REFREC001
CARDIOLOGY REFERRAL RECOMMENDATIONS
Diagnosis / Symptomatology
General problems include:
 Atrial Fibrillation / Flutter
 Bradyarrhythmias
 Chest pain
 Heart failure / breathlessness
 Hyperlipidaemia
Evaluation
These general symptoms may include
any and/or all of the general or specific
problems noted. A thorough history
and physical examination is required to
determine the diagnosis. All case
histories should include alcohol and
tobacco use, drug and allergy history.
Management Options
Specific treatments depend on the
specific problem identified, as noted
below.
Referral Guidelines
Evaluation results should be included
with referral information provided to
hospital.
 Hypertension
 Murmurs
 Other
 Palpitation
 Supraventricular Tachycardia
(SVT)
 Syncope or presyncope
 Ventricular tachyarrhythmias
Last updated February 2006
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REFREC001
Diagnosis / Symptomatology
Atrial Fibrillation/Flutter
Evaluation
History – duration of symptoms.
Evidence of underlying lung
disease/HT/cardiac disease/thyroid
disease/strokes/TIAs/diabetes.
Drug history including alcohol and
tobacco.
Associated symptoms, eg. angina,
dyspnoea, syncope and presyncope.
Management Options
Chronic or recurrent paroxysmal.

Consider anti-arrhythmia and
anticoagulation therapy after
discussion with specialist, as
required.
Acute AF/Atrial Flutter.

Discuss or refer immediately for
management.
Referral Guidelines
Refer all patients for assessment after
discussing options.
Acute AF – Category 1 – admission for
haemodynamic compromise.
Admission may not be required if
stable.
Chronic AF – Category 3 – routine.
ECG.
Thyroid Function Tests, UEC.
CXR.
Echocardiogram
Diagnosis / Symptomatology
Bradyarrhythmias, eg:
– Heart block
– Sinus Bradycardia
– Sick Sinus syndrome
Last updated February 2006
Evaluation
History – duration of symptoms.
Evidence of underlying cardiac
disease.
Drug history (including eye drops).
Associated symptoms, eg. syncope,
SOB, dizziness, palpitations.
Consider 24 hour ambulatory ECG
recording or event recorder if
paroxysmal.
ECG.
Thyroid function tests.
Consider echocardiography.
Management Options
Asymptomatic:
 Discuss.
Symptomatic:
Referral Guidelines
Complete heart block and syncope –
Category 1.
Bradyarrhythmia with dizziness –
Category 2.
 Refer for outpatient assessment.

Consider acute assessment if
symptoms severe.
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REFREC001
Diagnosis / Symptomatology
Chest pain
Evaluation
History – duration, precipitants, type,
radiation, response to treatment.
Evidence of underlying cardiac/
respiratory/gastric disease.
Drug history.
Associated symptoms, eg. SOB,
palpitations, GI symptoms.
ECG.
Cardiac enzymes if acute.
Lipids.
FBC.
Management Options
Referral Guidelines
Acute or suspected MI – aspirin and
immediate admission.
Refer management options which
defines referral guidelines.
Unstable symptoms or rest pain – refer
for immediate admission.
Acute MI
Probable stable angina, commence
aspirin and nitrolingual spray and BBlockers if no contraindication.
(Ultimately will require ACE I and
statin as well). Risk factor
modification. Refer for outpatient
opinion.
}
Category 1.
Acute unstable angina }
New onset angina
}
Angina CCS 3-4
}
Category 2.
Stable angina CCS 1-2 – Category 3.
UEC.
Glucose.
CXR.
Exercise stress testing.
Possible chronic angina – consider
trial of medication (aspirin, beta
blockers and nitrates). Consider
referral to appropriate service.
Risk factor evaluation.
Immediate admission – Category 1.
Suspected pulmonary embolus/aortic
dissection – immediate admission to
appropriate specialty.
Last updated February 2006
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REFREC001
Diagnosis / Symptomatology
Heart failure/breathlessness
Last updated February 2006
Evaluation
Management Options
History – duration, PND, orthopnoea,
NYHA class.
Evidence of underlying cardiac/
respiratory/thyroid disease.
Drug history.
Associated symptoms, eg. angina,
palpitations.
ECG.
FBC, U&E, blood glucose, lipid profile,
TFTs, LFTs.
CXR.
Echocardiography.
Weight.
Risk factor evaluation.
Alcohol history.
If acute heart failure, refer for
assessment/admission. Oxygen,
nitrate patch and IV Frusemide prior to
transfer.
Referral Guidelines
Acute heart failure – Category 1
All non-acute patients – initial
assessment – Category 3.
If evaluation suggests heart failure,
commence diuretics and other
treatment as appropriate. This includes
ACE I (if no aortic stenosis),
carvedilol, spironolactone, and digoxin
with atrial fibrillation. Management of
precipitating conditions, eg. obesity,
thyroid disease, alcohol consumption
and anaemia.
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REFREC001
Diagnosis / Symptomatology
Hyperlipidaemia
Last updated February 2006
Evaluation
Rick factor evaluation:

