The role of community pharmacies for better detection of HVD in England

photo credits: Hush Naidoo Jade Photography

The Farnborough Community Pharmacy Digital Stethoscope Pilot

Cardiovascular disease is a significant ailment. It is responsible for 25% of all annual mortality. A significant proportion of this cardiovascular mortality is caused by Heart Valve Disease(HVD). 1.5 million patients in the UK, over the age of 65, and have HVD. Because HVD is largely a disease of the elderly, and because our elderly population is increasing, HVD is predicted to increase to 2.7 million by 2040.

We know that if heart valve disease is left untreated, mortality is high. If left untreated, 50% of patients with severe aortic stenosis have a 2-year mortality. The five-year survival of untreated severe aortic stenosis is 3% – less than most metastatic cancers. However, we also know that if heart valve disease is detected early, optimum management can be employed (medical and surgical intervention) to prevent decompensation of the heart.

However, the significant issue is that the true prevalence of heart valve disease is unknown, because of the high number of patients with heart valve disease who are as yet undiagnosed.

This is known as the HVD GAP.

Percentage of significant HVD Undiagnosed each year:

– 46% – Severe Aortic Stenosis

– 41% – Moderate to severe Mitral Valve Regurgitation.

– 81% – Moderate to severe Tricuspid Regurgitation.

Therefore, if these patients are not diagnosed before they decompensate, then the likelihood of them dying or becoming severely disabled increases significantly. This, therefore, has a significant impact on both the patient’s life and well-being, as well as the Nation’s Wealth due to increased admissions to hospitals, casualty attendances, cost of caring for the patient at home,etc.

WHY IS THE GAP PRESENT

This gap is present for a number of reasons. To begin with, HVD is the poor cousin to Ischaemic Heart Disease (IHD) and as a result, there is a lack of awareness both with GPs and with patients. When a patient presents with sometimes vague symptoms of HVD (« I don’t feel well », « I feel lightheaded », « I get a little breathless » etc), the heart is often not listened to and therefore « The Murmur » (the hallmark of HVD) is often missed. Also, as GPs are not particularly skilled in cardiac auscultation, murmurs can be missed or misinterpreted, and early valve disease can go unnoticed.

Moreover, in the UK because of COVID-19 and the reduced number of GPs, the number of face-to-face consultations has been significantly reduced, directly affecting the number of patients having their hearts listened to.

Another issue in diagnosing the elderly is that the symptoms are often attributed to ageing or blamed on other comorbidities, e.g. COPD, bronchiectasis, pulmonary fibrosis etc. With reduced mobility, e.g. arthritis, patients are often exercising to a much lower degree, which results in HVD symptoms presenting much later down the line.

There is a reduction in Echo facilities in England, due to a reduction in sonographers and the administrative closure of GPwSI Echo clinics. This has led to a significant increase in waiting times for diagnostic Echo and even longer waiting times before a patient is treated.

This gap, therefore, leads to late presentation of HVD and to a decompensated heart, increase in morbidity and mortality and in hospitalisation and cost for the NHS. ​​​​

SOLUTION

These significant problems led us to formulate a long-term plan, which would allow us to increase the early detection of HVD in the community, meaning that optimum management could be deployed before cardiac decompensation.

How this could be done:

1. Increased awareness of HVD through promotion to GPs, to patients and to media.
2. Strong recommendations to community medics to check for heart murmurs.
3. Providing greater access to Echo in the community, the value of GPwSI in cardiology & Echo should not be overlooked.
4. Wider use of ancillary staff (Health care assistants, Practice Nurses and Community Pharmacists) with the aid of technology, to increase auscultation and HVD detection in the community.

THE USE OF COMMUNITY PHARMACY

We know that « Community Pharmacists » have already been involved with ancillary projects – hypertension detection, and AF detection. We also know, particularly during Covid, that patients were still going to their community pharmacist for advice and help. 87% of patients felt well treated by their community pharmacist and 91% of patients felt that they had been given good advice. For that reason, we feel that with the aid of technology, community pharmacists would be well-placed to see and assess patients for murmurs, and therefore increase the detection of HVD in the community.

We therefore formulated the hypothesis that with the aid of digital auscultation and artificial intelligence technology, community pharmacists can effectively diagnose patients with heart murmurs and therefore heart valve disease.

There were various outcomes that we were interested in finding out with this hypothesis. These include;

– Would the logistics work,i.e. would a busy community pharmacy be able to adapt to accepting patients for digital auscultation.

– Would the patients accept this new service and trust the community pharmacist to perform an adequate examination.

– Would the local Health Authority and local GPs accept our project, as we would be dealing with their patients.

– Would the pilot pick up a meaningful number of murmurs.

– Would these detected murmurs translate into picking up a meaningful percentage of heart valve disease.

– Would the patients detected with significant heart valve disease be able to be processed adequately (be referred for a timely Echo and then be referred onwards for specialist intervention if necessary).

