Innovative primary care lead community palpitation management and investigation pathway

Abstract

Abstract Funding Acknowledgements Type of funding sources: None. Background Palpitations are a common reason for General Practitioner (GP) appointment in primary care and a frequent reason for cardiology referral. In the region where this project was performed, this translated to approximately 24,000 primary care and out of hours consultations in 2021 alone. Purpose The purpose of this pilot was to evaluate a pathway for palpitations diagnosis and management in primary care. The proposed pathway was designed to avoid unnecessary referrals to secondary care, to shorten the waiting time to diagnosis for patients and to cut down visits to A&E and out of hours service in primary care. Method The pathway, which was piloted at a federation for 30,000 patients, was based on a community cardiology approach, where a GP with Special interest in cardiology could offer the service for the wider community. The pathway began with an initial clinical evaluation comprising medical history, physical examination, and a standard 12-lead ECG. After ruling out of any red flags and otherwise deemed appropriate to continue to be assessed with the proposed diagnostic method, the patients were provided with a handheld ECG device for intermittent 30 seconds ECG registration at home. During a four-week investigation period the patients would record their ECG when experiencing symptoms. The primary care team remotely monitored the traces which were received on a cloud-based system with AI capabilities, and if pathology was recorded, patient was contacted and informed of management plan. If after four weeks no pathology was found, patients received a discharge consultation for reassurance and final report was generated. Results During the 24-month pilot we screened the total of 191 patients. Out of the patients screened 24 (13%) were diagnosed with atrial fibrillation, 92 (48%) were diagnosed with benign ectopics as the cause of their palpitations. Two rare occurrences of a life threatening broad complex tachycardias were also detected, both of which ended up needing defib implantation. Table 1. further presents the results by diagnosis for rest of the patients. Conclusions The results from the pilot indicated a reduction in GP / out of hours consultations by 50% and over 90% reduction in referral to secondary care for Holter monitoring by implementing an easy-to-use handheld ECG as part of the community led palpitation pathway. The results further implied that a district-wide implementation could lead to at least 120 new AF diagnosis in our project district per year, having a knock-on benefit of stroke reduction and cost economic impact in the society by reducing anxiety, lost employment hours and increasing productivity. Another key outcome seen is the reassurance value of conducting symptomatic palpitation monitoring to reassure patients, majority of whom had either normal sinus rhythm or benign ventricular ectopics and had failed to be satisfied with conventional Holter monitoring in the past.