1. Community Cardiology Service North Wales 2017
A quiet evolution
“talking about a revolution”

3. Community Cardiology Team
Academic Nurse Consultant (0.5)
Administrators (3)
Cardiac physiologists (1.6)
Cardiologists (0.3)
GPwSI (0.1)
HF nurses (13)
Pharmacists (1.5)
Chest pain (4) and AF (4) nurses
Anticoagulation pharmacists (3)
Cardiac Rehab (3 teams)

5. Process NTproBNP + ECG event monitor triaged GP and ANP referrals
One stop diagnostic echo clinics within 20 minutes travel time of 95% of the population
Cardiac Imaging Specialist history, clinical examination, echo
GPwSI or Consultant confirm diagnosis and form management plan for patient and GP
LVSD heart failure to HFN led teams to cardiac rehab
Further assessment via chest pain and arrhythmia pathways (stress echo)

6. Patient
Stable Chest pain
CP Nurse Triage pre post test probability for CAD
Diagnostic test
None
CaCT
Angiography Functional incl Stress echocardiogram
Primary Care assessment and optimisation / cardiac rehab
Fatigue
Breathlessness
Oedema
Suspected / confirmed Heart Failure
NTproBNP
and ECG in primary care.
Clinician
Diagnostic Echocardiogram
Management plan
Heart Failure Nurse
for optimisation and Cardiac Rehabilitation
Palpitations
Targeted case finding
Pulse check
ECG +/- ECG monitor
Anticoagulation
Arrhythmia Nurse / Pharmacist
Confirmation of diagnosis
and management of symptoms. Optimal anticoagulation and Cardiac Rehabilitation.
Sub optimal Hypertension control
24 hour ABPM
Practice based pharmacist
Targeted case finding in community and primary care including software searches
Smoking cessation mobile promotions
Pulse checks of symptomatic chronic disease patients >75yrs
Echo post MI
Community venue BP checks and LDL levels
Lost to follow up Adult Congenital Heart Disease (ACHD) searches

9. BNP: a test for heart failure?
32 AA polypeptide; released as a 76 AA precursor (proBNP)
Released in response to myocardial stretch
Causes salt and water loss
BUT
Conditions other than HF can raise BNP:
LV wall stress: HT, valve disease
LA performance: AF
RVEDP: COPD, PE, PAH
Treated/compensated HF: normal BNP
Issues with BNP assays
The “normal” range
age, gender, obesity, renal function
JACC 2004;44:740
LVEDP = hallmark of LV dysfunction
BNP release: mirrors LVEDP 9

11. 80 GP referrals Sept ‘16 monthly capacity 120 (1,000+ p.a.)

12. 70% of patients managed actively

13. Population HF prevalences

14. In order of echo access!

16. Echo and HF diagnostic service in GP

17. Monthly referrals to HF teams 2:1 out patient to in patient

18. HF teams 1,000 active patients

20. HF hospital admissions Ynys Môn 2008-2016 slow steady investment

21. BCU East 2008-2016 HF admissions, no new investment

22. BCU Central 2008-11 HF admissions no new investment

23. BCU Central 2011-2016 priority investment

24. Ysbyty Glan Clwyd Heart Failure Admissions 2007-14↑
LLGH clinic ↑
C&D project
2013 ↑
DI clinic
2014 ↑
RAH clinic

25. The New Frontiers – integrated cardiology and rehab
Specialist Cardiology + rehab teams - not micro niche ghettos
Chest Pain
Shorter stays (may be hours not weeks in CP and AF)
Exertional chest pain diagnostics more complex (potentially) but exercise stress echo dovetails
Atrial fibrillation
Paroxysmal / persistent AF diagnosis and significance
NOAC LES / DES anticoagulation where TTR <65%

26. Lowest Effective Intensity for Warfarin Therapy for Stroke Prevention INR 2-3
The relationship between the risk of stroke anti INR in patients with atrial fibrillation treated with warfarin is shown on this slide. The risk of stroke increases dramatically when the INR falls below 2.0, although there appears to be some protection when the INR is above 1.5.
Hylek EM, et al. NEJM 1996;335:

