Adult lipid and cardiovascular risk clinic. We see patients with high blood fats/lipids, review their results to try and establish the cause of the high lipids and work out if treatment is required and, if so, what options are available to you. Some lipid conditions run in families and it may be that your relatives e.g. your children need testing. One major role of the clinic is to make sure that we do not miss asymptomatic relatives in order to try and prevent future heart attacks and strokes.
Who do we see?
Dyslipidaemias (high or deranged blood lipids). People with complications of lipid problems e.g. pancreatitis and premature vascular disease People with side effects to lipid lowering medication People with poor control on current medications who require more treatment Specialist testing particularly looking into families with potential genetic lipid conditions or family history of premature vascular disease such as heart attacks and strokes. Limited screening of relatives directly, advice in regards to when family screening is required and what tests to perform. Also see general Metabolic patients particularly at Good hope hospital and sometimes at Heartlands
Location?
Outpatient department in Heartlands.
Slide1
Slide10
Slide11
Slide12
Slide2
Slide3
Slide4
Slide5
Slide6
Slide7
Slide8
Slide9
Outpatient department Good Hope
Contact information (if you want to speak to clinic organisers)?
Booking service for appointment alterations via contact information on the appointment letter
Contact Lipid clinic secretary for all other queries as follows:
Heartlands hospital Secretary: 0121 42 43228 This email address is being protected from spambots. You need JavaScript enabled to view it.
Good Hope hospital Secretary: 0121 42 47246 This email address is being protected from spambots. You need JavaScript enabled to view it.
What are the prereferral tests?
To help guide us with your management your GP will arrange for you to have some blood tests
What do you need to bring?
It is helpful to have a list of your medications if you can’t remember what they are.
What do I need to do?
Besides bringing your tablet list sometimes we ask people for fasting blood tests. Sometimes lipid tests can be done non-fasting. Please let us know if you cannot make an appointment as sometimes, even at late notice, an emergency patient can be asked to attend to fill your slot.
What do we do?
Diagnosis is based on your medical history, clinical examination and blood tests. Sometimes further investigations e.g. treadmill test may be indicated. Once a diagnosis is established then most treatment involves diet and lifestyle changes and some require medications, such as statins and fibrates, to reach treatment targets.
Who will I see?
The team at Heartlands consists of
Dr Alan Jones (Consultant Chemical Pathologist)
Dr Ummu Mayana (Honorary Consultant Chemical Pathologist)
Dr Sud Ramachandran (Consultant Chemical Pathologist) sees patients who have been referred to Good Hope at Good Hope Hospital. Heartlands and Good Hope are teaching hospitals therefore occasionally medical students and doctors in training may be present.
Other services available?
Some patients can be referred to the dietetics department for dietary advice. In rare cases we may ask cardiology or the diabetic team to become involved in your care. There is no paediatric or genetics service attached to the clinic. For children picked up in the clinic as having a genetic lipid disorder we refer them to the Birmingham Children’s Hospital to discuss further treatment.
In the last 5 years requests for tumour marker tests from Primary Care have more than doubled. This high use in Primary Care is worrying because the majority of tumour markers (eg. CEA, CA19-9) are neither specific nor sensitive enough for use in the diagnosis of malignancy. See this link for a summary of the main tumour markers, their uses and limitations.
The main use for tumour markers is in monitoring disease progression, treatment or recurrence of a histologically diagnosed cancer. A recent audit of Primary Care requests for tumour markers found that only 9% of CEA and 4% of CA19-9 were requested for these reasons; the rest being for non-specific symptoms.
In contrast to the above, CA125 and PSA do have use in diagnosis of their related cancers, however it should also be noted that these are still only a diagnostic aid and should be used with caution as both can be raised in a number of other benign conditions (see table). Please click the relevant links below of links to guidelines relating to their use in Primary Care.
Phoning limits for biochemistry tests are as follows:
Decision limits for phoning
Analyte
Phone results below or equal to:
Phone results above or equal to:
Units
Notes
Sodium
120
150
mmol/L
Potassium
2.5
6.5
mmol/L
Urea
-
Adults: 30
Paediatrics: 10
mmol/L
Except those on renal wards or under renal consultants.
