Patient details

Name
Address
Postcode
Tel. no
DOB
NHS no
Hospital no

Referring GP / Consultant / HF matron

Name
Address
Tel. no
Fax no

Patients GP (if not detailed above)

Name
Address
Tel. no
Fax no
Referral Date: PCT area:

ScreenLink Report

ETIOLOGY OF CARDIOMYOPATHY	{{EtiOfCardi}}
NYHA CLASS	{{nyha-class}}
ECHO AVAILABLE	{{echoavailable}}
LVEF % LAST ECHO	{{lveflastecho}}%
PRIOR MI	{{priormi}}
> 40 DAYS	{{grater40days}}
ARRHYTHMIAS HISTORY	{{arrhythmiashistory}}
PRIOR SUDDEN CARDIAC ARREST	{{priorsuddencardiacarrest}}
SYNCOPE	{{syncope}}
SURVIVAL EXPECTATION GREATER THAN 1 YEAR	{{survivalMore1Year}}
LEFT BUNDLE BRANCH BLOCK	{{lbb}}
QRS WIDTH	{{qrswidth}}
OPTIMAL MEDICAL THERAPY	{{optimalmedicaltherapy}}
ATRIAL RHYTHM	{{atrialRhythm}}
SEVERE SYMPTOMS DESPITE OMT > 2 MONTHS	{{severe_symptoms_omt}}
NUMBER OF REHOSPITALIZATIONS FOR HF IN 12 MONTHS ≥ 3	{{number_rehospitalizations}}
DEPENDANCE ON INTRAVENOUS INOTROPIC THERAPY	{{intravenous_inotropic_therapy}}
PROGRESSIVE END-ORGAN DYSFUNCTION (WORSENING RENAL AND/OR HEPATIC FUNCTION) DUE TO REDUCED PERFUSION AND NOT TO INADEQUATE VENTRICULAR FILLING PRESSURE (PCWP ≥ 20 MMHG AND SBP ≤ 80-90 MMHG OR CI ≤ 2 L/MIN/M2)	{{progressive_organ_dysfunction}}
ABSENCE OF SEVERE RIGHT VENTRICULAR DYSFUNCTION TOGETHER WITH SEVERE TRICUSPID REGURGITATION	{{severe_right_ventricular_dysfunction}}
UPGRADE FROM CONVENTIONAL IPG OR ICD WITH HIGH PERCENTAGE OF VENTRICULAR PACING	{{upgrade}}
INDICATION FOR CONVENTIONAL PACING WITH HIGH DEGREE AV BLOCK	{{conventionalPacing}}

Guidelines results

{{guidelines}}

SOURCE OF REFERRAL

BRIEF PRESENTING HISTORY:

(SOBAR, SOBOE, orthopnea, PND etc)

SELF ASSESSED NYHA SCORE: ❏ I ❏ II ❏ III ❏ IV

CLINICAL FINDINGS:

(Peripheral /pulmonary oedema, murmur etc)
BP:
................................................................................

MEDICATION:

• NYHA I

  No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation or dyspnea

• NYHA II

  Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation or dyspnea

• NYHA III

  Marked limitation of physical activity. Comfortable at rest but less than ordinary activity results in fatigue, palpitation or dyspnea

• NYHA IV

  Unable to carry on any physical activity without discomfort. Symptoms at rest. If any physical activity is undertaken, discomfort is increased

SYMPTOMS DURING ATRIAL FIBRILLATION



• EHRA I

  ‘No symptoms’

• EHRA II

  ‘Mild symptoms’; normal daily activity not affected

• EHRA III

  ‘Severe symptoms’; normal daily activity affected

• EHRA IV

  ‘Disabling symptoms’; normal daily activity discontinued

Source: 2010 ESC Guidelines for the management of atrial Fibrillation (European Heart Journal doi:10.1093/eurheartj/ehq278)

• First diagnosed episode of atrial fibrillation

• Paroxysmal
  (usually ≤ 48h)

• Persistent
  (>7 daysor requires CV)

• Long-standing Persistent
  (>1 year)

• Permanent
  (accepted)

Different types of AF. AF = atrial fibrillation; CV =cardioversion.
The arrhythmia tends to progress from paroxysmal (self-terminating, usually <48h) to persistent [non-self-terminating or requiring cardioversion (CV)], long-standing persistent (lasting longer than 1 year) and eventually to permanent (accepted) AF.
First-onset AF may be the first of recurrent attacks or already be deemed permanent.
Source:2010 ESC Guidelines for the management of atrial Fibrillation (European Heart Journal doi:10.1093/eurheartj/ehq278)