A cardiac sonographer led follow up clinic for heart valve disease

doi:10.1016/j.ijcard.2007.11.076

International Journal of Cardiology

Volume 132, Issue 2, 20 February 2009, Pages 240-243

https://doi.org/10.1016/j.ijcard.2007.11.076 Get rights and content

Abstract

Introduction

This study describes the effect of introducing a cardiac sonographer led follow up clinic for patients with stable heart valve disease. The 2 years before and after the instigation of the valve clinic were audited.

Materials and methods

The clinic was conducted in a single centre and undertaken in the cardiology department of a district general hospital. 382 patients, with 397 clinically significant valve lesions, but for whom surgery was not yet indicated but follow up required, were seen in a cardiac sonographer run clinics. These patients no longer attended a medical follow up clinic unless there was clinical or echocardiographic deterioration. Effectiveness was judged by the percentage treated according to current best practice guidelines, the number of echocardiograms performed and the number of hospital out patient visits attended. In addition mortality data for the subjects in the clinic was collected.

Results

The proportion followed up according to best practice guidelines rose from 157 (41%) to 354 (92%) (p < 0.01). The total number of echocardiograms performed fell from 807 to 550. Total number of out patient visits fell from 998 to 31. 11 patients died in the two year study period, none from progressive valve disease.

Discussion

This study demonstrates that a protocol driven sonographer led heart valve disease follow up clinic, significantly improved the quality of follow up while bringing about a major reduction in out patients visits, without compromising patient safety.

Introduction

The burden of heart valve disease has been generally underestimated. The fall in rheumatic heart disease has been mirrored by a rise in degenerative valve disease associated with the aging population in the western world. The most recent estimate puts the prevalence of moderate to severe valvular heart disease as 0.7% in the under forty four age group rising to over 13% in the amongst over seventy five year olds.[1] The adverse prognostic implication of valve disease has highlighted the need for appropriate detection and follow up strategies. Despite clear guidelines [2], [3], [4], this is often poorly standardised. In order to address this perceived unmet need, a novel cardiac sonographer led service was established for patients requiring follow up solely for their valve condition. This paper presents the results of an audit designed to assess the impact of this initiative on the management of patients with heart valve disease.

Section snippets

Materials and methods

The sonographer led heart valve clinic was established in 2002 to meet a perceived unmet need in the follow up of patients with valvular heart.

Results

In the first 2 years 382 patients were admitted to the valve follow up clinic. Of these 197 (51%) were male and the median age was 51 years (17–94). Table 1 outlines the breakdown of valve lesions within the clinic. There were 382 native valve disease and 162 (42%) on whom some form of valve intervention had been undertaken of which 147 (38%) were prosthetic heart valves. The mean age of the population was 68 (full rang 21–84). 22% was female. All patients were judged to be stable at entrance

Discussion

The detection and follow up of heart valve disease is one of the unrecognised epidemics in cardiology. Current evidence points to a significant increase in degenerative valve disease with age. Recent data from Nkomo et al. [1] highlights that important left sided heart valve lesions are seen in a significant percentage of two otherwise unselected general populations. Worryingly, comparing a clinical population with a cohort study surveillance population, a significantly higher pick up rate of

Conclusion

This study has highlighted both that the traditional follow up of heart valve disease is poorly standardised and that devolving this responsibility to sonographers working under protocol can significantly improve safety and efficiency. This is a highly cost effective strategy as patients were already undergoing echocardiography so the only expenditure relates to a small administrative cost. This model of care may go someway to providing appropriate follow up for the increasing population of

References (6)

V. Nkomo et al.
Burden of valvular heart disease: a population based study
Lancet
(2006)
Guidelines for the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology
Eur Heart J
(2007)
Guidelines on prevention, diagnosis and treatment of infective endocarditis executive summary: The Task Force on Infective Endocarditis of the European Society of Cardiology
Eur Heart J
(2004)

There are more references available in the full text version of this article.

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Specialist valve clinics make watchful waiting safe in severe mitral regurgitation25 but also deliver better care in severe AS, with symptoms detected earlier and when less severe in a valve clinic compared with those referred from general clinics.26 The cost of specialist valve clinics is lower than for conventional clinics, predominantly because of a reduction in unnecessary echocardiograms.13 In devolved clinics there are also cost savings because salaries for nurses or scientists are less than for physicians.27
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A retrospective cross-sectional analysis was performed of 3,781 consecutive outpatients referred for transthoracic echocardiography (TTE) from July to December 2008. Data from the electronic medical records were extracted to see if patients with at least moderate left-sided valvular stenosis or regurgitation underwent subsequent echocardiographic studies within 60 days of the period recommended by the 2006 American College of Cardiology and American Heart Association valve guidelines document.
Of 342 outpatients with at least moderate valve dysfunction, 38 (11%) were excluded for reasons that precluded the need for a follow-up study (e.g. death, surgery). Of the remaining 304 patients, only 179 (59%) underwent follow-up echocardiography within the recommended period. Rates of timely follow-up TTE were higher when ordering physicians were cardiologists or cardiovascular surgeons (65%) compared with primary care physicians or internal medicine specialists (45%) (P < .01). Follow-up rates were significantly different for aortic stenosis (77%), mitral stenosis (67%), aortic regurgitation (49%), and mitral regurgitation (49%) (P < .01). Patients receiving timely follow-up TTE were younger (66 ± 15 vs 71 ± 15 years, P = .002) and more likely to be male (odds ratio, 1.79; 95% CI, 1.12–2.85; P = .01).
To the authors’ knowledge, this is the first study demonstrating low rates of compliance with guideline-recommended monitoring TTE in patients with at least moderate valve dysfunction. Cardiac practitioners have significantly better compliance. Strategies are needed to improve timely follow-up care in this population.
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A cardiac sonographer led follow up clinic for heart valve disease

Abstract

Introduction

Materials and methods

Results

Discussion

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusion

Burden of valvular heart disease: a population based study

Lancet

Guidelines for the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology

Eur Heart J

Guidelines on prevention, diagnosis and treatment of infective endocarditis executive summary: The Task Force on Infective Endocarditis of the European Society of Cardiology

Eur Heart J