Cardiomyopathy routine follow up

Annual Follow up of Dilated Cardiomyopathy

This guidance/explanation is for GPs and Patients - and ideally used in association with advice from a Cardiologist or Physician with specialist interest in heart failure and cardiomyopathy.

Why do we need a follow up protocol?

Because of increasing congestion in Cardiology Outpatients, low-risk patients with milder heart conditions can be given the option for 'shared care' with their GP where our protocol can be followed in the more convenient surroundings of the GP Surgery backed up by specialist testing provided by Cardiologists using direct access services.

We hope that 'shared care' will provide more convenient and patient-centred access to specialist medicine without the inconvenience of long waits or seeing a different junior doctor at each visit.   Because the GP and Patient follow a specialist protocol, and have access to the specialist team using telemedicine clinics, its easier to detect subtle changes in a patients condition and access the specialist teams.

These protocols are now made possible because of 'direct access' echocardiography and wider availability of BNP blood test for GPs as well as new Telecardiology care provided by the Haste Cardiology team.

Principles

Some patients with dilated cardiomyopathy  may develop worsening symptoms such as breathlessness and fatigue at which point they will should be seen in the specialist cardiology outpatient department.

It is also important to recognise that worsening ventricular function can occur without much in the way of change of symptoms.  This type of progressive may be more often seen in “non complainers” or patients who have a high threshold for visiting the doctor.  To guard against this possibility most Cardiologists recommend serial assessments and echocardiographic follow up for milder cases that could be 2-3 years apart.

In addition to echocardiographic follow up an annual clinical review is recommended and at this review a record should be taken of whether any warning symptoms have developed such as worsening breathlessness, angina, ankle oedema, orthopnoea, black outs in addition to palpitations.  The clinical examination should include auscultation to see if there have been any new murmurs, any lung crackles or elevation of the venous pressure.

The blood pressure (should be below 135/85 mmHg) and heart rate, and whether this is regular should also be recorded.

A 12-lead ECG should be taken, and heart rhythm noted especially if the pulse is not regular, and for all cases of aortic valve disease, since onset of atrial fibrillation and flutter can occur without symptoms for all cases of dilated cardiomyopathy and development of T wave abnormalities can indicate disease progression.

The BNP is a very consistent marker of cardiac 'strain' and is easily measured by the GP. When measured serially it can be extremely useful benchmark of patient status. It would be very unusual for a patient's heart condition t have deteriorated without a significant increase (>20%) in BNP, making it a very useful test for the annual check.

Our Protocol for GPs

  1. Ask about any limitations of exercise
  2. NYHA Grade (see link for NYHA grades- 1-IV)
  3. Check BP- treat if consistently above 135/85 mmHg
  4. Check Pulse - if erratic or fast arrange an ECG
  5. Assess JVP and ankles if high, add diuretic and refer back
  6. Listen to chest and lungs
  7. Look at ECG- compare with last, check for new AF, T changes
  8. Measure BNP, FBC and U&Es
  9. If significant or moderate, Echo between every 1 and 3 years

Suggestions for referring back (which are by no means exclusive):

  1. Increasing symptoms on effort or orthopnea, esp if CXR shows larger heart or pulmonary congestion or if the and BNP is rising.
  2. Rising BNP (>20% change).
  3. Worsening U&Es.
  4. An echocardiogram showing LV systolic dimension increasing by more than 20%.

Related Pages

Open access Echocardiography
Shared Care for Valve conditions
Shared Care aortic stenosis
 



Written by

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Edward Leatham is a Consultant Cardiologist in Surrey and a Trustee of Haste and Haste Academy.

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