Download Western Locality Kernow Clinical Commissioning Group Direct

Western Locality
Kernow Clinical Commissioning Group
Direct access echocardiography request form
Patient details (affix label)
Name:
d.o.b.
/
/
[NB age > 18 yrs]
NHS No.
Address:
Reason for request:
Post code:
Tel:
GP Details
Name:
Surgery:
Tel:
Fax:
E-Mail:
Please include your E-mail address if you would like to
receive an electronically transmitted report.
Please attach a 12-lead ECG (within past 6 months)
Attachments must be full size and legible.
Reason for request:
1.
Suspected new heart failure diagnosis
Symptoms (e.g. breathlessness) and
 previous proven MI or
 Male patient with ankle oedema
All other symptomatic patients first check
Refer directly for echocardiogram
(NT-proBNP not required)
NT-proBNP result:
A diagnosis of heart failure is very unlikely with a normal ECG and/or normal NT-proBNP result.
An abnormal ECG showing evidence of previous Q-wave infarction, atrial fibrillation, left bundle branch block
conduction and/or left ventricular hypertrophy raises the likelihood of heart failure.
2.
Other clinical indications (tick all that apply)




Murmur ?cause
Atrial fibrillation
LVH
Other (please describe)
Please attach any previous
echo reports if available
ALL REQUESTS: does the patient have any relevant history? (tick all that apply)
 Hypertension
 Coronary artery disease (angina / MI / PCI + stent / CABG)
Please give details
ALL REQUESTS: is the patient on medication? (tick all that apply)
 ACEi or sartan
 Aspirin
 Loop diuretic
 Warfarin
 Beta-blocker
 Digoxin
 Calcium channel blocker
 Statin
REQUESTING ECHOCARDIOGRAMS
HOW TO REQUEST AN ECHO
As a result of confusion as to how and when to order an echocardiogram, and in order to provide
unified access for all GP practices referring to Derriford, a new request form has been designed.
This should replace all previous forms and should be used for all providers. An accompanying referral
letter is not necessary but can be helpful if you wish to provide more information.
All echocardiogram requests must be accompanied by a recent ECG
All requests for investigation of breathlessness/? Heart failure must be accompanied by BNP level
unless PMH of MI or ankle oedema in a male patient
WHEN TO REQUEST AN ECHO
Although echocardiography can provide useful information in many cardiac conditions, it is not
possible to fund unqualified access. Unaffordable numbers of echos are being requested and a
significant minority of requests are clinically inappropriate. Please also check with the patient and
the hospital notes that echo has not been recently performed in hospital, as there has also been a
significant amount of duplication
Breathlessness
Echocardiography is a key investigation in the breathless patient in whom heart failure is suspected.
Heart failure is unlikely in the presence of a normal ECG (approximate 90% sensitivity) so this test
should be performed first. If the ECG is abnormal, or if heart failure is still strongly suspected on
clinical grounds then BNP testing should be requested (unless there is a history of prior MI when
BNP testing is not necessary.) If the BNP is normal for the patient’s age then Heart Failure is
extremely unlikely. Requests for echo in these circumstances would normally be rejected unless an
accompanying brief letter to the GPWSi triagers clarifies the reason for the request.
Atrial Fibrillation
Current guidelines suggest consideration of echo as a test in AF patients. Echo is indicated in younger
patients, in those with murmurs and is usually undertaken in those who are being considered for
cardioversion. In the elderly patient for whom a rate control strategy is indicated echocardiography
may be unnecessary as it rarely changes patient management
New presentation of cardiac murmur is a clear indication for echocardiography
All other requests for echocardiography must be accompanied by a clear clinical reason for the
request and will be considered individually by the GPWSi triagers. Echocardiography is not usually
indicated in the investigation of IHD, palpitations or syncope in the primary care setting.
Rosie Heath GPWSi NHS Plymouth