24 hour tapes and

Echocardiograms for

primary care

Dr Andrew Wragg

Cardiologist

Barts Health NHS

Trust

Requesting and Interpretation of 24 hour tapes and Echocardiograms in primary care

• How and whom to refer

• How to interpret the reports– 24 hour tapes

– Echocardiograms

• Avoiding over or misinterpretation

• Deciphering jargon

• Cases

• NOT COVERING OBVIOUS PATHALOGY

How to refer

email to BHNT.CardiacTests@nhs.net

fax to 0203-594-3209

• Cardiac diagnostics

• Cardiac Dept

• 2nd Floor, North Tower, Royal London Hospital.

• Patients will be phoned to receive an appointment within 2 weeks

24 hour tapes

• Generally low yield diagnostic test

• Can be reassuring

• Normal tape does not RULE out serious rhythm disturbance

• Patient diary very helpful

• Always ask if 24 hour tape really necessary

Indications

• Palpitations

• Syncope

• Always consider background of a patient

• High risk features: known cardiac disease/ risk factors

Generally benign findings on tapes

• Sinus arrhythmia

• Sinus bradycardia or tachycardia

• Ectopics (VEs or SVEs)

• Nocturnal conduction disturbances

• Very short arrhythmias (e.g few beats of SVT or AF)

Echocardiography

• Main indications for echo

– Assess LV structure and function

– Assess valve structure and function

– Estimate pulmonary artery pressures

• TH referral form

– ? Heart failure/ Breathlessness/ other

• Other (cardiac masses/ pericardial disease etc)

Echo jargon and abbreviations

• LV• RV• AV• MV• TV• PV• PASP• IVC• IAS• RWMAs

Echo jargon and abbreviations

• LV left ventricle• RV right ventricle• AV aortic• MV mitral• TV tricuspid• PV pulmonary• PASP pulmonary artery systolic pressure• IVC inferior venae cavae• IAS inter atrial septum• RWMAs regional wall motion abnormalities

LV systolic function

• Normal LV < 56 mm at the end of diastole

• Normal LV systolic function: EF > 55%

• However LV EF may not measured

• Report may be qualitative

• MILD/ MODERATE/ SEVERE LV impairment

Murmurs and valve disease

Indication for echo:

• Murmur + cardiac or respiratory symptoms

• Murmur in an asymptomatic individual if structural heart disease suspected

– history

– clinical features

– other investigation (ECG)

Echocardiography and valve disease

• Mild or trace regurgitation requires NO action

• If valve anatomy abnormal but functional lesion mild, consider referral

• Sometimes echo underestimates valve severity: bad symptoms or clear signs refer on

• In most settings valve disease is a chronic process

Echo detail and the breathless patient

• Diastolic dysfunction

• Regional wall motion abnormalities (RWMA)

• Pulmonary artery pressures (PAP or PASP)

• Pericardial effusions

Diastolic dysfunction

• Often mentioned on echo reports (elderly/ hypertensive/ DM/ CKD patients)

• Questionable significance if pt well

• No prognostic therapies

• Symptom based approach based on diuretics

• Therefore only relevant in breathless patient

Regional wall motion abnormalities

• Often mentioned on echo reports

• Questionable significance

• May be due to a previous cardiac event

• If patient well & no symptoms & LV normal size and function then unlikely to be important

Pulmonary artery pressures

• Raised PASP usually secondary:

– Lung disease

– Left sided heart disease

– OSA

• Normal PAP <30 mmHg

• Report might not say pulmonary hypertension but only comment on PASP

Pulmonary artery pressures

• How do we calculate PASP?

• Calculated by measuring the velocity of the TR jet

• Fast TR jet: high PASP

• If normal PASP there is likely to be no TR

• Therefore impossible to measure PASP

• No TR on echo = normal PASP

Pericardial effusions

• May be mentioned on reports

• Pericardial effusion up to 1cm likely to be physiological

• For larger effusions:

– If no echo mention haemodynamic compromise

– No symptoms

No need for urgent action

The breathless patient

• Age

• Fitness

• Lung disease

• Obesity

• Heart failure

What to do if report confusing or management uncertain?

• Ring the department if technical question:

0203-594-2000

• Email the cardiology email advice line:

BHNT.Advice-Cardiology-Barts@nhs.net

74 breathless obese patient

• Tachycardia• Mild-moderately impaired systolic function• Dilated impaired RV• Trace of AR and mild MR and PR• Moderate to severe TR with PASP 75 mmHg + RAP• Lots going on: refer

65 yo breathless female

• LV not dilated and good systolic function

• Trace MR and TR and trace PI

• Small effusion (no compromise)

• Normal Study

26 yo female

62 yo female

59 yo male

What to do if report confusing or management uncertain?

• Ring the department if technical question:

0203-594-2000

• Email the cardiology email advice line:

BHNT.Advice-Cardiology-Barts@nhs.net