Direct Access Echocardiography Request Form
PATIENT DETAILS:
Title
Surname
Forename(s)
DOB/Age
Male/Female
NHS No
Address
Postcode
Telephone Preferred
Telephone Home
Telephone Mobile
GP DETAILS:
Referring GP
Usual GP
Practice Code
Telephone
Generic email Address
Practice Name
Practice Address
Practice Postcode
Translator Required
Specify Language
Indication for Echocardiograph (Please select)
1. Suspected Heart Failure due to LVSD – ensure patient has had a 12-lead ECG in last 6months
Symptoms (e.g. breathlessness) and previous proven MI or male patient with ankle oedema
Refer directly for echocardiogram NT-proBNP not required
All other symptomatic patients first check NT-proBNP result
2. New murmur
3. New on-set Atrial Fibrillation (in line with NICE recommendations)
In past 12 months has patient had:
Chest X-Ray
ECG
Ace-inhibitor or sartan
Beta-blocker
Diuretic
If the BNP is < 400 heart failure is very unlikely except in patients < 75 please see table below. Patients
with BNP in the normal range will not be offered echo.
Normal values (95% confidence interval) - MEN
Age
18-44
45-54
NTproBNP pg/ml
62.9
83.9
55-64
161
65-74
241
>75
486
Normal values (95% confidence interval ) - WOMEN
Age
18-44
45-54
55-64
NTproBNP pg/ml
116
169
247
65-74
285
>75
738
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REQUESTING ECHOCARDIOGRAMS, CHANGES TO THE SERVICE
HOW TO REQUEST AN ECHO
As a result of confusion as to how and when to order an echocardiogram, a new request form has been
designed. This should replace all previous forms and should be used for all providers. Requests not on this
form will be RETURNED TO THE REFERER
All echocardiogram requests must be accompanied by a recent ECG
All requests for investigation of breathlessness/? Heart failure must be accompanied by BNP level
unless PMH of MI or ankle oedema in a male patient
WHEN TO REQUEST AN ECHO
Although echocardiography can provide useful information in many cardiac conditions, it is not possible to
fund unqualified access. Unaffordable numbers of echos are being requested and a significant minority of
requests are clinically inappropriate (OR GENERATED BY HOSPITAL CLINICIANS WHO SHOULD BE
ORGANISING THESE TESTS THEMSELVES TO BE DONE IN PHT)
The list of indications for echocardiography has therefore been narrowed. If you feel that your patient
requires an echo outside of the criteria on the form please send a brief written request which will be triaged
and possibly sent for echocardiography if appropriate. Echocardiography is not usually indicated in the
investigation of IHD, palpitations or syncope in the primary care setting.
Rosie Heath, GPWSi NEW Devon CCG
Gary Lenden, Western Locality Planned Care Lead of NEW Devon CCG / Projects Lead DRSS
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