Cardiology Clinic

Cardiology Referral Guidelines for MAP Handbook

1. Emergency Room referral:
   Patients with accelerated angina (Canadian Cardiovascular Class III-IV [i.e. symptoms with minimal effort or at rest, respectively]) should generally be sent to the emergency room. If there are situational questions please consult the cardiologist by phone.
2. Appropriate URGENT and/or econsult referrals to Cardiology
   • Worsening dyspnea New York Heart Association (NYHA) class III-IV (i.e. symptoms with minimal effort or at rest, respectively) and/or worsening orthopnea or paroxysmal nocturnal dyspnea
     • Describe conditions that elicit dyspnea
     • Refer to cardiology and obtain or initiate echocardiogram
   • Sustained HR>120 bpm
     • Refer to cardiology and obtain or initiate ECG, 24 hour Holter and echocardiogram
   • Syncope with injury
     • Refer to cardiology and obtain or initiate ECG, 24 hour Holter and echocardiogram
   • Decompensated heart failure or myocardial infarction
     • Refer to cardiology and obtain or initiate ECG and echocardiogram
     • Indicate if Recent admission for condition
3. Appropriate ROUTINE referrals
   • Chest Pain. Patients with Canadian Cardiovascular Class I-II angina (but Duke Chest pain score >85%, i.e. classic symptoms for angina) that represents a change in symptoms for the patient should be referred to the cardiologist with the anticipation of possible heart catheterization.
     • Describe quality, circumstances of onset and termination, relation to exertion (Canadian Cardiovascular Class)
     • Provide results of stress ECG (if intermediate risk [Duke Chest pain score>20% but <85%], ambulatory and has a readable ECG) or Lexiscan nuclear (if intermediate risk [Duke Chest pain score] but cannot ambulate and/or unreadable ECG [e.g. paced rhythm or LBBB])
     • The outcome of the stress test will determine triage at this point (If positive or equivocal, then consult cardiology. If negative, then PCP should evaluate and treat patient for alternative etiologies of chest pain.)
     • Low risk patients (those with atypical chest pain (Duke Chest Pain score <20%) should not undergo stress testing and in general do not need a cardiology consult. Rather they should be treated empirically for a more likely etiology of the pain.
   • Dyspnea
     • Patients with NYHA class I-II symptoms that represents a change in symptoms for the patient should be referred to the cardiologist.
       • Describe relationship exertion (NYHA class), presence of orthopnea, PND and/or edema
       • Provide results of echocardiogram
     • Any patient with dyspnea and significant structural heart disease on echocardiogram (reduced systolic function, diastolic dysfunction, severe LVH, moderate or severe valve pathology) should be referred to cardiology
   • Syncope
     • Describe presence or absence of prodromal symptoms, relationship to postural changes, sensation of palpitations and presence or absence of injury
   • Murmur
     • Describe murmur, including loudness (less than III/VI, or III/VI or greater)
     • Soft systolic murmurs (grade II/VI or less do not require an echo or a cardiology consult) as they are almost always innocent murmurs.
   • Palpitations
     • Provide results of ECG and 24 hour Holter monitor and TSH; optional echocardiogram (especially if runs of tachyarrhytmias suspected or PVCs over 20% overall beats) and stress ECG (especially if symptoms related to exercise)
     • Please refer to cardiology if significant arrhythmias are found on Holter or stress test, or the patient has significant structural heart disease (e.g. dilated cardiomyopathy)
     • Symptoms of prolonged heart racing or symptoms of palpitations should be referred to cardiology
   • Other significant arrhythmias: PVCs greater than 20% heart beats on 24 hour Holter monitor (usually >20,000); atrial fibrillation, atrial flutter, sustained SVT (over 30 seconds), sustained VT (over 30 seconds) , 2 degree AVB, 3 degree AVB, sustained HR<35 bpm (over 30 seconds), pauses >3 seconds
     • Please refer to cardiology and provide results of ECG, 24 hour Holter monitor and echocardiogram.
   • Peripheral edema when heart failure is suspected (NYHA class I or greater symptoms of dyspnea, orthopnea, PND, and /or JVD and S3 gallop on physical exam, elevated B-NP).
     • Provide results of echocardiogram prior to cardiology appointment
   • Known CAD with worsening of angina (CCVC I or II)
     • Repeat stress testing (stress ECG if preferred if patient has a readable ECG [e.g. no LBBB] and is sufficiently ambulatory) before referral if symptoms are atypical for angina.
   • Valve disease
     • Patients with moderate-to-severe valve pathology on echocardiogram, regardless of symptoms, should be referred to cardiology.
   • Refractory Hypertension (unable to achieve target BP despite maximum doses of three non-diuretic antihypertensive medications)
     • Please obtain renal artery Doppler prior to cardiology appointment.
4. Stable Heart Conditions that can be managed by PCP
   • Stable CAD (known disease. Remote MI, coronary stent or CABG)-minimal symptoms of angina. Management: daily ASA 81 mg, atorvastatin 80 mg q day, metoprolol tartate 25 mg BID, Mediterranean Diet
   • Post valve surgery-wafarin with INR management (if mechanical prosthesis). Annual echocardiogram (consult cardiology if valve function worsening on echo)
   • Chronic Atrial Fibrillation-maintain rate control with beta blockers (plus/minus cardizem, verapamil or digoxin). Warfarin or NOAC if CHADSvasc score 2 or more and no significant risk of bleeding or falling.
   • Chronic Heart Failure
     • Systolic failure (HFrEF) (LVEF<40%) but stable NYHA class I-II. Maintain on carvedilol, lisinopril or losartan (or Entresto) and spironolactone. Maintain volume status with low salt diet, conservative fluid intake and conditional Lasix. Weigh daily. If weight gain over 3 lbs in one day or 5 lbs in one week, take Lasix 40 mg (with potassium supplement). Annual echocardiogram.
     • Diastolic heart failure (HFpEF). (LVEF>40%). Maintain volume status with low salt diet, conservative fluid intake and conditional Lasix. Weigh daily. If weight gain over 3 lbs in one day or 5 lbs in one week, take Lasix 40 mg (with potassium supplement). Optimize blood pressure control.
   • Pacemaker, ICD or ILR patient. Regular device check at the device clinic at MPT (Dr. Mauricio Hong. 512-324-3440)
   • Minor palpitations (not associated with prolonged heart racing, syncope or near syncope). Consider 24 hr holter. Check TSH. Restrict caffeine, alcohol and decongestants.
5. Conditions that should be referred elsewhere
   • Dizziness (refer to ENT)
   • General fatigue without dyspnea (check H/h and TSH and consider sleep evaluation)
   • Pediatric patients (under 18 years old) (refer to Pediatric Cardiologist)
6. Documentation required for scheduling referral
   • Last PCP note, problem list, medication list, last DC summary with prior cardiac history
   • Risk factors for CAD: cigarette smoking, hypertension, FHX of early onset (before age 55 yrs), diabetes and dyslipidemia.
   • Test results as requested in this document
   • Most recent lab results
   • Any other available cardiac-related information (recent echocardiogram, recent catheterization report, heart surgery operative note, etc.)
   • (NOTE: Please do not order advanced cardiac imaging (e.g. stress nuclear, Lexiscan nuclear, stress echo, cardiac MR, Cardiac CT and Transesophageal echo) without first discussing case with cardiologist by eConsult prior to ordering or referral, unless the test is requested above.)