Skip links and keyboard navigation

Cardiology Referral Guidelines homepage

Arrhythmia  |  Cardiac murmur  |  Cardiomyopathy  |  Chest Pain / Ischaemic Heart Disease  |  Coronary Angiogram  |  Heart Failure  |  Hyperlipidaemia  |  Hypertension  |  Pacemaker  |  Syncope  |  Referral by Cardiac Investiagtion Test |    External Resources  |  Specialist Clinics Home

Arrhythmia

 Diagnosis

 Evaluation

 Management

 Referral Guidelines

Atrial Fibrillation

History / Exam

  • Associated symptoms
  • Resolved / persistent
  • TIA / stroke

Risk factors
Bloods

  • Renal, FBC, TFT's

CXR

Calculate CHADS2 score  See scoring
Anti-coagulate with Warfarin / Aspirin +/- Clopidogrel
Rate control with beta-blocker or CCB or digoxin
Refer if - symptomaticf, treatment strategy uncertain, rhythm management required, underlying structural disease, suspected paroxysmal AF (not detected)

Haemodynamic compromise urgent referral to ED

New onset (within 24hours) - urgent cardioversion via ED

Stable refer cardiology out-patients (see opposite)
OP referral form (please attach ECG's with evidence of arrhythmia)

SVT

History / Exam

  • Associated symptoms
  • Resolved / persistent

Bloods

  • Renal, FBC, TFT's

Resting ECG

Acute - attempt Valsalva manoeuvres, carotid sinus massage

Recurrent - consider beta-blocker as pill in pocket or daily

Refer to ED if manœuvres unsuccessful


Refer to cardiology out-patients for further investigation
OP referral form (please attach ECG's with evidence of arrhythmia)

Palpitations

History / Exam

  • Frequency
  • Associated symptoms

Bloods

  • Renal, FBC, TFT's

Resting ECG

Consider beta-blocker as pill in pocket or daily


 

If no associated symptoms refer for 24hr ECG
If associated symptoms refer cardiology out-patients
OP referral form (please attach ECG's with evidence of arrhythmia)

Ventricular Tachycardia     Call 000
Loss of consciousness - defibrillate (if defibrillator present) or provide CPR
Inform on call registrar of referral +61 7 4226 9999

Go to Toptop of page



Cardiac Murmur

 Diagnosis

 Evaluation

 Management

 Referral Guidelines

Murmur

 

 

 

 

Known murmur with worsening symptoms or suspected endocarditis

Known valve disease / surgery / rheumatic valve disease

History / Exam

  • Rheumatic fever
  • Associated symptoms

Resting ECG

CXR

 

 

 

 

 

 

 

 

In rheumatic valvular heart disease patients - ongoing Bicillin injections

If symptomatic or cardiac enlargement on CXR refer cardiology
OP referral form
If asymptomatic refer for echocardiogram
If evaluation suggests innocent (benign flow) murmur - reassure
Urgent referral to cardiology
OP referral form

 

Ensure ongoing regular valve clinic follow-up

Go to Toptop of page



Cardiomyopathy

 Diagnosis

 Evaluation

 Management

 Referral Guidelines

Hypertrophic

cardiomyopathy

HCM

Dilated cardiomyopathy

20 cardiomyopathy

History / Exam

  • Symptoms
  • Family Hx
  • Alcohol

Investigations

  • Resting ECG
  • Renal, TFT's, lipids
  • CXR

Echocardiogram

24hr ECG

HCM - ensure family screening
Start on beta-blocker or calcium channel blocker

Urgent referral with syncope or rest breathlessness

Ensure regular follow up in cardiology
OP referral form

If positive family history with abnormal ECG refer to cardiology for further investigation
OP referral form

Go to Toptop of page



Chest Pain / Ischaemic Heart Disease

 Diagnosis

 Evaluation

 Management

 Referral Guidelines

Acute severe chest pain

History / Exam

  • Cardiac
  • PE
  • Dissection
  • Upper GI

Resting ECG

Oxygen
Pain relief with morpine
GTN s/l and Aspirin 300mg stat if cardiac

 

Dial 000
Urgent ED referral
Inform admitting registrar +61 7 4226 9999

Rest chest pain

History

  • Possible cardiac
  • Upper GI
  • Musculo-skeletal

Risk factors
Examination
Medications
Blood glucose
Resting ECG

Pain relief with GTN s/l, analgesics, antacids Refer ED

Exertional chest pain

 

Worsening of Known IHD

History
Risk factors
Medications
Examination
Bloods

  • Glucose, Lipids, Renal, FBC

Resting ECG

Offer lifestyle advise - smoking, diet, exercise
Start Aspirin 100mg od, Simvastatin 40mg on and Metoprolol or Nitrate
GTN s/l prn

Known IHD titrate up anti-anginals - beta-blockers, nitrates, nicorandil, CCB's, ivabradine

Refer to cardiology out-patients
OP referral form

Refer to Rapid Access Chest Pain Clinic (RACPC)
RACPC referral form


Refer to cardiology-outpatients
OP referral form

Non cardiac chest pain

History

  • Musculo-skeletal
  • Upper GI

Risk Factors
Resting ECG

Lifestyle advice
Analgesics, antacids, PPI's

 

Refer for exercise stress testing or RACPC if high cardiac risk patient
RACPC referral form

Cardiac rehab   For any patient post - MI, unstable angina, CABG, PCI or valve surgery

OP referral form

0437553922

Go to Toptop of page



Coronary Angiogram

 Diagnosis

 Evaluation

 Management

 Referral Guidelines

 

