Heart Failure, BCIS (British Cardiac Intervention Society) and
Arrhythmia Management/ Pacing.
MINAP audits the care of patients attending MPH with a positive Troponin and diagnosis of ACS,
NSTEMI or STEMI. The Primary Angioplasty service is measured by MINAP and annually
compared to other hospitals in England & Wales for door to balloon and call to balloon times. The
local door to balloon (DTB) target is 30 minutes and call to balloon (CTB) target 120 minutes
versus the national targets of 90 minutes DTB and 150 minutes CTB. Musgrove Park was
amongst the top in the country in last year’s Public Report. Dr Dan McKenzie is Clinical Lead for
MINAP as well as Cardiac Audit as a whole.
Heart Failure audits the care of patients attending MPH with a discharge diagnosis of heart
failure. There is currently no heart failure service. Dr Mark Dayer is Clinical Lead for Heart
Failure.
BCIS audits the care of patients receiving coronary angioplasty, including IVUS (intravascular
ultrasound) and FFR studies (Flow Wire or Pressure Wire Studies). The audit also measures
complication rates. The Clinical Lead for BCIS is Dr David Beacock.
Arrhythmia Management or Pacing audits the care of all patients undergoing pacing procedures
at MPH, including complication rates such as infection. The Clinical Lead for Pacing is Dr Mark
Dayer. The audit is maintained by Dr Mark Dayer and staff from the Clinical Investigations Unit.
There is a full time Cardiac Audit nurse, Judith Medlen, who maintains three of the national
cardiac audits (MINAP, Heart Failure & BCIS). Her role is too liaise with NICOR (National
Institute for Cardiac Outcomes Research) on behalf of Musgrove Park Hospital regarding these
three audits to ensure our participation is maintained, current and accurate and that patient
attending MPH continue to receive a high standard of care.
All local cardiac audits are dealt with by the Audit Department.
Website
The Cardiology Department can be found on the Trust Intranet and contains a wide range of
information including:
The Team
Policies, Protocols & Guidelines
Patient Information
Cardiolinks & Education (including forthcoming training days e.g adult congenital heart disease)
Cardiac Audit
Cardiology Dashboard (Trust’s measurement of performance)
Cardiology Research Trials (currently under construction).
If there is anything you would like to see added to the website please feel free to email
[email protected]
18
Cardiology Induction for Junior Doctors
Discharge Policy
All patient discharged from the wards should be accompanied by a real time discharge letter
including TTAs (or more recently, a photocopy of the drug chart). This letter should include a list of
the patient’s problems as ratified by the consultant looking after that patient at the time of
discharge not the list formulated by the admitting doctor.
Sometimes patients who have undergone invasive inpatient procedures in the cardiac day unit
(CDU) remain in the CDU following the procedure because they have been identified as patients
who can go home later the same day or the following day. These patients will have a paper TTA
discharge letter hand-written by the consultant who does the procedure. The consultant performing
the invasive procedure will dictate a letter to the GP in addition, detailing the procedure and
resulting plan.
Ward patients will only receive an out patient appointment if it is specifically requested by a
cardiology consultant or there remains an outstanding issue which needs a cardiology decision.
Only a consultant can specify a timeframe as short timeframes will require a clinic overbook.
Patients should be advised that they will receive the next available or a routine appointment
Outpatient follow up should be booked through the booking team in the Cardiology office
If a test is planned as an outpatient the relevant request card should be completed before
discharge with the results to be returned to that consultant. Outpatient coronary angiography and
PCI should be booked with the cardiology booking team before discharge by completing a
cardiology request card.
Dr Beacock 2128, Dr Dayer 2154, Dr Kilbey 2951, Dr MacConnell 3909, Dr MacIver 2129, Dr
McKenzie 2119, Dr Seddon 2951, Dr Walker 2356
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Cardiology Induction for Junior Doctors
Protocols, pathways and guidelines
Current departmental protocols, pathways and guidelines can be found on the trust intranet site at
http://intranet.tsft.nhs.uk/cardiology/PoliciesProtocolsGuidelines/tabid/6513/language/enGB/Default.aspx
The latest relevant NICE Technology Appraisals (TA) and Clinical Guidelines (CG) can be
accessed via these links
TA256 Atrial fibrillation (stroke prevention) - rivaroxaban
TA249 Atrial fibrillation - dabigatran etexilate
CG130 Hyperglycaemia in acute coronary syndromes
TA236 Acute coronary syndromes - ticagrelor
CG127 Hypertension
CG126 Stable angina
TA230 Myocardial infarction (persistent ST-segment elevation) - bivalirudin
TA210 Vascular disease - clopidogrel and dipyridamole
CG109 Transient loss of consciousness in adults and young people
CG108 Chronic heart failure
TA197 Atrial fibrillation - dronedarone
CG94
Unstable angina and NSTEMI
CG95
Chest pain of recent onset
TA182 Acute coronary syndrome - prasugrel
CG64
Prophylaxis against infective endocarditis
CG48
MI: secondary prevention
The European Society of Cardiology latest guidelines on a range of cardiac conditions can be
found at
http://www.escardio.org/guidelines
DVLA Driving Guidelines for patients with cardiac conditions can be found in the “DVLA at a
glance” summary document . These guidelines are frequently updated and the latest edition can
be found at
http://www.dft.gov.uk/dvla/medical/ataglance.aspx
ACUTE CORONARY SYNDROMES: See Hospital Algorithm below.
The 2 key questions are (1) How is the patient, and (2) What does the ECG show.
The ECG is important since it determines which pathway to follow. If there is STelevation, an artery is blocked and needs opening NOW – seek urgent help.
20
Cardiology Induction for Junior Doctors
SUSPECTED ACUTE CARDIAC CHEST PAIN PROTOCOL
The First 24 Hours
Taunton & Somerset Hospital
Review date April 2012
HISTORY AND EXAMINATION
Use this protocol for patients with cardiac-sounding chest pain lasting >15 min
Give Aspirin 300 mg stat. Venflon inserted.
ECG every 15 min during pain. Repeat when pain free, then after 30 min, 1 and 4 hr.
STEMI PATHWAY
ST elevation in 2 leads:
>2 mm in leads V1-6 or
>1 mm in limb leads or
ST depression compatible with
posterior infarct or
Left bundle branch block:
(New or presumed new &
good history)
OXYGEN, GTN SL, CLOPIDOGREL 600 mg
stat (unless pre-loaded). Check Aspirin
300mg has been given. If necessary, give
MORPHINE 5-10mg IV &
METOCLOPRAMIDE 10mg IV
Urgent call CCU (2066 or 3066)
for Primary PCI. CCU to contact
switch board (2222) who contact
on-call interventional cardiologist
and pPCI team. Transfer pt to
Cath lab or CCU as directed.
Further therapy with IV βblocker, GP IIb/IIIa inhibitors,
prasugrel, bivalirudin and/or
heparin etc. at discretion of the
interventional cardiologist
ISOKET 2-10mg/hr IV for pain/HF.
