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2 Specialties Cardiovascular medicineTable 2 Guidelines from the National Institute for Health and Care Excellence 2008–2012(http//guidance.nice.org.uk/)Clinical guidelinesProphylaxis against infective endocarditisCardiovascular risk assessment and modification of blood lipidsDiagnosis and initial management of acute stroke and transient ischaemic attack (TIA)Identification and management of familial hypercholesterolaemiaUnstable angina and non-ST segment elevated myocardial infarction (NSTEMI)Chest pain of recent onsetHypertensive disorders during pregnancyChronic heart failureStable anginaHypertensionMarch 2008 (CG64)May 2008 (CG67)July 2008 (CG68)August 2008 (CG71)March 2010 (CG94)March 2010 (CG95)August 2010 (CG107)August 2010 (CG108)July 2011 (CG126)August 2011 (CG127)Interventional procedure guidelinesTranscatheter aortic valve implantation for aortic stenosisThoracoscopic epicardial radiofrequency ablation for atrial fibrillation (AF)Percutaneous epicardial catheter radiofrequency ablation for AFPercutaneous epicardial catheter radiofrequency ablation for ventricular tachycardiaPercutaneous laser revascularisation for refractory angina pectorisPercutaneous mitral valve leaflet repair for mitral regurgitationTranscatheter endovascular closure of perimembranous ventricular septal defectPercutaneous occlusion of left atrial appendage for non-valvular AFPercutaneous closure of patent foramen ovale (PFO) for recurrent migrainePercutaneous closure of PFO for prevention of paradoxical emboliJune 2008 (IPG266)January 2009 (IPG286)March 2009 (IPG294)March 2009 (IPG295)May 2009 (IPG302)August 2009 (IPG309)March 2010 (IPG336)June 2010 (IPG349)December 2010 (IPG370)December 2010 (IPG371)Technology appraisalsDrug-eluting stents for the treatment of coronary artery diseaseDabigatran etexilate for the prevention of venous thromboembolism after hip or knee replacementDabigatran etexilate in AFPrasugrel for treatment of acute coronary syndromes with percutaneous coronary interventionDronedarone for treatment of non-permanent AFClopidogrel and modified-release dipyridamole for prevention of occlusive vascular eventsIvabradine for the treatment of chronic heart failureJuly 2008 (TA152)September 2008 (TA157)March 2012 (TA249)October 2009 (TA182)August 2010 (TA197)December 2010 (TA210)November 2012 (TA267)Public health guidancePrevention of cardiovascular disease at the population levelJune 2010 (PH25)C○ Royal College of Physicians 2013 55
Consultant physicians working with patientsCentre. Our national audits against the above standardshave already provided key evidence on which to basefurther cost-effective service improvements andimprovements in patient outcomes.6 Clinical work of consultantsHow a consultant works in this specialtyConsultant cardiologists increasingly work in teams toprovide a specialised cardiology inpatient servicewithout involvement in acute medicine commitmentsother than the care of patients in the predominantlycardiac portion of the emergency ‘take’ of the cardiaccare unit and the continuing care and heart failurewards. Importantly, they provide a consultation serviceto other specialists (as described in sections 2 and 4).Their patient numbers exceed 500 per annum, and wardor front-door emergency consultations may beunderestimated.Outpatient workMost cardiologists will hold one to two outpatientclinics per week. These will include new patients andfollow-up patients, with numbers as recommended bythe RCP and BCS. They will also hold specialistoutpatient clinics, increasingly on a one-stop basis, fornew patients who present with chest pain,breathlessness or suspected heart failure, murmurs andvalve disease, arrhythmia or syncope. Specialistoutpatient follow-up clinics will also carry out thefollowing activities (see Table 1): follow-up of patients with pacemakers and otherdevices, arrhythmias, valvular disease and cardiacdisease in pregnancy follow-up of patients after myocardial infarction andPCI (an opportunity to integrate with cardiacrehabilitation – see section 7) monitoring heart failure requiring specialist input.Specialist investigative and therapeuticproceduresMost consultant cardiologists will directly undertake,supervise and report laboratory procedures (seeTable 1).Specialist on callProvision of an on-call consultation service requires aminimum of six consultants. Ten are preferred to coverleave. The provision of a cardiac catheterisationlaboratory service around the clock, 7 days a week (as isneeded for PPCI) also requires specialised cardiacnurses, physiologists and radiographers.Other specialist activity and activities beyond thelocal servicesMost cardiologists have developed an area of specialinterest, such as imaging, heart failure, GUCH,electrophysiology or PCI. They are expected to provideevidence of the quality of such work through appraisal,CPD and membership, and by contribution to therelevant affiliated groups of the BCS. Attendance atregional, national and international meetings isexpected. Appropriate engagement in clinical senates tosupport networks is advised.Clinically related administration: timely andappropriate communicationWorking in a multidisciplinary environment andcontributing to local cardiac networks and patientpathways to improve healthcare delivery are all part ofthe clinical duty of a cardiologist. The interdisciplinaryliaisondetailedinsection4isanobligation.Balance of clinics, wards, acute and specialty careMost consultant cardiologists undertake all of theseactivities, and therefore will have an individualisedbalance of these activities in their personal job plans.They will make allowance for on-call duties and theneeds of the particular trust and cardiology service.Some consultants may be designated with responsibilityfor certain interdisciplinary work.Direct work compared with supervisionand teamworkCardiology is fundamentally a team-based specialty.Consultants provide leadership to trainees, physiologistsand extended-role practitioner nurses who may delivercertain aspects of the service, but consultants engagedirectly in many activities themselves.Work in hospitals and the communityCardiac network pathways have developed to span thecommunity, the primary/secondary care interface andsecondary/tertiary inter-hospital transfers, and sharegood practice. Cardiologists need to clinically manageacute pathways, adult and paediatric coronary careunits, cardiac wards, cardiac physiology departments,cardiac catheter laboratories and rehabilitation services.They may be engaged in community clinics to ensuresafe referral practice, with cardiovascular disease stillrepresenting the most common cause of mortality.There are also cardiac networks in place in Wales andNorthern Ireland.56 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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