Consultant physicians working with patients - Royal College of ...

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2 Specialties Cardiovascular medicineCardiovascular medicine and paediatric cardiologywith adult congenital cardiologyDr Jane Flint BSc MD FRCP Consultant cardiologist1 Description of the specialtyWhat is the specialty?Cardiovascular medicine involves the management ofpatients with suspected or confirmed cardiovasculardisease and conditions of the heart, circulation andlinked organs associated with diabetes, renal disease orcerebrovascular disease. Paediatric cardiology is aspecialty that deals with all aspects of care of patientswith congenital heart disease, from before birth toadulthood. More and more patients have grown-upcongenital heart disease (GUCH) and they are followedin GUCH centres and local centres with joint expertise –an example of improved integration of services (seesection 7). Regionally coordinated genetics andpathology services are being developed forinvestigation of people with a family history of suddendeath. There is no room for complacency if we are toprevent further cases of premature cardiac death andimprove quality of life for people with chronic heartdisease.Who are the patients?Most patients arrive at emergency departments as acuteadmissions, presenting with shortness of breath, chestpain or some other cardiac symptom such as transientloss of consciousness. They are stratified according torisk so that those with acute coronary or anotherhigh-risk syndrome (eg arrhythmia) receive appropriatespecialist care on cardiac care units (CCUs), or oncontinuing care or heart failure wards. By mid 2011,94% of patients with ST-elevation myocardial infarction(STEMI) were taken to network-designated centres inEngland for primary percutaneous coronaryintervention (PPCI). 1 Follow-up of many differentcardiac disorders with increasing subspecialty focus,eg cardiomyopathy and valve disease, isappropriate. Congenital heart disease affects 8out of every 1,000 live births, and this represents amajor clinical challenge for detection andmanagement.Main disease patternsThe current emphasis is on early primary prevention,diagnosis and secondary prevention in a largerpopulation of people with coronary heart disease whoare living for longer. The increase in patients withheart failure is being addressed through specialisedsupport in the community, but palliative care forpatients with heart failure and cardiac rehabilitationcompleting all care pathways are priorities inEngland in the cardiovascular disease (CVD)Outcomes Strategy (March 2013). Severe aorticstenosis in frail patients can now be managed bytransarterial valve implantation (TAVI). The field ofpaediatric cardiology has also become increasinglysubspecialised, with new developments in prenataldetection and interventional and electrophysiologicaltreatments, and the outlook for these patients hasbeen greatly improved. Treatments for pulmonaryhypertension, cardiac transplantation, andimplantation of left ventricular assist devices (LVADs)are concentrated within supra-regional centres. Thepattern of endocarditis is ever-changing, and extravigilance is needed since the National Institute forHealth and Care Excellence (NICE) recommendedremoving routine prophylaxis for most susceptiblepatients in 2008.2 Organisation of the service and patternsof referralA typical serviceThe aim is to provide a seamless transition for adult andchild patients from primary to secondary and then totertiary care, as necessary, and back to localrehabilitation within cardiac networks through the useof agreed care pathways. Some advances in serviceprovision pioneered within tertiary care are appropriatefor regular use in secondary care, such as implantationprocedures and follow-up of patients with implantablecardioverter defibrillators (ICDs). A key part of theagenda for cardiac networks is equity of healthcareC○ Royal College of Physicians 2013 47
Consultant physicians working with patientsacross sectors. It is hoped that the outcome forpaediatric cardiology within the review Safe andsustainable children’s congenital heart services 2 willsupport continued access to similarly integratedprimary, secondary and tertiary care for all regions.Supra-regional services should be justifiablyrationalised to preserve quality for patients(and their families) who have to travel somedistance.Primary care is focused on primary prevention andlifestyle counselling, through monitoring andmanagement of hypertension, hyperlipidaemia,diabetes and renal disease. It also involves secondaryprevention of chronic coronary heart disease andmonitoring of heart failure. The main emphasis inpaediatric cardiology should be on the earlydetection and prevention of congenital heart disease.Symptoms must be recognised, and innocent heartmurmurs must be differentiated from pathologicalones.Paediatricians in secondary care offer reassurance topatients with innocent murmurs, and those who have aspecial interest in cardiology are greatly valued.Secondary care can provide almost all acute cardiac careandelectiveoutpatientinvestigationsinadults,withinterventions other than implantation of pacemakersand complex devices being through network agreement(see Table 1).Tertiary care provides surgery for disease of thecoronary arteries, aorta and valves, as well as complexinterventions with on-site surgical cover, paediatricand GUCH centres (see above), interventions withadvanced imaging support, and complex invasiveelectrophysiology. ‘Heart-attack centres’ for patientswho need PPCI tend to be based (but not exclusively)in tertiary care.Sources of referral from primary, secondary andtertiary levelsIn addition to the above, one-stop clinics are indevelopment, following the success of rapid access forpatients with angina. These clinics are for patients withheart failure and arrhythmias, and have protocols forthe management of atrial fibrillation through fromprimary care. Strong secondary care is vital for thesupervision of care pathways and community clinics.Risk assessment in secondary care to determine theneed for catheterisation and onward referral forintervention or surgery is critical for all patients withcardiac conditions. Tertiary care should offer amultidisciplinary approach for assessing the optimumintervention in referred patients. Patients should berepatriated locally for rehabilitation and follow-up afteran intervention at the tertiary level, and this should beensured in care pathways. Special patterns of referral forpatients with congenital heart disease may occur, butthe local secondary care service should maintaindocumentation in these cases. Prenatal detectionservices are not comprehensively available, and babieswho are suspected of having congenital heart disease arereferred from secondary care to outreach clinics,tertiary centre clinics, or as inpatients, depending upontheir clinical condition. Children who need cardiacsurgery are referred by paediatric cardiologists, ratherthan directly to cardiac surgeons by either their GP or alocal paediatrician. A breathless baby with cyanosisshould be referred urgently to a tertiary carespecialist.Locality-based and regional servicesPatient and carer stakeholder discussions within thenetworks have expressed a wish for local districtservices, except where network or regional levels confersome additional benefit, as described above (see alsosection 1). The cardiovascular network strategy and thecoordination of jointly agreed standards for specialisedservices across several networks can determine thelocation of newer strategic services for the patientsdescribed in section 1. This model is ideal forinvolvement of commissioners (see section 10). Thefamilies of children with congenital heart disease arecontent to travel greater distances in order to benefitfrom definitive, specialised surgery in an appropriatelycommitted environment.Community models of careThere are registers in primary care for people at risk ofcardiovascular disease (including smokers, obese anddiabetic patients) and patients with coronary heartdisease or heart failure. This was recommended inEngland by the national service framework (NSF) forcoronary heart disease. 3 Professional communityhealthcare networks are increasing for patients withheart failure and for people in need of palliative care orrehabilitation. Non-invasive cardiac investigations maybe practised, ideally under the supervision of specialists,in line with care pathways linked to local cardiologyservices. Cardiac rehabilitation, particularly during themaintenance phase, may be community based.48 C○ Royal College of Physicians 2013
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