INSULIN infusion if glucose >11
mmol/l (24 hours)
MIDDLE PATHWAY
ST depression >0.5 mm
or
T wave inversion >2 mm deep
or
Transient ST elevation
or
GRACE risk score 6 month mortality
>3.1%
LOW RISK PATHWAY
Pain resolved
and
GRACE risk score 6 month mortality
≤3%
and
ECG normal
OXYGEN, GTN SL, CLOPIDOGREL 300 mg
stat (unless pre-loaded). Check Aspirin
300mg has been given. If necessary, give
MORPHINE
5-10mg
IV
&
METOCLOPRAMIDE 10mg IV
Trial of sublingual GTN
and/or GAVISCON
GRACE RISK SCORE
Assess 6 months risk of death:
http://www.outcomesumassmed.org/GRACE/acs_ri
sk/acs_risk_content.html also
on Intranet – Hospital
Systems:
GRACE 6/12 death risk 3-6%
or abnormal TNT >14 ng/l
(exclude non ACS causes)
go to Intermediate risk
pathway
GRACE 6/12 death risk ≥6%
or hypotension or heart
failure or pulmonary oedema
go to High risk pathway
Refer to Chest Pain Nurse
Bleep 2473
Exclude alternative diagnoses
Check TNT on arrival
ADMIT if >14 ng/l
Repeat if negative
6 hr Troponin only if early
discharge planned, otherwise
repeat TNT at ≥12 hours
Refer to Chest Pain Nurse
Bleep 2473
Troponin T
abnormal >14 ng/l
(exclude non ACS causes)
POSITIVE
NEGATIVE
DISCHARGE EARLY
IF PAIN FREE
ECG: repeat at 90 min post pPCI
MIDDLE
PATHWAY
(see over)
Admit to CCU
If CAD still possible,
formal referral to
Chest Pain Nurses (use
Red Top referral) within
24 hours.
Rx ASPIRIN 75 mg od, CLOPIDOGREL 75 mg od, BISOPROLOL 2.5 mg od
if no contraindications, RAMIPRIL 2.5 mg bd initially (discharge21
on OD),
Atorvastatin 80 mg nocte (unless interactions etc.).GTN s/l PRN
Cardiology Induction for Junior Doctors
MIDDLE PATHWAY
continued
ASPIRIN 300mg stat. followed by 75 mg od. CLOPIDOGREL 300 mg stat. followed by 75 mg od. BISOPROLOL 2.5
mg if no C/I. FONDAPARINUX 2.5 mg s/c OD (if eGFR<20ml/min use clexane 1 mg/kg OD instead) NB set Fondaparinux
review date (normally after 48 hr). ATORVASTATIN 80 mg nocte (unless interactions etc.). RAMIPRIL 2.5 mg bd
(discharge on OD). Add ISOKET 2-10 mg/hr IV infusion if continuing pain.
HIGH RISK PATHWAY
GRACE risk 6 month mortality ≥6%
or
Heart failure/hypotension*
or
Continuing ischaemic pain or dynamic ST changes*
or
Diabetes
(NB exclude alternative diagnoses e.g. dissection/PE)
INTERMEDIATE RISK PATHWAY
GRACE Risk 6 month mortality <6%
and
Stable, well
and
Pain free
(NB exclude alternative diagnoses e.g. dissection/PE)
TRIAGE TO CARDIOLOGY WARD or
Refer to Cardiology PTWR (within 24 hr)
TRIAGE TO CCU
1st Troponin T (on arrival)
POSITIVE >14 ng/l
NEGATIVE ≤14 ng/l
Invasive Strategy
If GRACE mortality ≥6%
start
TIROFIBAN unless C/I
2nd Troponin T (≥12 hours after the onset of pain)
POSITIVE >14 ng/l
If GRACE mortality
≥6% start
TIROFIBAN
unless C/I
and early <72 hrs
Invasive Strategy
If in doubt discuss
with senior
colleague and then
on call cardiologist
as appropriate
NEGATIVE ≤14 ng/l
CLINICALLY UNSTABLE
Ongoing Chest Pain
Heart Failure
Abnormal ECG.
CLINICALLY STABLE
Stop Tirofiban
Inpatient ETT,
(or Myoview scan/Stress Echo)
Abnormal – Refer CARDIOLOGY
for ?Invasive Strategy
Normal – DISCHARGE
If in doubt seek advice
22
Cardiology Induction for Junior Doctors
Guidelines for the control of anticoagulation in patients undergoing invasive procedures
NOTE guidance is different for (i) Angiography/ PCI vs (ii) Implantation of PPMs / ICDs
(i) Angiography and PCI
It is important that patients requiring admission for control of anticoagulation (high\intermediate
risk) are identified at the time of ‘listing’ for their invasive procedure to prevent inadvertent
discontinuation of warfarin without concomitant heparin cover.
High Risk
Intermediate Risk
Low Risk
Mechanical prosthetic valve replacement
AF with other structural heart disease
Xenograft/homograft (non-mechanical) valve replacement
AF with mitral stenosis
Previous thromboembolic disease
Lone AF
Management – High Risk
Interruption in warfarin therapy should be bridged peri-procedurally as per protocol below
Management – Intermediate Risk
Requirement for heparin cover for intermediate risk patients is at doctor’s discretion and should be
discussed with referring physician or an appropriate alternative physician.If heparin cover is
required pre and post-operatively management is as ‘high-risk’ patients
Management – Low Risk
Warfarin (or the newer anticoagulants Dabigatran / Rivaroxaban / Apixaban) should be
discontinued 5 days before the invasive procedure. These patients can be admitted on the
morning of their procedure.
Anticoagulation can usually be recommenced on the evening of the procedure.
The patient can be discharged as per usual post-operative protocol with appropriate arrangements
for INR checking in place (if on warfarin).
(ii) Implantation of Pacemakers / ICDs
See See www.markdayer.com/guidance/pacing/
Management – High Risk and Intermediate Risk
There is evidence that patients who continue their warfarin around the time of device implant bleed
less than those who are transferred to bridging heparin therapy.
Warfarin should be continued – the procedure can proceed if the INR is less than or equal to 3.0.
The haematologists have supported this policy. If severe bleeding occurs then octaplex or beriplex
should be administered.
Management – Low Risk
Warfarin (and the new anticoagulants) should be withheld, as in patients due to have angiography
or PCI.
23
Cardiology Induction for Junior Doctors
Operations should not be performed on patients taking Dabigatran or Rivaroxaban. These agents
are not clearly reversible. If it is not safe to stop angicoagulation they should be transferred onto
Warfarin.
Please discuss warfarin management with the operator likely to undertake the procedure.
Management of Bridging Therapy in Patients with Mechanical Heart
Valves
Key Points:
1. Introduction
 Patients with mechanical prosthetic heart valves are at increased risk for arterial
thromboembolism, which includes stroke, systemic embolism and valvular or intracardiac
thrombosis.
 Because of this increased risk, patients with mechanical prosthetic valves need long term
anticoagulation therapy. Anticoagulation is usually achieved with the use of a vitamin K
antagonist (VKA), such as warfarin.