– Would this community pathway be comparable to the current pathway of only GPs referring patients in for echocardiography on detection of a murmur.

THE PILOT

We selected Farnborough PCN (primary care network), as I knew this area and also knew James Martin and Mak Johal, both community pharmacists at the independent pharmacy « Chapel Pharmacy » in Farnborough. We selected Chapel pharmacy as they were already experienced in delivering extracurricular services (BP monitoring and AF detection) and being independent they would be more flexible in partaking with this pilot.

We had to get clearance from the Health Authority and PCN doctors to start the pilot. This required getting governance clearance, with respect to data collection and storage.

We then decided on a cohort of patients to target, and selected patients who fitted the following criteria:

– over 75 years old.

– Patients with a history of hypertension.

– Patients with a history of type II diabetes.

– Patients with a history of ischaemic heart disease.

– Patients with a history of atrial fibrillation.

We selected these patients as they represented a cohort that would be more likely to have heart valve disease. The pharmacy was also able to process patients who had walked into the pharmacy with symptoms suggestive of heart valve disease.

We decided to use the Littmann digital stethoscope, along with artificial intelligence software provided by eMurmur (company in Austria) which would analyse the digital sound picked up by the digital stethoscope.

We also sent out leaflets advertising the service, to the cohort of patients within the PCN area and invited them to come to Chapel pharmacy for a Heart Check auscultation. Patients who had not responded to the leaflet within 2 weeks, were followed up with a phone call. This proved to be very productive.

A consultation room within Chapel pharmacy was designated for the examination (digital cardiac auscultation) and James Martin was selected to perform the examination. He attended my community echocardiogram clinic where I trained him in the art of auscultation. This only took 3 or 4 clinics, as this was only training in how to position the patient and where to place the stethoscope, rather than how to interpret the heart sounds. The interpretation would be the job of the eMurmur software.

My community clinic was chosen to perform echocardiograms on patients picked up by the digital stethoscope and eMurmur software. The reason for this is that it was a one-stop shop clinic, where echocardiography and clinical management were performed by myself in the same sitting.

GPs of the patients who were seen at Chapel pharmacy were notified that they had been seen, and any patient who had been referred to me for an Echo, had a full Echo report formulated and these were sent on to the GP as well. Any patient who was found to have significant heart valve disease, was referred directly to our local hospital cardiology Department, with the Echo report and Echo images being made available to them.

Patients were seen over a period of about 6 months. During this period I also compared patients who were referred directly to me, with heart murmurs, by GPs within that PCN.

At the end of 6 months 86 patients were seen and analysed by the pharmacy. Of these 45% had a murmur detected, and were referred to me for echocardiography. 55% of patients seen had no murmur detected and therefore not processed any further.

This compared favourably with those patients that were referred to me directly by their GPs. In this group, 42% of patients referred actually had a murmur, and 58% had no murmur.

21% of the pharmacy-referred patients had significant heart valve disease. This represented 70% more patients with significant heart valve disease compared to those referred by the GPs.

What was also discovered during the period, was that the pilot demonstrated that this pathway could also process critical patients. This included a 79-year-old patient who presented with breathlessness and a murmur, but who had been missed by the hospital. He presented as a walk-in to Chapel pharmacy. He was clinically unwell, and his heart was listened to by James Martin, with the digital stethoscope. The eMurmur software detected a pathological murmur, and James was able to phone me (I was in clinic 5 miles away) and tell me about this case. As the eMurmursoftware stored the audio files within a portal on « the cloud », I was able to listen to the murmur remotely, and make a diagnosis of severe aortic stenosis. This process took minutes, and I was able to advise James to send the patient, with this information, back to the hospital and advised that the cardiology team should process him.

Fortunately, this was done, and the patient was found to have critical aortic stenosis and an appointment was made for him a few days later in the TAVI clinic. I am happy to say that this gentleman has subsequently had his aortic valve replaced and is now doing phenomenally well.

OUTCOMES

The pilot worked well, and was easy to set up and the patients were processed seamlessly. Data was collected efficiently, which allowed good analysis which provided results as summarised above.

This pathway, using non-clinical ancillary staff (community pharmacists) with the aid of technology (digital stethoscope and eMurmur AI software), was found to be at least as good as that currently being provided by GPs referring directly to the Echo service. In other words, community pharmacy was able to detect heart valve disease in the community.

Patients loved the service, and as « word-of-mouth » spread, we were getting requests from patients outside the service, to see if they could have their hearts listened to as well.

The GPs liked the service and we were able to process their patients optimally.

This pathway was also able to deal with unexpected critical cases.

CONCLUSION

We felt that this pilot was a success, and therefore we are now in the process of trying to replicate this project on a larger scale, using pharmacies and patient populations from different areas.

If this is also found to be successful, then this would be a very strong argument to incorporate community pharmacies into the process of community heart valve disease detection, as part of NHS policy nationwide.