Direct Access Echocardiography Request Form

PATIENT DETAILS: / GP DETAILS:
Title / «Pat.Title» / Referring GP / «Pat.RefDocFullName»
Surname / «Pat.Surname» / Usual GP / «Pat.UsualDocFullName»
Forename(s) / «Pat.Forenames» / Practice Code / «Prac.Code»
DOB/Age
«Pat.DOB{dateFormat:=%zda/%zmo/%zce%zye}» / «Pat.Age» / Telephone / «Prac.Tel»
Male/Female / «Pat.Sex» / Generic email Address / «Prac.Email»
NHS No / «Pat.NHSNumNew» / Practice Name / «Prac.Name»
Address / «Pat.CurrAdd.Full» / Practice Address / «Prac.AddHouseName»«Prac.AddRoadName»«Prac.AddLocality»«Prac.AddPostTown»«Prac.AddCounty»
Postcode / Practice Postcode / «Pat.CurrAdd.Postcode»
TelPreferred / «Pat.CurrAdd.Tel1» / Translator Required
TelHome / «Pat.CurrAdd.Tel2» / Specify Language
TelMobile / «Pat.MobileTel.Tel»
Indication for Echocardiograph (please select)
  1. All symptomatic patientssuggestive of heart failure first check Serum natriuretic peptides
Recent proven MI (12 months) refer directly for cardiological opinion
Serum natriuretic peptides not required if previous proven MI or male patient with ankle oedema
(for explanation see Heart Failure diagnosismanagement CRGs NorthernEasternWestern localities)
2. New murmur
3. New on-set Atrial Fibrillation (in line with NICE recommendations)

*All other patients should be referred directly for cardiological opinion*

Is the patient taking (or attach medication list)?
Ace-inhibitor or A2RA
Diuretic
Beta-blocker
  1. For suspected heart failure with previous history of MI – arrange echo within two weeks
  1. Suspected heart failure with no previous history of MI - do a NTproBNP blood test or BNP
  • NTproBNP level less than 400pg/ml or BNP of less than 100 in an untreated patient makes a diagnosis of heart failure unlikely
  • NTproBNP = 400-2000pg/ml or BNP of 100-400ng/l is an indication of heart failure. Refer patients with suspected heart failure to have transthoracic Doppler 2D echocardiography within 6 weeks
  • NTproBNP = greater than 2000pg/ml or BNP of more than 400ng/l is a significant indication of heart failure and should be referred within 2 weeks

The list of indications for echocardiography has been narrowed. If you feel that your patient requires an echo outside of the criteria on the form please send a referral tocardiology 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.

Direct AccessEchoform V8 NEW Devon