Chest pain

PAEDIATRIC

  • If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.

    Chest pain (adult)

    • Suspected acute coronary syndrome
    • Suspected pulmonary embolism or aortic dissection
    • Suspected or confirmed endocarditis, myocarditis or pericarditis
    • Suspected chest pain within 24 hours with any of the following concerning features:
      • severe or ongoing chest pain
      • chest pain lasting ten minutes or more
      • recurrent chest pain that is new at rest or occurring with minimal activity
      • chest pain accompanied by severe dyspnoea
      • chest pain that is associated with any of the following clinical signs:
        • syncope / pre-syncope
        • respiratory rate > 30 breaths per minute
        • tachycardia >120
        • systolic BP < 90mmHg
        • heart failure / suspected pulmonary oedema
        • ST elevation or depression
        • complete heart block
        • new left bundle branch block

    Atrial fibrillation

    • Atrial fibrillation / flutter with any of the following concerning features:
      • haemodynamic instability
      • shortness of breath
      • chest pain
      • syncope/pre syncope/dizziness
      • known Wolff-Parkinson-White
      • neurological deficit indicative of TIA/stroke

    Chest pain (paediatric)

    • Current chest pain with haemodynamic compromise

    Heart failure

    • Acute or chronic heart failure with any of the following concerning features:
      • NYHA Class IV heart failure
      • ongoing chest pain
      • increasing shortness of breath
      • oxygen saturation < 90%
      • signs of acute pulmonary oedema
      • haemodynamic instability:
        • pre-syncope / syncope / severe dizziness
        • altered level of consciousness
        • heart rate > 120 beats per minute
        • systolic BP < 90mmHg
      • significant pulmonary or pedal oedema
      • recent myocardial infarction (within 2 weeks)
      • pregnant patient
      • signs of myocarditis
      • signs of acute decompensated heart failure

    Hypertension

    • Hypertensive emergency (BP>220/140)
    • Severe hypertension (systolic BP >180) with known ischaemic heart disease or cardiomyopathy AND any of the following concerning features:
      • headache
      • confusion
      • blurred vision
      • retinal haemorrhage
      • reduced level of consciousness
      • seizures
      • proteinuria
      • papilloedema
      • signs of heart failure
      • chest pain
    • If suspected pregnancy induced hypertension or pre-eclampsia refer patient to the emergency department of a facility that offers obstetric services where possible.

    Murmur (adults or children)

    • New murmur with any of the following concerning features:
      • haemodynamic instability
      • persistent or progressive shortness of breath (NYHA Class III – IV)
      • chest pain
      • syncope / pre-syncope / dizziness
      • neurological deficit indicative of TIA/stroke
      • abnormal ECG (e.g. LV hypertrophy, AF, LBBB, RBBB)
      • fever or constitutional symptoms suggestive of infection (eg endocarditis, acute rheumatic fever)
      • signs of heart failure

    Murmur (Infant)

    • Infant <3 months with newly noted murmur and any of the following concerning features:
      • poor feeding
      • slow weight gain
      • weak or absent femoral pulses
      • post ductal (foot) oxygen saturation < 95%
      • respiratory signs (wheeze, recession or tachypnoea)
    • Suspected heart failure or endocarditis

    Palpitations

    • Palpitations with any of the following concerning features:
      • chest pain
      • shortness of breath
      • loss of consciousness
      • syncope / pre-syncope
      • persisting tachyarrhythmia on ECG

    Supraventricular tachycardia

    • Unresolved acute supraventricular tachycardia with any of the following concerning features:
      • syncope
      • severe dizziness
      • ongoing chest pain
      • increasing shortness of breath
      • hypotension
      • signs of cardiac failure
      • ventricular rate >120

    Syncope / pre-syncope

    • Syncope with any of the following concerning features:
      • exertional onset
      • chest pain
      • persistent hypotension (systolic BP <90mmHg)
      • severe persistent headache
      • focal neurological deficits
      • preceded by or associated with palpitations
      • known ischaemic heart disease or reduced LV systolic function
      • associated with SVT or paroxysmal atrial fibrillation
      • pre-excited QRS (delta waves) on ECG
      • suspected malfunction of pacemaker or ICD
      • absence of prodrome
      • associated injury
      • occurs while supine or sitting

