Croydon Health Service
NHS Trust
Private and Confidential
16-APR-2015
Clinic Date: 16 APR 2015
MRN: XXXXXXXXXXXX
Integrated Heart Failure Specialist Nurses
12 – 18 Lennard Road
Croydon CR9 2RS
Tel: 020 8274 6416
Fax: 020 8274 6174
Dr XX
20 SATURN ROAD
NORBURY
LONDON
SWXX XXX
Dear Dr XX,
RE:
A PATIENT - DOB XX-DEC-1935 (79 Years) NHS No.XXX XXX XXXX
390 JUPITER AVE. LONDON SWXX XXX TELEPHONE: XXXXXXXXX
Transfer of NYHA 1-2 Heart Failure Patients to Primary Care
Personalised Management Plan
It is the intention of the Croydon CCG Cardiology Implementation Group to transfer the longterm care of patients with Chronic Heart Failure and left ventricular systolic dysfunction with
minor or no symptoms (NYHA functional classes 1 and 2) wholly to primary care.
Prior to transfer, patients will undergo detailed clinical review by the Croydon Health
Services Cardiology and Integrated Heart Failure Nurse Specialist team. This management
plan is intended to provide guidance on managing these patients, and establish lines of
communication with the Croydon Health Services team for help when required (see attached
document).
Diagnosis: Heart failure due to poor left ventricular systolic function due to a combination of
anteroseptal myocardial infarction and hypertensive heart disease.
Heart Failure Code 585F (echocardiogram shows left ventricular systolic dysfunction).
Past Medical History/Co-morbidities: Hypertension, Type 2 diabetes. Ischaemic heart
disease with old antero-septal myocardial infarction and a further presentation in 2009 in
which she underwent primary PCI to the obtuse marginal circumflex with a bare metal stent.
At angiography she was found to have an ostially occluded anterior descending and
moderate ostial stenosis of the right coronary. Asthma.
Echocardiogram (St George's Hospital 20 July 2014): Moderately dilated left ventricle
with septal hypertrophy but otherwise normal wall thickness and severe systolic dysfunction
(Simpson's bi plane ejection fraction 26%). Moderately dilated right ventricle with preserved
systolic function. Moderate bi atrial dilatation. No significant valvular heart disease.
Moderate pulmonary hypertension (estimated RV systolic pressure 45-50mm Hg). No
pericardial disease.
Other Investigations: Cardiac MRI was performed at St George's Hospital on 24 October
2014. This showed a dilated left ventricle with mild concentric hypertrophy and basal septal
bulge. Severe systolic LV dysfunction (ejection fraction 35% by MRI). Dysynchronous left
ventricular contractility consistent with broad left bundle branch block. Late gadolinium
enhancement of the anteroseptal wall consistent with prior infarction. No inducible perfusion
defect noted on adenosine stress testing. The extent of ischaemic scar was not sufficient to
explain the severity of her LV dysfunction suggesting a combination of both ischaemic heart
disease and hypertension as the aetiologies of her heart failure. Bloods 10.2.15: Hb 119g/L,
platelets 223, sodium 141, potassium 4.1, urea 6.4, creatinine 67 (eGFR >60ml/min),
albumin 39. Other liver function tests normal. TSH (5.9.14) 1.98 (normal).
ECG December 2014, St George's Hospital: Sinus rhythm with broad left bundle branch
block (QRSD 140ms) and first degree heart block (PR interval 210ms). Ventricular rate 56
bpm.
Current Medication: Bisoprolol 5mg od (please reduce this to 2.5mg od), Ramipril 5mg bd,
Eplerenone 25mg od, Furosemide 40mg od, ISMN MR 60mg od, Aspirin 75mg od,
Atorvastatin 40mg od, Metformin 500mg tds, Chlorpromazine, Orphenadrine, Lansoprazole
and Senna.
Medication Stopped/Intolerance: Penicillin.
Recent Symptoms: This is difficult to determine as she undertakes relatively low levels of
physical activity but certainly she is no worse than NYHA Functional Class 2. She is a little
fatigued and does report wheezing at times which is relieved by her inhalers. I note two
presentations in the last few months to CUH A&E Department with exacerbations of asthma.
She denies angina pectoris, dizziness, syncope or palpitations. Heart rate 63 regular,
oxygen saturations 95% on room air, blood pressure 140/70 lying and standing. Weight 63.8
kilos. No peripheral oedema. Chest clear to auscultation.
Action for GP
 Please code patient as HF Code 585F (echocardiogram shows left ventricular
systolic dysfunction).

Necessary (prognostic) medication: She should continue on Ramipril 5mg bd and
Eplerenone 25mg od lifelong if tolerated for prognostic benefit. I am concerned her
cardioselective beta blocker is exacerbating her asthma a little so I would
recommend halving the dose of Bisoprolol to 2.5mg od but not stopping it altogether
(again because it delivers prognostic benefit). Blood pressure requires slightly better
control and I would recommend initiating Hydralazine 25mg bd in the first instance to
achieve this. There is good evidence of its effectiveness also in heart failure
patients. If following beta blocker dose reduction her resting heart rate rises to above
70 she will need to start Ivabradine initially at 2.5mg bd aiming for at least 5mg bd
and titrated against the heart rate (i.e. to keep it in the 60s). Please consider giving
Mrs Ali a separate dosette box containing as required rescue Furosemide in case of
deterioration.

Further investigation treatment: She currently fits NICE criteria for recommending a
biventricular defibrillator implant so I will ask her to be reviewed by our Pacing
Devices Consultant Dr Kamdar shortly to go through this with her.

Monitoring: Recording of body weight, full blood count, renal biochemistry and clinical
review in primary care at least 6-monthly.

If you have any concerns please contact the GP Cardiology Advice Line on 020
8401 3000 ext. 4487

Please refer to the Croydon Prescribing Guidelines:
www.nhscroydonintranet.croydonpct.nhs.uk/TeamsAndDepartments/primarycarecom
missioning/prescribing/Pages/Documents.aspx
Action for CHS Cardiology
 She has probably Class 2 symptoms with heart failure due to poor LV systolic
function and broad left bundle branch block and therefore qualifies for a biventricular
defibrillator (ICD component for primary prevention). I will ask my colleague Dr
Kamdar to see her in his Outpatient Clinic to discuss this with her.
Action for Patient
 We would recommend that you try to improve your levels of physical activity you
undertake on a daily basis to keep your heart as fit as possible.
 It is recommended that you reduced the amount of salt you eat and avoid adding
extra salt to your food.
 Please adhere to a 1.5 litre fluid restriction in 24 hours.
 Please weigh yourself on a weekly basis and record your weight. If you notice a
weight gain of 1.5 kg (2-3 Ibs) in one day make sure you weigh yourself the following
day. If your weight continues to rise please contact your GP. A sudden weight gain
can indicate fluid retention.
 Please make a non-urgent appointment within the next 3 weeks to arrange to
see your GP to discuss this letter
Kind regards and best wishes
Yours sincerely
Dr Sanjay Kumar
Lead Consultant Cardiologist
Lilly Mandarano
Integrated Heart Failure Nurse
CC:
Ms A. PATIENT
390 JUPITER AVE.
LONDON
SWXX XXX
Dr Ravi Kamdar
Consultant Cardiologist
CUH