1. Managing Palpitations in Primary care Dr Ivan Benett GPwSI cardiology 12/10/2014Dr Ivan Benett GPwSI for AA meeting

2. Referrals from GPs ≈ 1:3 referrals is for the assessment of palpitations Tariff for cardiology referrals £200+ per adult first attendance ≈37 referrals each month for palps in C M/cr ≈ £ 86,000 pa + £97 per adult follow-up 12/10/2014Dr Ivan Benett GPwSI for AA meeting

3. Managing palpitations The role of the Generalist Marginalise Danger Explore probability Manage uncertainty The role of the Specialist Marginalise error Explore Possibility Eliminate uncertainty Marshall Marinker 1995

4. Role of the GP Exclude Cardiac cause Reassurance Counselling Identify AF Manage rate/rhythm Risk of stroke Refer complex arrhythmias Further diagnosis Intervention 12/10/2014Dr Ivan Benett GPwSI for AA meeting

5. “Listen to the patient and they will tell you the diagnosis“ Sir William Osler 1849 - 1919 12/10/2014Dr Ivan Benett GPwSI for AA meeting

6. Primary Assessment Frequency, Duration, Provocation Symptoms during episodes F H heart disease or sudden death? History Pulse rate and rhythm Auscultation Signs of Heart Failure Examination 12 lead ECG Mandatory Bloods – TFTS, FBC, biochemistry Rhythm monitor & Echocardiogram Investigation 12/10/2014Dr Ivan Benett GPwSI for AA meeting

7. Capturing the rhythm DURING symptoms is the key to diagnosis Wrist monitor – self activated 24-hour tape – continuous over short time 12/10/2014 Dr Ivan Benett GPwSI for AA meeting Infrequent palpitations occurring more than every two or three days Available in many practices Accessible from Primary Care Cardiology /Tier 2 service Very frequent palpitations, daily or every other day May find asymptomatic arrhythmias Only available from secondary care at present, incurring first outpatient tariff £200+ follow-up

8. Palpitations Gateway – risk stratification 12/10/2014Dr Ivan Benett and Amanda Schofield8

9. Reassurance starts with Exploring health beliefs Ideas Addressing fears Concerns Establishing what they would like you to do Expectation 12/10/2014Dr Ivan Benett GPwSI for AA meeting

10. Palpitations Conclusion Large numbers of people present with palpitations High cost to the NHS Type of monitoring depends on frequency of symptoms Nearly all can be managed in primary care with reassurance or counselling Only 10% of referrals need secondary/tertiary care 12/10/2014Dr Ivan Benett GPwSI for AA meeting