 At times these patients’ anticoagulation may be inadequate, either intentionally, if the VKA is
withheld to reduce the risk of bleeding in preparation for an invasive procedure, or nonintentionally should the International Normalised Ratio (INR) become subtherapeutic, because of
under dosing, drug interaction or other causes.
 Both groups of patients would traditionally have been admitted to hospital for intravenous (IV)
unfractionated heparin (UFH) as bridging therapy for the time that the International Normalised
Ratio (INR) is subtherapeutic (INR <1.8).
 This strategy has a number of disadvantages, including the inconvenience to patients of
having to be admitted for IV UFH, the increased cost and burden on bed numbers associated
with an extended hospital admission, and concerns regarding the fluctuating APTR results
associated with IV UFH.
 The use of Low Molecular Weight Heparins (LMWH), such as enoxaparin, as bridging
therapy for patients with mechanical prosthetic valves is unlicensed. However, there are clinical
trials and registry data assessing LMWH for this use, showing that it is both safe and effective
compared to IV UFH for most patient groups.
 This protocol addresses the management of patients with mechanical prosthetic heart valves
who need their warfarin withheld because of invasive procedures, and patients whose INR nonintentionally becomes subtherapeutic.
2. Study Data
 There is clinical trial and registry evidence demonstrating LMWH is at least as efficacious, if
not better, than UFH as bridging therapy in patients with mechanical prosthetic valves.
 In a study by Montalescot et al1 LMWH was shown to be more effective at producing the
desired level of anticoagulation, whilst having similar bleeding rates and reduced rates of
thromboembolism. 102 patients in the LMWH group achieved 87% and 100% therapeutic
24
Cardiology Induction for Junior Doctors
anticoagulation on day 2 and on the last study day respectively, as measured by anti Xa levels,
with 19% over anticoagulated. This was significantly better than the UFH group (106 patients,
9% and 27% therapeutic APTR, with 62% over anticoagulated).
 In a pre-specified subgroup analysis from the REGIMEN registry (a large prospective,
multicentre registry) UFH (n=73) and LMWH (n=172) were compared as bridging anticoagulation
in patients with mechanical prosthetic heart valves. The rates of major adverse events and major
bleeds were similar between the groups (5.5% vs. 1.03%, p=0.23; 4.2% vs. 8.8%, p=0.17,
respectively); 1 arterial thromboembolic event occurred in each group. Patients in the LMWH
group were discharged sooner and treated as outpatients compared to those in the UFH group
(discharged <24 hours: 68.6% vs. 6.8%, p<0.0001).2 Similar results were found in a number of
prospective studies, including 14
cohort studies, involving bridging anticoagulation in
approximately 1300 patients with mechanical heart valves, which was used by the American
College of Chest Physicians (ACCP) in producing their guidelines.3
 LMWH is the preferred bridging method by the American College of Chest Physicians
(ACCP), in their practice guidelines for the perioperative management of antithrombotic therapy.3
 In the majority of studies the dose of Clexane used was 1mg/kg BD, and this is the ACCP
guideline recommendation. 1,3,4
 The use of enoxaparin for thromboprophylaxis in pregnant women with mechanical prosthetic
valves should be discussed on an individual basis and as a multi disciplinary team (O+G,
Cardiology, Haematology).5
3. Clinical Protocol
Inclusion criteria
Patients with a metallic prosthetic heart valve who:
1. Have a subtherapeutic INR <1.8.
2. OR are due to undergo an invasive procedure that requires the cessation of their
anticoagulation.
Exclusion criteria
Pregnancy.
Creatinine Clearance <30ml/min.
History of heparin induced thrombocytopenia or an allergy to heparin.
Protocol
Each patient should be treated on their individual merits and a risk–benefit assessment
performed. Patients with valves in the mitral position have a greater thromboembolic risk than
those in the aortic position, ball-and-cage (Starr-Edwards) valves have a greater risk than tilting
disc valves (Bjork-Shiley, St Jude etc). Other risk factors such as atrial fibrillation, smoking, age
and previous thromboembolic event should also be taken into consideration. 6
Low risk patients (such as those with a mechanical aortic valve prosthesis and no other risk
factors for thromboembolism) can safely have their procedure performed off all anticoagulation.
Equally, some operators may be happy for the patient to continue warfarin during the procedure
but this should be confirmed with the operator that will be performing the procedure beforehand.
25
Cardiology Induction for Junior Doctors
For patients who are found to have a subtherapeutic INR:
 Administer Enoxaparin at 1mg/kg BD.
 Adjust VKA dose to improve anticoagulation, as per the usual protocol.
 Continue Enoxaparin until INR > 2 for 48 hours.
For patients who are stopping their anticoagulation in preparation for an invasive
procedure:
 Stop warfarin 5 days prior to procedure.
 Give Enoxaparin 1mg/kg BD – 1st dose 48 hours after stopping warfarin.
 Stop Enoxaparin 24 hours prior to procedure (i.e. last dose on the morning the day before).
 Admit on day of procedure and check INR.
 Restart warfarin on the evening, as per the usually dosing protocol, after the procedure, if
haemostasis has been achieved.
 Give first dose Enoxaparin 24 hours after procedure, provided the clinician is happy with
haemostasis.
 Give the patient enough LMWH to last 5 days (10 doses) – they can give it themselves if
happy, or arrangements made for the practice / district nurse should be made by the clinician
responsible.
 Continue Enoxaparin until 48 hours after INR >2. If any extra doses of clexane are needed
(i.e. beyond 5 days), the GP would prescribe these.
General considerations:
The clinician making the clinical decision to commence Enoxaparin should prescribe enough
doses and arrange for the patient or relative to receive training in administrating it – either by
hospital-based nurses or by the practice or district nurses, depending on the circumstances. This
should be documented and the GP informed in writing.
If the patient or relative is unable or unwilling to administer the Enoxaparin then arrangements
should be made with the relevant practice or district nurse to administer it.
Baseline FBC and U&E’s in all patients.
>5 days treatment, repeat FBC to monitor platelet level.
Patients weighing >130kg, measure anti Xa levels 4-6 hrs post first sc injection.
Separate protocols for patients remaining on warfarin, undergoing device implantation,
angiography or percutaneous coronary intervention.
At times a longer period without anticoagulation may be desired or necessary, but it should be
discussed with a consultant Cardiologist or Haematologist.
Audit and Compliance
The details of any patient on this protocol should be sent to Dr McKenzie (by e-mail or copy of
discharge summary / letter).
The patients treated will be audited and the data presented at one of the Divisional Audit
meetings in 2012 (Dr McKenzie is the lead for these meetings and will arrange).
Performance Monitoring
Any problems should be discussed with the clinician responsible for the patient. Any concerns
regarding this document should be discussed with one of the authors.
Review
26
Cardiology Induction for Junior Doctors
This protocol will be reviewed in December 2012
References
1. Montalescot G et al. Low molecular weight heparin after mechanical heart valve replacement.
Circulation, 2000; 101(10): 1083-1086.