Creatinine
-
Paediatrics: 200
umol/L
eGFR
Adults: 15
-
ml/min
AKI
-
2
Not CKD patients (AKI 2 discretionary)
Glucose
2.5
25
mmol/L
Calcium adjusted
1.8
3.5
mmol/L
Magnesium
0.4
-
mmol/L
Phosphate
0.3
-
mmol/L
AST
-
600
U/L
ALT
-
600
U/L
Total CK
-
5000
U/L
Amylase
-
500
U/L
Digoxin
-
2.5
ng/mL
Theophylline
-
25
mg/L
Phenytoin
-
25
mg/L
Lithium
-
1.5
mmol/L
Troponin T
-
GP only: >14
ng/L
GP only
Ammonia
-
100
umol/L
Ethanol
-
Paediatrics only: any detectable
mg/L
Paediatrics only
Paracetamol
-
10
mg/L
Not ED patients
Salicylate
-
300
mg/L
Not ED patients
Conj bilirubin (DBIL)
-
Paediatrics only:
25
umol/L
Paediatrics only
Total bilirubin
-
Paediatrics only: 225
umol/L
Paediatrics only
Carbamazepine
-
25
ug /mL
Iron
-
ED only: 70
umol/L
ED only
Phenobarbitone
-
70
mg/L
CSF Gluc
3.3
-
mmol/L
CSF Prot
-
0.45
g/L
Lactate
-
2.3
CRP
-
300
Total bile acids
-
20
Methotrexate
Phone all
umol/L
Immunology results to be telephoned:
CD4 count <200 cells/cumm or <10% on new patients (paediatric levels are different, but agreed with Paed consultants)
Lymphocyte subsets in infants <2yo: Any T cell subset below age-related normal range, any other abnormality suggesting SCID (e.g. MHC class II deficiency). (Note this is not exclusive: any abnormality may be discussed with requesting clinician)
New positive GBM antibodiest
New positive MPO antibodies
New positive PR3 antibodies
New paraprotein IgG , A or M > 20g/L
IgD or IgE (any size)
serum monoclonal free light chains (any size, whether or not with intact paraprotein)
Abnormal Laboratory Test Results – Triggers for Telephoning Results Haematology
Haemoglobin
White Blood Cell Count
<8.0 g/dl normochromic and normocytic
Low result – neutropenia <0.5 x 10 9/L
<7.0 g/dl microcytic and hypochromic
High result – White cell count >40 x 10 9/L
<7.0 g/dl macrocytic
or Lymph count > 20 x 10 9/L
<5.0 g/dl renal patients
Any presence of blast cells
Platelets
Clotting Studies
Lower limit - <70 x 10 9/L
INR - >5.0
Upper limit - >1000 x 10 9/L
PTT - >180 seconds
Fibrinogen < 1.0g/l
All Positive Malaria Screens
All Anti FXa results >1.20 iu/ml
If the patient is known to the department and has had a similar result within the previous 7 days then the urgent contact is not necessary.
HPA Microbiology – List of abnormal results telephoned to clinical staff
Bacteriology
Gram stain results of positive blood culture on Day 1
Positive CSF results
Positive sterile site results
Significant in-patient results from enteric bench
Multi resistant gram negative and gram positive isolates including mupirocin resistant MRSA
Group B streptococcal isolates from neonates
Group A in patient isolates
Positive Legionella urinary antigen and Pneumococcal urine antigen results
Smear and culture positive Mycobacteria
Antibiotic assay results outside normal ranges
Any other significant results at the discretion of Medical Microbiologists
Virology
Serological evidence of acute infection with Hep A, Hep B and in pregnant patients CMV, Parvovirus and Rubella
New diagnoses of HIV
VZV IgG negative from exposed patients at risk of severe VZV infection
New diagnosis of Hep B, Hep C and HIV in haemodialysis patients
Evidence of Hep B/Hep C and HIV in needle stick injury source patients
Clinically important positive respiratory PCR results i.e.: influenza, RSV in immunocompromised patients
Positive PCR results in outbreaks
Positive blood PCR for CMV and Adenovirus
Negative blood results for CMV PCR
Significant blood PCR results for EBV and Polyomavirus
On 22.11.201, the formula to calculate eGFR at UHB will be changed from MDRD to CKD-EPI. This is in line with long standing NICE guidance. This is a more accurate equation to estimate GFR. This will not affect the management of patients and should not lead to a major eGFR change on an individual patient basis. As per NICE guidance, it is no longer necessary to correct for ethnicity.
Further information
At present, eGFR is calculated at UHB using the MDRD equation. This equation was based upon measurements in patients with established renal disease. It uses creatinine, sex, age, and the ethnicity of the patient to estimate the GFR. The group that developed the MDRD equation subsequently developed the CKD-EPI equation using data from patients who had normal and impaired renal function. Like MDRD, the original CKD-EPI equation used creatinine, sex, age, and the ethnicity of the patient to estimate the GFR however recent NICE guidance has recommended that ethnicity is no longer used. CKD-EPI is thought to reflect renal function better than the MDRD equation. Compared to measured GFR, performance of the two equations are similar when GFR is < 60 mL/min/1.73 m2 with the MDRD equation underestimating GFR at levels > 60 mL/min/1.73 m2 when compared to the CKD-EPI equation. It is thought that the impact on patient management will be minimal however there is a possibility that CKD classifications could change due to CKD-EPI more closely reflecting the ‘true’ GFR. NICE has recommended using the CKD-EPI equation to calculate eGFR since 2014 with ethnicity removal outlined this year.
There is no change to specimen requirements or test requesting.
For clinical queries relating to this change please contact Professor Paul Cockwell (This email address is being protected from spambots. You need JavaScript enabled to view it.). For laboratory queries please contact Dr Alex Lawson (This email address is being protected from spambots. You need JavaScript enabled to view it.).
References
Chronic kidney disease: assessment and management. NICE guideline [NG203]
UK Kidney Association The rationale for removing adjustment for ethnicity from eGFRcreatinine and recommendations for implementation of the change in practice
Dyslipidaemias (high or deranged blood lipids). People with complications of lipid problems e.g. pancreatitis and premature vascular disease People with side effects to lipid lowering medication People with poor control on current medications who require more treatment Specialist testing particularly looking into families with potential genetic lipid conditions or family history of premature vascular disease such as heart attacks and strokes. Limited screening of relatives directly, advice in regards to when family screening is required and what tests to perform. Also see general Metabolic patients particularly at Good hope hospital and sometimes at Heartlands