    Other

    • Pacemaker/ICD
      • delivery of 2 or more shocks by ICD in 24 hours
      • suspected pacemaker/defibrillator malfunction (with ECG evidence)
      • pacemaker/ICD device erosion
    • Bradycardia including any of the following:
      • symptomatic bradycardia
      • PR interval on ECG exceeding 300ms
      • second degree or complete heart block
    • Broad complex tachycardia
    • Suspected or confirmed endocarditis, myocarditis or pericarditis
    • Refer to HealthPathways for assessment and management information or local guidelines if available
    • Non-exertional chest pain should be referred to General Paediatrics in the first instance.
    • If you have a reason to suspect a child in Queensland is experiencing harm, or is at risk of experiencing harm, you need to contact Child Safety Services Department of Children, Youth Justice and multicultural Affairs.
    • Statement of intent – the prioritisation of health services for children and young people in the child protection system
    • Clinical urgency is the dominant consideration in the prioritisation of a referral for a child currently in out of home care (OOHC), or at risk of entering or leaving OOHC.
    • In the majority of cases, it is thought inappropriate for children to wait more than 6 months for an outpatient initial appointment.
Minimum Referral Criteria
Category 1
(appointment within 30 calendar days)
  • Recurrent chest pain without haemodynamic compromise or history of cardiac disease should be seen in General Paediatrics.
  • A child currently in out of home care (OOHC) or at risk of entering or leaving OOHC, where they have previously been on a waiting list for this problem and were removed without receiving a service.
Category 2
(appointment within 90 calendar days)
  • Chest pain – other, refer to General Paediatrics
Category 3
(appointment within 365 calendar days)
  • No Category 3 criteria

Please insert the below information and minimum referral criteria into referral

1. Reason for request Indicate on the referral

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

2. Essential referral information Referral will be returned without this

  • Medical history including gestational history
  • Details of any known cardiac conditions
  • Details of relevant signs and symptoms
  • Details of any treatments offered and efficacy
  • ECG
  • Confirmation of OOHC (where appropriate)

3. Additional referral information Useful for processing the referral

  • Investigations (if available) including CXR, cardiac imaging and/or echocardiogram

4. Request

  • Patient's Demographic Details

    • Full name (including aliases)
    • Date of birth
    • Residential and postal address
    • Telephone contact number/s – home, mobile and alternative
    • Medicare number (where eligible)
    • Name of the parent or caregiver (if appropriate)
    • Preferred language and interpreter requirements
    • Identifies as Aboriginal and/or Torres Strait Islander

    Referring Practitioner Details

    • Full name
    • Full address
    • Contact details – telephone, fax, email
    • Provider number
    • Date of referral
    • Signature

    Relevant clinical information about the condition

    • Presenting symptoms (evolution and duration)
    • Physical findings
    • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
    • Body mass index (BMI)
    • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
    • Current medications and dosages
    • Drug allergies
    • Alcohol, tobacco and other drugs use

    Reason for request

    • To establish a diagnosis
    • For treatment or intervention
    • For advice and management
    • For specialist to take over management
    • Reassurance for GP/second opinion
    • For a specified test/investigation the GP can't order, or the patient can't afford or access
    • Reassurance for the patient/family
    • For other reason (e.g. rapidly accelerating disease progression)
    • Clinical judgement indicates a referral for specialist review is necessary

    Clinical modifiers

    • Impact on employment
    • Impact on education
    • Impact on home
    • Impact on activities of daily living
    • Impact on ability to care for others
    • Impact on personal frailty or safety
    • Identifies as Aboriginal and/or Torres Strait Islander

    Other relevant information

    • Willingness to have surgery (where surgery is a likely intervention)
    • Choice to be treated as a public or private patient
    • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)

  • If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.

    • Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service.  Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.

    • A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.

    • Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

Last updated: 17 September 2019

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