2. Spyropoulos AC et al. Perioperative bridging therapy with unfractionated heparin or lowmolecular-weight heparin in patients with mechanical prosthetic heart valves on long term oral
anticoagulants (from the REGIMEN Registry). American Journal of Cardiology, 2008; 102(7):
883-9 2008.
3. Douketis J et al. The Perioperative Management of Antithrombotic therapy: American College
of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition), Chest 2008; 133:
299S-339S.
4. Dixon D. Safety of enoxaparin bridge therapy in patients with mechanical heart valves. The
Annals of Pharmacotherapy; 42, No 1: 143-144.
5. Groce J. Bridging therapy with low molecular weight heparin in pregnant patients with
mechanical prosthetic heart valves. J Thromb Thrombolysis, 2003; 16(1-2); 79-82.
6. Bonow RO et al. ACC/AHA 2006 Guidelines for the Management of Patients With Valvular
Heart Disease; A Report of the American College of Cardiology/ American Heart Association
Task Force on Practice Guidelines Developed in Collaboration With the Society of
Cardiovascular Anaethesiologists : Endorsed by the Society for Cardiovascular Angiography and
Interventions and the Society of Thoracic Surgeons. Circulation 2006; 114: e84-e231.
27
Cardiology Induction for Junior Doctors
Insertion of a Temporary Pacing Wire
Indications:
Symptomatic bradycardia
pulse < 40 + bp < 100 systolic
Heart block
ventricular rate < 40
heart block with asystolic spells  4 seconds
BP < 100 systolic
Sinus node disease
associated with symptoms
In context of myocardial infarction
Symptomatic CHB with inferior MI
Asymptomatic CHB with anterior MI
Overdrive of VT and atrial flutter
The temporary wire should be inserted by an appropriately qualified doctor in the pacing room
Substantive cardiology registrar or above, (all other registrars to confer with on call consultant
cardiologist)
Supported by:
nurse from ccu
pacing technician (page or mobile via switchboard, rota in CCU)
radiographer (page via switchboard)
Approach
The operator should use the great vein he or she is most familiar with on the patient’s dominant
(usually R) side (subclavian or internal jugular). Should the patient require a PPM it will be inserted
on the non-dominant side. The femoral vein should be used if patient is anti-coagulated
A stable position with a threshold <2.5v is acceptable. Thresholds should be assessed on a daily
basis on the CCU ward round. Stability can be checked by asking patient to take deep breath and
cough.
Pacemaker settings
The temporary box should be set to optimise patient haemodynamics.
e.g if intermittent CHB, rate just below normal sinus rate.
General comments
If any member of the team has concerns about the need for implantation, implantation, or
subsequent performance of device, they are to contact the on call cardiologist immediately. This
will usually be the senior nurse or technician.
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Cardiology Induction for Junior Doctors
Educational Opportunities
F1,F2, ST1 & ST2 are expected to attend activities as laid on by Division, these include:
The Grand Round
ST teaching
F1 & F2 teaching
Divisional Audit
Wednesday Lunchtime 1pm Post grad
Wednesday Morning
During Consultant Ward Rounds
3rd Wednesday am January, April, July, October
In addition
Trainees are expected to attend all or part of 2-3 outpatient clinics during their attachment please arrange individually with a consultant
Department meeting Friday lunchtime 12.45
Department M&M and audit 2nd Friday every 2 month12-2pm
Trainees are encourage to attend echo, angiography and PCI, and pacemaker sessions on an ad
hoc basis
29
Cardiology Induction for Junior Doctors
Outpatients – Cardiology Follow-up
Routine outpatient follow-up should be regarded as the exception rather than the norm. Any
patient who needs to be followed-up should be discussed with the consultant responsible for their
care.
Follow up of patients awaiting test results should only occur if a result is expected which will
require complex discussion with the patient. We have very few out-patient follow-up slots.
Discharging patients will free up time in the service allowing us to see patients who have become
unstable in a more timely fashion.
Ward Patients
Ward patients will only receive an out-patient appointment if it is specifically requested by a
cardiology consultant or there remains an outstanding issue which needs a cardiology decision.
Patients should be advised that they will receive the next available or a routine appointment.
If patients need to be seen within a short timeframe then a specific request to the booking staff
from the consultant is required.
Post-procedure patients
Patients undergoing procedures such as cardioversion should ideally have a management plan in
notes which can be followed irrespective of the need for follow up. This means that should patients
require follow up it can be done on a next available slot basis
Out Patients
Outpatients should not routinely be followed-up. For example stable angina, treated palpitations
and treated hypertension are not conditions that require routine follow up.
Congenital Heart Disease
A specialist area and beyond the scope of these guidelines. They should all be followed-up in the
joint clinics by David MacIver and Graham Stuart.
Post PCI
Post PCI patients are seen in nurse-led clinics and do not require follow-up unless there is a
particular reason – for example to determine if a second lesion requires intervention.
Post CABG
These patients will be seen by the surgeons post-operatively and then receive cardiac
rehabilitation. They should not be seen routinely in cardiology outpatients unless there is an
outstanding medical issue.
Prosthetic valves
After some discussion the consensus opinion is as follows:
All patients who have had a valve replacement/repair should be seen once in clinic and a baseline
echo should be performed. Most patients should then be discharged.
It is appropriate to follow-up, usually yearly:
Patients who have had a mitral valve replacement.
Patients who have had more than one valve replaced.
30
Cardiology Induction for Junior Doctors
Patients who have a residual valve lesion/other cardiological condition that may require
intervention in time, for example a young patient with severe heart failure after a mitral
valve repair.
Patients in whom a complication, such as patient-prosthesis mismatch or a paravalvular leak is identified.
It should be emphasised in the discharge letter that the recurrence of symptoms, for example
breathlessness, should prompt an urgent re-referral.
Most arrhythmias
Should not require follow-up.
Post DCCV
Patients undergoing procedures such as cardioversion should have a management plan in the
notes which can be followed. They should be followed-up once by the arrhythmia/cardioversion
nurses.
Devices
Most simple pacemakers should not require routine follow-up and can be followed-up in pacing
clinic.
It is reasonable to see ICDs/CRTs once post-op. For ICDs that can be at the time of the DFT test
(these are done 4-6 weeks after implant at Taunton & Somerset NHS Trust) unless it is within a
few days.
Post Ablation
Most people who have had an ablation will be seen in the centre where the ablation was done
post-operatively and do not need follow-up unless there is a specific clinical reason.
Heart failure
Most patients with heart failure should be followed up in the community.
The only indications for follow up are:
o If transplantation is being considered if symptoms worsen or fail to improve.
o If a device may be indicated.
o If renal replacement therapy may be required.
o If there is clinical instability which has proven difficult to control in primary care and admission
may be avoided.
o To discuss end-of-life issues.
Uptitration of medication should normally be undertaken by the GP or community heart failure
specialist nurses.
Hypertension
Should not require routine follow-up unless there are significant issues with BP control.
