GPs should deal with heart rhythm problems

Dr Matt Fay is a speaker at the Heart Rhythm Congress which is held this week in Birmingham, England.

When it comes to treating heart rhythm problems, I personally feel that GPs are the population specialists and should deal with the majority of cases, rather than cardiologists. Of course, if people are symptomatic and they need further intervention, or there is a concern about antiocoagulant therapy, then they need to be referred on to a specialist in a hospital setting. But this should not be the default. And cardiologists are not necessarily heart rhythm specialists anyway.

I am a GP who specialises in heart arrthymias in a specialist practice in Atrial Fibrillation in Bradford. We see more complicated cases referred to us from practices throughout the Bradford and Airedale area. Before patients see me, they have already had stroke work done and been assessed for anticoagulation therapy and initiated. I am happy assist my local colleagues in challenging cases such as, I was referred a patient who had AF and short bowel syndrome – he had had ischemic bowel in the past and the GP was wondering how this would affect the choice of anticoagulation.

Despite some examples of best practice in different parts of the country, there are still GPs who will just refer the patient on as soon as they diagnose the condition. I think this is inefficient and not in the best interest of the patient.

All GPs should be able to detect cases of AF. Two thirds of people with AF have no symptoms and their heart rhythm problem is picked up when they come to the GP surgery complaining of another health problem. Taking someone’s pulse can quickly establish if a heart arrthymia is present and this can be confirmed by an ECG. Although AF affects only around two per cent of the population, we tend to see a lot more of older people over the age of 65 in local surgeries, so around one in ten of the patients who
attend have AF.

When a diagnosis has been made, a GP is perfectly positioned to assess the patient for stroke risk, informed by the knowledge of the patient, their health history and co-morbidities. After that, they can help the patient choose their medication – warfarin is often prescribed but there are a new generation of anticoagulants too – and ensure regular follow-ups.

This scenario should be the norm across the country, but there is still a long way to go. There seems to be a reluctance of the part of some GPs to take proative steps to identify AF patients without symptoms even though  they are at higher risk of AF-related stroke. So many people slip through the net. Some good initiatives include taking pulse rates at flu clinics and doctors are now prompted to record pulse and heart rates when seeing patients with a range of chronic diseases.

If GPs can manage the majority of cases, the patients who do need to be seen by specialists will have shorter waiting times and longer appointments. I would much rather that a cardiologist spent 30 minutes with one symptomatic patient rather than 10 minutes each with three patients, when two had no symptoms.

For patients who have already been diagnosed and have been referred to a cardiologist, the Heart Rhythm Checklist is a useful thing to use as a guide before going to see a consultant. This means that they can use their time more usefully in the meeting because they will have already thought about the questions they want to ask. This adds to patient empowerment and makes most effective use of the specialist’s time.