Go to Toptop of page



Heart Failure

 Diagnosis

 Evaluation

 Management

 Referral Guidelines

Acute rest breathlessness History / Exam
Oxygen saturations
Resting ECG
High flow Oxygen
Upright position
Morphine
Dial 000
Urgent ED referral
Inform admitting registrar +61 7 4226 9999

Exertional breathlessness
(suspected HF)

 

 


Worsening of known HF

History / Exam
Risk factors
Bloods

  • BNP
  • Renal, FBC, Glucose, Lipids, TFT's

CXR
Resting ECG

Lifestyle advice - fluid restriction, daily weights, salt intake
Frusemide
ACE I (ARB's if side effects) and beta-blocker if abnormal BNP or CXR and ECG


Titrate up diuretics

Refer cardiology out-patients
OP referral form

 

 

 

Refer to heart failure team
OP referral form
0437831048

Go to Toptop of page



Hyperlipidaemia

 Diagnosis

 Evaluation

 Management

 Referral Guidelines

Hyperlipidaemia

History / Exam

  • Symptoms
  • Family Hx
  • Risk factors

Fasting lipids on 2 occasions

Glucose, TFT's, Renal, FBC

Lifestyle and dietary advice

Refer to NHF guidelines

Manage other risk factors

Consider referral if poorly controlled lipids or with familial hyperlipidaemia
Referral for consideration of lipid lowering therapy according to NHF guidelines
OP referral form

Go to Toptop of page



Hypertension

 Diagnosis

 Evaluation

 Management

 Referral Guidelines

Hypertension

History / Exam

  • Symptoms
  • Underlying cardiac, renal or endocrine disease
  • Drug Hx

Investigations

  • 24 hour urine collection
  • FBC, renal, TFT's, lipids
  • ECG
  • CXR

24 hr ambulatory BP

Lifestyle advice
Measure BP seated on 3 occasions at 3 visits
Estimate 10 year cardiovascular risk
Refer if - secondary cause likely, difficult to control, symptomatic, decline in renal function, drug intolerances
Medical management - refer to resources below

Malignant hypertension - urgent referral to ED
Severe BP >200/120 urgent referral
OP referral form

Hypertension in pregnancy refer to obstetrician

 

Go to Toptop of page



Pacemaker

 Diagnosis

 Evaluation

 Management

 Referral Guidelines

 

Go to Toptop of page



Syncope

 Diagnosis

 Evaluation

 Management

 Referral Guidelines

Malignant - sudden onset with injury


Benign - vasovagal / presyncope

History / Exam

  • Onset, frequency, prodrome
  • Rule out neuro cause
  • ? Family history
  • Pulse, BP (lying/standing), Murmurs

Bloods

  • Renal, FBC, Glucose

Resting ECG

Features suggestive of cardiac cause - when supine, on exertion, with palpitations, known structural heart disease.

 

 

 

Urgent referral to ED

 


Cardiology referral if considered cardiac origin or recurrent
OP referral form
Request tilt testing / 24hr ECG if considered benign
Isolated event and negative findings - reassure.

Go to Toptop of page



Referral by Cardiac Investiagtion Test

Resting ECG 
24 hour ECG Stable patients with palpitations and syncope, monitoring and diagnosing arrhythmias / AF.
24 hour BP monitoring Confirm diagnosis of hypertension, white coat hypertension, monitor BP control.
Tilt testing Evaluation of patients with syncope of unknown cause
Exercise stress testing

To confirm / exclude the diagnosis of angina and assess the severity of angina
Consider referral to RACPC if patient has rest chest pain considered to be new onset exertional angina
RACPC referral form

Trans-thoracic Echocardiogram Assess for structural cardiac disease - HF, IHD, valvular, HT
Trans-oesophageal Echocardiogram After cardiology review only
Echo agitated saline (bubble) study In young patients who have had stroke / TIA
Dobutamine stress echocardiogram To confirm / exclude the diagnosis of angina and assess the severity of angina in patients unable to undertake exercise stress testing
CT coronary angiogram After cardiology review only
OP referral form
Cardiac MRI After cardiology review only
OP referral form
Coronary angiogram After cardiology review only
OP referral form
Coronary angioplasty After cardiology review only
OP referral form
Pacemaker clinic All patients with permanent pacemaker should have regular follow-up locally
OP referral form

Go to Toptop of page



CHADS2 Scoring

The selection of optimal anti-thrombotic prophylaxis depends on the patient's risk of ischaemic stroke and the benefits and risks of long-term warfarin versus aspirin. This is independent of rate or rhythm control strategy.

Ischaemic stroke risk is estimated with the CHADS2 score: 

  • Chronic heart failure
1
  • Hypertension
1
  • Age = 75 years
1
  • Diabetes
1
  • Stroke or previous TIA
2
score =2 Patient should be started on warfarin if no contra-indications

score is <2

Aspirin +/- Clopidogrel can be used or if Warfarin is contra-indicated
  • Patients with valvular atrial fibrillation should be started on warfarin
  • INR is recommended to be maintained at 2-3 (ideal 2.5)
  • Stroke rate is similar for paroxysmal, persistent and permanent AF

Back to Arrhythmia

Go to Toptop of page



External Resources

Acute coronary syndromes

Angina - Exertional

Arrhythmia

Cardic Murmur

Cardiomyopathy

Heart Failure

Hyperlipidaemia

Hypertension

Secondary prevention

Syncope

Go to Toptop of page




Last updated: 1 August 2013