27. Waiting Room BP Assessment Corwen Family Practice

29. An apical 4 chamber image of the heart taken with the portable scanner
Community Heart Scan Service A Pioneering Project in North Wales Viki Jenkins, Heart Failure Nurse specialist
Pushing the Boundaries of Practice
The pioneering mobile heart scanning clinic is pushing the boundaries of nursing practice as well as cutting waiting times for patients in rural parts of North Wales.
Viki Jenkins is an advanced nurse practitioner and is currently training in echocardiography, which would create a potentially unique “bridging” role where she can oversee the entire patient journey from initial investigation through to treatment.
The clinic, the first of its kind in the UK, was set up 8 years ago by Dr Graham Thomas, a GP with Special Interest in Cardiology and Echocardiography. The clinics are run by Betsi Cadwaladr University Health Board, and staffed by senior cardiac physiologists with clinical examination skills and uses state of the art portable machinery.
The One-stop diagnostic echo clinics are delivered in community hospitals, GP surgeries and sometimes the homes of housebound patients, meaning people in rural areas of North Wales are given access to assessment and diagnosis close to home, rather than having to travel to the district general hospitals.
Viki Jenkins, Advanced Nurse Practitioner, scans 79-year-old Molly Evans from Dolgellau whilst Liana Shirley, Cardiac Imaging Specialist, provides training and guidance.
Conclusion
Expected Benefits include:
Increased service resilience and improved access to the current one-stop clinics.
Earlier diagnosis and optimisation of clinical management will be facilitated by more frequent local clinic provision.
Improved clinical outcomes for patients with a variety of conditions currently neglected including angina, heart failure with normal ejection fraction, hypertension and atrial fibrillation.
The patient experience of living with cardiac long term conditions will become more tolerable.
Cost savings in terms of reduced admissions and length of hospital stay.
Key Words:
Prudent Healthcare
Pushing boundaries of nursing practice
Reducing hospital admissions
Reducing waiting times
The community heart scan clinic is once again pushing the boundaries through Viki Jenkins becoming the first advanced nurse practitioner to train in echocardiography. Viki will become British Society of Echocardiography accredited as a measure of gold standard of practice.
This will result in Viki being the first nurse in the UK, and possibly worldwide, to develop this academically accredited scope and role. Viki will receive direct referrals and determine appropriate investigations, undertake the heart scan, diagnose and commence treatment in one appointment close to the patient’s home. This streamlined locality based service ensures that appropriate treatments are started sooner. Prompt diagnosis and treatment of suspected Heart Failure reduces unnecessary hospital admissions, clinical decompensations and delays in investigations.
Patients can be referred by GPs, Consultants and Community Advanced Nurse Practitioners with around a 2-4 week wait (a reduction of up to 50%), from receipt of referral to diagnosis. We will interpret the scans and can give results there and then, as well as initiate the next course of action, where necessary.
This innovation is perfectly aligned with Dr Chris Jones’s “Setting the Direction” paper and the Prudent Healthcare Principles set out by the Bevan Commission in 2013, which describes the need to “shift the balance of care to be provided by the most appropriate person in the least intensive setting”.  
Figure 1: Your caption to go here
An apical 4 chamber image of the heart taken with the portable scanner

30. Pre test risk of CAD

31. NICE Chest Pain clinic 10-29% offer CT calcium scoring
If CTCS >0-400 proceed to CTCA
If >400 proceed to angiography
30-60% functional imaging
Stress echo, MPI, stress MRI
61-90% angiography (or CTCA and ETT)
Stress echo / MPI for prognostication

32. What?! Done to detect functionally-significant coronary artery disease
Inducible wall motion abnormalities
Viability
Ischaemic cascade: a reminder
Change in perfusion leads to metabolic change
Subsequent diastolic then systolic dysfunction
Finally to ECG changes and patient symptoms