Pulmonary Hypertension
Should be routinely followed by the respiratory physicians, unless secondary to valve disease
under follow-up.
Native Valve Disease
The most common reason for follow-up is native valve disease.
The availability of percutaneous valve techniques means that patients previously ineligible for
intervention may now be suitable for intervention.
See the latest ACC/AHA guidelines.
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Cardiology Induction for Junior Doctors
Tricuspid and pulmonary valve disease
There are very few patients with significant tricuspid and pulmonary valve disease requiring followup and most of these will have underlying congenital heart disease. They should be followed-up by
David MacIver in the congenital heart disease clinic if appropriate.
Mitral stenosis
Echocardiography is reasonable in the re-evaluation of asymptomatic patients with MS and stable
clinical findings to assess pulmonary artery pressure (for those with severe MS, every year;
moderate MS, every 1 to 2 years; and mild MS, every 3 to 5 years).
Mitral regurgitation
Mild MR with leaflet prolapse (or suspicion of): 3-5 years.
Moderate MR: 1 year.
Severe MR: 6 months.
Aortic stenosis (asymptomatic)
Mild AS: 3-5 years.
Moderate AS: 1-2 years.
Severe AS: 1 year.
Patients with bicuspid aortic valves and dilatation of the aortic root or ascending aorta (diameter
greater than 4.0cm – NB. need to correct for body surface area) should undergo serial evaluation
of aortic root/ascending aorta size and morphology by echocardiography, cardiac magnetic
resonance, or computed tomography on a yearly basis.
Aortic regurgitation (asymptomatic, normal LV function)
After an initial diagnosis of moderate to severe AR it is appropriate to review the patient in 2-3
months to ensure a rapidly progressive process is not underway.
Asymptomatic patients with mild AR, little or no LV dilatation, and normal LV systolic function can
be seen on a yearly basis, with instructions to alert the physician if symptoms develop in the
interim. Yearly echocardiography is not necessary unless there is clinical evidence that
regurgitation has worsened. Routine echocardiography can be performed every 2 to 3 years in
such patients.
Asymptomatic patients with normal systolic function but severe AR and significant LV dilatation
(end-diastolic dimension greater than 60 mm), if not referred for surgery, require more frequent
and careful re-evaluation, with a history and physical examination every 6 months and
echocardiography every 6 to 12 months, depending on the severity of dilatation and stability of
measurements. If patients are stable, echocardiographic measurements are not required more
frequently than every 12 months.
In patients with more advanced LV dilatation (end-diastolic dimension greater than 70 mm or
endsystolic dimension greater than 50 mm), if not referred for surgery, for whom the risk of
developing symptoms or LV dysfunction ranges between 10% and 20% per year, it is reasonable
to perform serial echocardiograms as frequently as every 4 to 6 months.
Patients with echocardiographic evidence of progressive ventricular dilatation or declining systolic
function have a greater likelihood of developing symptoms or LV dysfunction and should have
more frequent follow-up examinations (every 6 months) than those with stable LV function.
Thoracic Aortic Aneurysms/Dilated Aortic Roots/Post Aortic Root repair/replacement
This is a complex situation and precise guidelines on follow-up are difficult.
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Cardiology Induction for Junior Doctors
As a general rule, patients with a dilated aortic root require yearly follow-up, but more frequent
follow-up may be required.
It is generally appropriate to follow patients on a yearly basis after aortic repair, unless there is
concomitant follow-up at the operating centre, in which case it is not required here.
Heart transplantation
Yearly follow-up.
33
Cardiology Induction for Junior Doctors
Cardiology Department Induction Checklist
Name of Doctor
Date of Appointment
Department
Grade
Name of Clinical Supervisor
Name of Mentor
ASPECT OF INDUCTION
DATE COMPLETED N/A
Received contract and job description
Receive identity card, pager, map of hospital, other written information
IT training / passwords, use of the Trust intranet
Use of telephones & the paging system
Explanation of scope of duties (specific roles and responsibilities, on call arrangements and how
to access senior help and advice
Explanation of arrangements for taking leave
Explanation of relevant policies, protocols and guidelines (and how to access them):
Available on cardiology induction site
Introduction to clinical documentation and record keeping
Explanation and tour of work areas:
Wards, theatres, outpatient departments and other clinical areas
Residence and advice about obtaining food
Changing facilities and lockers
Security, security codes and location of keys if appropriate.
Library
Audit and research facilities
Car parking
Competency, taking consent and use of medical devices
Complete competency self-assessment checklist, including consent, medical devices
DOPS in Echocardiography, Permanent Pacing, Cardiac Catheter
Meet with clinical supervisor (clinical lead, college tutor, educational supervisor) to
discuss competencies and develop a personal learning plan
Plan for re-evaluation at least 6 monthly
Signature of new doctor
Date
Name and Signature of Clinical supervisor
Date
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Cardiology Induction for Junior Doctors
Practical Skills and Procedures Competency
Expected levels of competence are defined by the clinical supervisor.
Completion is the responsibility of the new doctor or dentist. The clinical supervisor is responsible for developing a learning plan
and specifying the duration of supervised practice.
Completion of the document must be monitored and archived by the clinical service lead.
Name of Doctor
Date of Appointment
Department
Grade
Name of Clinical Supervisor
Name of Mentor
All doctors have a duty to recognise and work within the limits of their professional competence.
The Trust has a responsibility not to require staff members to work outside their competence and
supervision of practice must be tailored accordingly. Personal development / learning plan must address the
means to gain outstanding competencies. This document is intended to help ensure these principles are
adhered to.
Self-assessment of competency
It is the responsibility of the new doctor to ensure that assessment of competencies is carried out. This
document must be completed and discussed with the clinical supervisor (consultant / educational
supervisor / college tutor) as soon as possible after taking up post.
Levels of competency
Level 1
Observes the clinical activity performed by a colleague
Level 2
Assists a colleague
Level 3
Performs the entire activity under direct supervision of a senior colleague
Level 4
Performs the entire activity with indirect supervision of a senior colleague
Level 5
Performs the entire activity competently without need for supervision
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Cardiology Induction for Junior Doctors
Clinical tasks (list all relevant tasks)
Technical task
Able to take consent forExpected level of
procedure
competency
Self assessed
level
Trainer to sign and
date
Generic tasks
Venesection
Insertion cannula
12 lead ECG
Basic Life Support
Oral airway
Bag and mask ventilation
Arterial blood gas sampling
Defibrillation (as part of ALS)
Central line insertion
External cardiac pacing
Consent
Booking Cardiac Investigations
Transfer to Cardiac Surgical Centres
Management of wound complications
Medical Devices (list all equipment that the doctor/dentist is required to use)
Use of Medical devices
(examples)
Defibrillator
Expected level of competency
Self assessed level
Trainer to sign and date
Monitoring equipment
(ECG, BP, oximetry)
Blood gas analyser
Mandatory courses (list only relevant courses)
Courses attended
Manual Handling
Basic life support
Advanced life support
Yes
No
N/A
Trainer to sign and date
Personal learning / development plan
Agreed period of supervised practice
Signature of new doctor
Date
Name and Signature of Clinical supervisor
Date
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Cardiology Induction for Junior Doctors
APPENDIX
37
Cardiology Induction for Junior Doctors
Patient identifier/label
consent form 3
Patient/parental agreement to investigation or treatment
(procedures where consciousness not impaired)
Name of procedure (include brief explanation if medical term not clear)
Cardiac catheterisation
Statement of health professional
(to be filled in by health professional with appropriate knowledge of
proposed procedure, as specified in consent policy)
I have explained the procedure to the patient/parent. In particular, I have explained:
The intended benefits: To assess the blood supply and function of the heart and its valves.
