Syncope / pre-syncope (Cardiology)
ADULT
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Emergency
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 ischaemic 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
- Acute onset chest pain from a potential cardiac cause
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
- Seizures
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
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Other useful information for referring practitioners Not and exhaustive list
Minimum Referral Criteria
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Category 1
(appointment within 30 calendar days)- New episode(s) of uninvestigated syncope / near syncope without 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
- Seizures
- New episode(s) of uninvestigated syncope / near syncope without any of the following concerning features
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Category 2
(appointment within 90 calendar days)- Recurrent syncope previously investigated with undetermined cause
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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
- Description of syncopal/pre-syncopal events including the following:
- timeline
- precipitating factors
- any warning pre-syncopal symptoms
- complete LOC or partial
- duration of LOC
- nature of recovery
- witnessed signs
- seizures
- pallor
- incontinence
- cyanosis
- irregular or absent pulse during attack
- associated injury
- Lying / standing or sitting / standing BP
- Presence of impaired LV function by any imaging modality (MRI, echo or MPS) if known
- FBC, TSH, ELFTs, magnesium results
- All available ECGs
3. Additional referral information Useful for processing the referral
- Details of all treatments offered and efficacy
- Relevant medical history
- Family history of cardiac disease or sudden cardiac death
- Holter monitor report (only useful if daily symptoms)
- Presence of impaired LV function by any imaging modality (MRI, echo or MPS) if known
- FBC, TSH, ELFTs, magnesium results
- Echocardiogram report (if available)
- CXR report
- History of drug use (including recreational drugs)
4. Request
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General referral information
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.)
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Notes
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: 22 June 2023
