Annual follow up for Aortic and Mitral Regurgitation

Why do we need a follow up protocol?

Because of increasing congestion in Cardiology Outpatients, where there are low-risk patients with milder heart conditions, we have evolved a protocol for shared care.

These protocols are now made possible because of 'direct access' echocardiography and wider availablity of BNP blood test for GPs.

Principles

On the whole, patients with progressive valvular heart conditions develop symptoms such as angina, breathlessness or fatigue, at which point they need to be seen in the Cardiology Outpatient Department.

In the cases of aortic regurgitation, exercise-related syncope or near syncope is also important to recognise and refer. 

In addition to taking note of symptoms, any follow-up protocol should take into account the small proportion of patients with valvular heart conditions that deteriorate over several years without necessarily reporting a reduction in symptoms.  This type of progression 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 echocardiographic follow-up,
that for milder cases, could be two to three years apart.

In addition to echocardiographic follow-up, an annual clinical review is recommended. At this review
a record should be taken of the patient’s exercise capacity and whether any warning symptoms have
developed such as worsening angina, ankle oedema, orthopnoea, blackouts etc in addition to a clinical
examination including auscultation of the heart to see if there has been any change in the intensity of
the murmur, the presence of any new murmurs, any lung crackles or elevation of the central venous
pressure and/or ankle swelling.

The blood pressure 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 development of T-wave abnormalities can indicate disease progression and onset of atrial fibrillation and flutter can occur without symptoms.

Providing symptoms are steady and no new signs are picked up, the patient can be simply reviewed from year to year without need for referral back to the Cardiology Department.

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 woul dbe 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.

Template

  1. Ask about any limitations of exercise
  2. NYHA Grade
  3. Check BP- treat if consistently above 135/85 mmHg
  4. Check Pulse - if erratic or faster than 90 bpm arrange review with 12 lead ECG (see 7)
  5. Assess JVP and ankles if high, add diuretic and refer back
  6. Listen to chest and lungs to make sure any crackles are recorded
  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', arrange Echocardiogram 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 and BNP rising
  2. Rising BNP (>20% change)
  3. Worsening U&Es
If a GP is worried about an ECHO result, but the patient is clinically stable it is not necessary to always refer back to outpatients. Write to us with the clinical details above and we will review the echo in our MDT. 
 
A downloadable version is shown below.

Related Stories

Shared care protocol for follow up of Aortic Stenosis
Open Access Echo for G&W GPs

 




Written by

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

Responses

You must be logged in to leave a reply. Login »