Serious or frequently occurring risks: Common: bruising / bleeding. Rarely: allergic reaction,
heart rhythm changes, damage to artery. Serious risks 1 in 1000 (heart attack, stroke,
major bleed)
I have also discussed what the procedure is likely to involve, the benefits and risks of any available
alternative treatments (including no treatment) and any particular concerns of those
involved.

The following leaflet/tape has been provided: Cardiac Catheterisation (day case or in patient),
information sheet for cardiac catheterisation
Signed: .…………………………………… Date ……... ……………………………………..
Name (PRINT) ………………………. ……….Job title ………………………………………….
Statement of interpreter (where appropriate)
I have interpreted the information above to the patient/parent to the best of my ability and in a way
in which I believe s/he/they can understand.
Signed ……………….……….Date…….…………..Name (PRINT)…………….…………………..
Statement of patient/person with parental responsibility for patient
I agree to the procedure described above.
I understand that you cannot give me a guarantee that a particular person will perform the
procedure. The person will, however, have appropriate experience.
I understand that the procedure will involve local anaesthesia.
Signature ……………………………………….
Name (PRINT) …………………………………
Date ……………………………..………………
Relationship to patient …………………………
Confirmation of consent (to be completed by a health professional when the patient is admitted for the
procedure, if the patient/parent has signed the form in advance)
I have confirmed that the patient/parent has no further questions and wishes the procedure to go
ahead.
Signed: ……………………………………
Name (PRINT) ………………………..………..
Date ……... …………………………….
Job title …………………………………
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Cardiology Induction for Junior Doctors
Patient identifier/label
consent form 3
Patient/parental agreement to investigation or treatment
(procedures where consciousness not impaired)
Name of procedure (include brief explanation if medical term not clear)
Coronary angioplasty +/- stenting
Statement of health professional (to be filled in by health professional with appropriate
knowledge of proposed procedure, as specified in consent policy)
I have explained the procedure to the patient/parent. In particular, I have explained:
The intended benefits: To improve the blood supply to the heart, improve symptoms of angina
and/or heart function.
Serious or frequently occurring risks: Common: bruising / bleeding. Rarely: allergic reaction,
heart rhythm changes, renal impairment, vascular damage. Serious risks 1 in 200 myocardial
infarction, serious bleed, less than 1 in 1000 stroke, less than 1 in 1000 for emergency bypass
surgery, death 1 in 100, from the serious risks mentioned.
I have also discussed what the procedure is likely to involve, the benefits and risks of any
available alternative treatments (including no treatment) and any particular concerns of those
involved.
 The following leaflet/tape has been provided: Cardiac Catheterisation (day case or in patient),
information sheet for cardiac catheterisation
Signed:
.……………………………………
Name (PRINT) ………………………. ……….
Date ……... ……………………………………..
Job title ………………………………………….
Statement of interpreter (where appropriate)
I have interpreted the information above to the patient/parent to the best of my ability and in a
way in which I believe s/he/they can understand.
Signed ……………….……….Date…….…………..Name (PRINT)…………….…………………..
Statement of patient/person with parental responsibility for patient
I agree to the procedure described above.
I understand that you cannot give me a guarantee that a particular person will perform the
procedure. The person will, however, have appropriate experience.
I understand that the procedure will involve local anaesthesia.
Signature ……………………………………….
Name (PRINT) …………………………………
Date ……………………………..………………
Relationship to patient …………………………
Confirmation of consent (to be completed by a health professional when the patient is admitted
for the procedure, if the patient/parent has signed the form in advance)
I have confirmed that the patient/parent has no further questions and wishes the procedure to go
ahead.
Signed: ……………………………………
Name (PRINT) ………………………..……
Date ……... …………………………….
Job title …………………………………
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Cardiology Induction for Junior Doctors
Patient identifier/label
Name of proposed procedure or course of treatment (include brief
explanation if medical term not clear)
Electrical Cardioversion (Use of an electrical defibrillator to shock the heart into a normal electrical
rhythm)
Statement of health professional (to be filled in by health professional with
appropriate knowledge of proposed procedure, as specified in consent policy )
I have explained the procedure to the patient. In particular, I have explained:
The intended benefits: To restore the heart into a normal electrical rhythm
Serious or frequently occurring risks: Risk of skin erythema / burning if multiple shocks required.
Possible failure to restore normal rhythm. Risks of general anaesthetic. Risk of stroke less than
1/100.
Any extra procedures which may become necessary during the procedure
 blood transfusion
 other procedure (please specify)
No (unless emergency)
No (unless emergency)
I have also discussed what the procedure is likely to involve, the benefits and risks of any available
alternative treatments (including no treatment) and any particular concerns of this patient.
 The following leaflet/tape has been provided ……………….…………………………..…
This procedure will involve:

general and/or regional anaesthesia
Signed:…….……………………………………
Name (PRINT) ………………………. ………

local anaesthesia

sedation
Date .. …………………….……….
Job title …….. ………………….…
Contact details (if patient wishes to discuss options later) …..……………….……………
Statement of interpreter (where appropriate)
I have interpreted the information above to the patient to the best of my ability and in a way in
which I believe s/he can understand.
Signed ………………………….……………………. Date ………………..…………….
Name (PRINT) …………………..………………………………………………………………
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Cardiology Induction for Junior Doctors
Statement of patient
Patient identifier/label
Please read this form carefully. If your treatment has been planned in advance, you should already have
your own copy of page 2 which describes the benefits and risks of the proposed treatment. If not, you will
be offered a copy now. If you have any further questions, do ask – we are here to help you. You have the
right to change your mind at any time, including after you have signed this form.
I agree to the procedure or course of treatment described on this form.
I understand that you cannot give me a guarantee that a particular person will perform the procedure. The
person will, however, have appropriate experience.
I understand that I will have the opportunity to discuss the details of anaesthesia with an anaesthetist
before the procedure, unless the urgency of my situation prevents this. (This only applies to patients having
general or regional anaesthesia.)
I understand that any procedure in addition to those described on this form will only be carried out if it is
necessary to save my life or to prevent serious harm to my health.
I have been told about additional procedures which may become necessary during my treatment. I have
listed below any procedures which I do not wish to be carried out without further discussion.
…………………………………………………………………………
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
…………………………………………………………………..
Patient’s signature …………………………………………..
Date…………………………..
Name (PRINT) ………………………………………………………………………………………
A witness should sign below if the patient is unable to sign but has indicated his or her consent.
Young people/children may also like a parent to sign here (see notes).
Signature ……………………………………………
Date ……………………..….………
Name (PRINT) ………………………………………………………………………………….…
Confirmation of consent (to be completed by a health professional when the patient is admitted for the
procedure, if the patient has signed the form in advance)
On behalf of the team treating the patient, I have confirmed with the patient that s/he has no further
questions and wishes the procedure to go ahead.
Signed:…….……………………………………
Name (PRINT) ………………………. ………
Date .. …………………….……….
Job title …….. ………………….…
Important notes: (tick if applicable)
 See also advance directive/living will (eg Jehovah’s Witness form)
 Patient has withdrawn consent (ask patient to sign /date here) ……………...……….
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Cardiology Induction for Junior Doctors
42
Cardiology Induction for Junior Doctors
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Cardiology Induction for Junior Doctors
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Cardiology Induction for Junior Doctors
RAPID ASPIRIN DESENSITIZATION
PROTOCOL:
FOR PATIENTS WITH URTICARIAL OR
ANGIOEDEMA ALLERGIC REACTION
TO ASPIRIN WHO REQUIRE
CORONARY ARTERY STENTS
DR MIKE SEDDON
CONSULTANT CARDIOLOGIST
MUSGROVE PARK HOSPITAL
JUNE 2011
45
Cardiology Induction for Junior Doctors
BACKGROUND:
● Percutaneous coronary intervention (PCI) using stents is the commonest method
of coronary revascularisation, and is performed for symptom relief, prognostic
benefit, or both.
● Stent deployment traumatizes the vessel wall, triggering an inflammatory
response and platelet activation.
● Early stent trials used aspirin monotherapy or aspirin plus warfarin to reduce the
risk of early thrombotic complications. However, rates of stent thrombosis were 1520% for aspirin monotherapy1 and with aspirin and warfarin in combination these
rates remained high (3.5% at the time of hospital discharge) and were associated
with high bleeding rates. The introduction of dual antiplatelet therapy with aspirin
and a thienopyridine (initially ticlopidine, superceded by clopidogrel and prasugrel)
has reduced the risk of stent thrombosis to less than 1% with acceptable bleeding
rates2-4.
● International clinical guidelines5,6 recommend dual antiplatelet therapy for a
minimum of 1 month for bare metal stents, up to 12 months for drug-eluting stents,
and up to 12 months (regardless of stent type) in the context of an acute coronary
syndrome. Beyond this, chronic aspirin therapy should be maintained indefinitely.
● However, some patients are unable to tolerate aspirin due to hypersensitivity,
manifested by aspirin-exacerbated respiratory tract disease, urticaria/angioedema,
or anaphylaxis7. Alternative antiplatelet options are limited in these patients – and
there is no evidence that monotherapy with either clopidogrel or prasugrel, or even
dual therapy with warfarin combined with one of these agents, is effective.
● The incidence of aspirin hypersensitivity in the general population ranges from 0.62.5%, but that in adult asthmatics ranges from 4.3-11%. Aspirin desensitization
therapy has demonstrated therapeutic effects. Various protocols and routes of
administration have been elaborated in the last two decades. Oral administration by
means of an initial desensitization with incremental doses of aspirin, followed by
daily therapy, has proven clinical efficacy and safety8,9. Several of these protocols
involved dosing intervals of 2-24 hours, which would require several days to
complete and would be impractical for patients with acute coronary syndromes.
However, rapid aspirin desensitization protocols have been developed which are
reported to allow subsequent long-term treatment with aspirin in 88-94% after a
protocol taking only 3-6 hours10-13. As a consequence, aspirin desensitization is
endorsed in the AHA/ACC/SCAI 2005 guideline update for PCI5 and in the ESC/EACTS
2010 guidelines on myocardial revascularization6.
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Cardiology Induction for Junior Doctors
● Aspirin desensitization works by degranulating mast cells of their histamine
content in a controlled fashion. Once the mast cells are fully degranulated, the
patient should be able to tolerate full dose aspirin without developing an allergic
response. Subsequently, the patient must remain on daily aspirin, since after
stopping aspirin the histamine reaccumulates in the mast cells and tolerance to
aspirin is lost.
PUBLISHED ASPIRIN DESENSITIZATION SERIES IN PATIENTS WITH CORONARY
ARTERY DISEASE
● Silberman et al.10 developed a rapid desensitization protocol based on an initial
desensitization of 16 patients (13 with urticarial/ angioedema, 3 with increased
asthma symptoms after aspirin exposure). None of the subjects received
pretreatment with antihistamines or corticosteroids. The first 7 patients received a
protocol of 8 aspirin doses over 3.5 hours (1, 2, 4, 8, 16, 32, 64, 100mg) with dose
intervals of 30 minutes. Patients were monitored for 3 hours after the protocol. 1
patient had a severe asthma attack 1 hour after the 100mg dose, treated
successfully with β-adrenergic agonist. The second consecutive group of 9 patients
received a shorter protocol of 5 doses over 2.5 hours (5, 10, 20, 40, 75mg) with dose
intervals of 30 minutes. One patient developed angioedema 3 hours after finishing
the protocol and responded to corticosteroids and adrenaline. This patient repeated
the protocol without event 2 days later. Patients were maintained on 75-100mg
daily. The investigators reported successful desensitization of an additional 18
patients without event.
● Wong et al.11 rapidly desensitized 11 patients with previous urticaria or
angioedema after aspirin exposure. 10 patients were pretreated with antihistamine
(one patient with a recent hypersensitivity reaction to aspirin was given
corticosteroid in addition). They received 10 doses over 4 hours (0.1, 0.3, 1, 3, 10, 30,
40, 81, 162, 325mg) and 9 patients completed the protocol uneventfully. Of the two
others (both had chronic idiopathic urticaria independent of aspirin exposure), one
developed chest tightness which responded to inhaled β-adrenergic agonist and the
other developed angioedema after protocol completion.
● In Rossini et al’s13 study of 1,014 patients admitted for cardiac catheterization, 26
(2.6%) had histories of aspirin sensitivity characterized by respiratory or cutaneous
manifestations (none had previous anaphylactic reactions); of these, 61.5%
presented with acute coronary syndromes. All patients underwent a rapid
desensitization challenge protocol before cardiac catheterization, except for those
presenting with ST-elevation myocardial infarctions (n = 4), who underwent
desensitization before hospital discharge. The desensitization procedure involved
the oral administration of 6 sequential doses of aspirin (1, 5, 10, 20, 40, and 100 mg)
over 5.5 hours without the use of corticosteroids or antihistamines. Patients were
47
Cardiology Induction for Junior Doctors
followed for 1 year to assess compliance with aspirin therapy and adverse events.
The desensitization procedure was successful in 23 patients (88.5%). 3 patients had
non-serious adverse reactions (2 of these had a history of chronic idiopathic
urticaria). Percutaneous coronary intervention with stent implantation was
performed in 22 patients (1.8 stents/ patient). Drug-eluting stents were used in all
patients except those who underwent primary percutaneous coronary intervention
(n = 3), in whom bare-metal stents were used. Multivessel percutaneous coronary
intervention was performed in 30.7% of patients. At follow-up, all patients who
successfully responded to the desensitization procedure tolerated maintenance daily
aspirin (100mg) well, without developing allergic reactions. Aspirin was withdrawn in
only 1 patient, because of a peptic ulcer. The authors concluded that rapid
desensitization is safe and highly effective in patients with aspirin sensitivity and
coronary artery disease who undergo coronary stent implantation, including those
who receive drug-eluting stents.
● In the most recently reported series14, 5 patients with a history of aspirin
hypersensitivity (3 urticaria, 2 facial angioedema) who had suffered an acute
coronary syndrome underwent rapid aspirin desensitization. The protocol was
adapted and modified from the studies above, with the administration of increasing
doses (0.1, 0.2, 1, 3, 10, 25, 50, and 100 mg) at 15-20 minute intervals, performed
under supervision but without antihistamine or corticosteroid premedication. Aspirin
desensitization was successfully achieved in all patients without any adverse
reactions in under 2 and a half hours. At follow-up (5-46 months), all patients were
still taking 100mg aspirin daily.
ALGORITHM FOR PATIENTS WITH ASPIRIN ALLERGY REQUIRING
CORONARY ANGIOGRAPHY +/- PCI AT MUSGROVE PARK HOSPITAL
● Patients with a history of aspirin allergy who present with either (i) ST-elevation MI
(STEMI), or (ii) unstable ACS (ongoing chest pain and /or dynamic ECG changes) are
not suitable for aspirin desensitization prior to coronary angiography due to time
constraints, and they should proceed directly to coronary angiography +/revascularization with further consideration given to their aspirin allergy afterwards.
48
Cardiology Induction for Junior Doctors
PROTOCOL FOR RAPID ORAL ASPIRIN DESENSITIZATION AT MPH:
Location:
(Outpatients)
Coronary Care Unit (Inpatients) or Cardiac Day Unit
Patients:
Exclude those with true anaphylaxis reaction
Consent:
Verbal consent must be obtained
Prior to protocol:
Establish IV access
Ensure that the following drugs are available: 200mg
hydrocortisone IV, 10mg piriton IV, adrenaline 0.5-1.0 ml of
1:1000 IM, salbutamol nebs. Ensure that the Resuscitation
Trolley is available.
Check baseline Pulse, Blood Pressure, Oxygen Saturations and
Peak Flow are satisfactory before starting. Baseline 12 lead
ECG.
Fexofenadine 120mg orally 1 hour before
Aspirin:
Dissolve 5 x 75mg soluble aspirin tablets in 375mls water,
providing a 1mg/ml suspension. Small doses should be given
using a purple sterile syringe for oral use.
49
Cardiology Induction for Junior Doctors
TIME (Minutes)
0
30
60
90
120
180
240
Maintenance Dose
Aspirin dose (mg)
1
5
10
20
40
100
150
150mg
Monitoring:
Pulse, Blood Pressure, Oxygen Saturations every 3o mins and
for 3 hours after completion of protocol.
Supervision:
CCU SHO and CCU/CDU nursing staff, who should liase with
SpR or Consultant if there are concerns regarding an allergic
reaction.
Allergic reactions:
For subjective symptoms, observe for 10 minutes until patient
feels better before continuing.
For objective mild symptoms (eg cutaneous) give additional
120mg Fexofenadine PO or 10mg Piriton IV.
For severe reactions follow BLS/ ALS protocol and emergency
management of anaphylaxis/ asthma.
Database:
Details of all patients to Dr Seddon for database records
REFERENCES:
1. Serruys PW, de Jaegere P, Kiemeneij F, et al. A comparison of balloon-expandablestent implantation with balloon angioplasty in patients with coronary artery disease.
Benestent Study Group. New England Journal of Medicine 1994; 31: 489-95.
2. Bertrand ME, Rupprecht HJ, Urban P, et al. Double-blind study of the safety of
clopidogrel with and without a loading dose in combination with aspirin compared
with ticlopidine in combination with aspirin after coronary stenting: the clopidogrel
aspirin stent international cooperative study (CLASSICS). Circulation 2000; 102: 6249.
3. Mehta SR, Yusuf S, Peters RJG et al. Effects of pretreatment with clopidogrel and
aspirin followed by long-term therapy in patients undergoing percutaneous coronary
intervention: the PCI-CURE study. Lancet 2001; 358: 527-33.
4. Wiviott SD, Braunwald E, McCabe CH, et al. for the TRITON-TIMI 38 Investigators.
Prasugrel vs clopidogrel in patients with acute coronary syndromes. New England
Journal of Medicine 2007; 357: 2001-15.
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Cardiology Induction for Junior Doctors
5. Smith SJ, Feldman T, Hirshfield JJ, et al. ACC/AHA/SCAI 2005 guideline update for
percutaneous coronary intervention: a report of the American College of Cardiology/
American Heart Association Task Force on Practical Guidelines. Journal of the
American College of Cardiology 2006; 47: e1-121.
6. Wijns W, Kolh P, Danchin N, et al. Guidelines on myocardial revascularization. The
Task Force on Myocardial Revascularization of the European Society of Cardiology
(ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). European
Heart Journal 2010; 31: 2501-2555.
7. Stevenson DD. Aspirin and NSAID sensitivity. Immunology Allergy Clinics of North
America 2004; 24: 491-505.
8. Page NA, Schroeder WS. Rapid desensitization protocols for patients with
cardiovascular disease and aspirin hypersensitivity in an era of dual antiplatelet
therapy. Annals of Pharmacotherapy 2007; 41: 61-7.
9. Pfaar O, Klimek L. Aspirin desensitization in aspirin intolerance: update on current
standards and recent improvements. Current Opinion in Allergy and Clinical
Immunology. 2006;6:161-6
10. Silberman S, Neukirch-Stoop C, Steg PG. Rapid desensitization procedure for patients
with aspirin hypersensitivity undergoing coronary stenting. American Journal of
Cardiology 2005; 95: 509-10.
11. Wong JT, Nagy CS, Krinzman SJ, et al. Rapid oral challenge-desensitization for
patients with aspirin-related urticarial-angioedema. Journal of Allergy and Clinical
Immunology 2000; 105: 997-1001.
12. Gollapudi RR, Teirstein PS, Stevenson DD, et al. Aspirin sensitivity: implications for
patients with coronary artery disease. Journal of the American Medical Association
2004; 292: 3017-23.
13. Rossini R, Angiolillo DJ, Musumeci G, et al. Aspirin desensitization in patients
undergoing percutaneous coronary interventions with stent implantation. American
Journal of Cardiology 2008; 101: 786-9.
14. Dalmau G, Gaig P, Gazquez V, et al. Rapid desensitization to acetylsalicylic acid in
acute coronary syndrome patients with NSAIDS intolerance. Revista Espanola de
Cardiologia 2009; 62: 224-5.
51