Family history, particularly age of
onset.

Smoking.

Hypertension.

Diabetes.

Cardio-vascular disease.

Obesity.

Age.

Fasting lipids (at least two
specimens).

Blood sugar.

Thyroid function / Liver function
Management Options
Refer to current guidelines – National
Heart Foundation, particularly dietary
advice.
Referral Guidelines
Referral letter for consideration of lipid
lowering therapy according to NHF
guidelines.
Management of other risk factors.
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REFREC001
Diagnosis / Symptomatology
Hypertension
Evaluation
History – duration.
Evidence of underlying cardiac/renal/
endocrine disease.
Management Options
Lifestyle modification.
Family history.
Antiypertensive treatment should be
individualised according to comorbid
conditions
Associated symptoms, eg. angina,
SOB, palpitations, neurological.
eg. angina and hypertension (BBlocker).
ECG.
Diabetes and hypertension – ACE
inhibitors.
Drug history, including alcohol.
FBC, U&E, blood glucose, lipid profile.
CXR.
Referral Guidelines
Refractory hypertension – patients on
three or more medications with BP
greater than 140/90.
Secondary hypertension should be
referred to appropriate service, ie.
endocrinology, renal or cardiac
service.
Hypertension in pregnancy should be
referred initially to obstetricians.
MSU.
Malignant hypertension – Category 1.
Risk factor evaluation.
Consider investigation of secondary
causes, eg. co-arctation,
phaeochromocytoma, Cushing’s,
Conn’s syndrome, renal artery
stenosis.
Last updated February 2006
Severe hypertension > 200/120 –
Category 2.
Other hypertension – Category 3.
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REFREC001
Diagnosis / Symptomatology
Murmurs
Evaluation
Management Options
Referral Guidelines
Suspected endocarditis – Category 1.
History – duration, rheumatic fever.
If evaluation suggests innocent
(benign flow) murmur – reassure.
Associated symptoms, eg. angina.
Otherwise, refer.
Cardiac enlargement
Developmental, gestational history.
Family history.
}
Category 3.
Non-innocent murmurs }
SOB, palpitations, syncope.
Any other stigmata of congenital
anomaly?
ECG.
CXR (if not pregnant).
Echocardiography.
Diagnosis / Symptomatology
Other, eg.
Asymptomatic cardiomegaly.
Asymptomatic patients with abnormal
ECGs.
Transfers of patients from other
hospitals into local care.
Last updated February 2006
Evaluation
History – duration: post treatments.
Evidence of underlying cardiac
disease.
Drug and alcohol history.
ECG.
CXR.
Consider echocardiography.
Weight.
Risk factor evaluation.
Management Options
Discuss with cardiologists if required.
Referral Guidelines
Referral if appropriate – Category 3.
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REFREC001
Diagnosis / Symptomatology
Palpitation – including SVT
Evaluation
History – duration of symptoms
(careful description of attack,
onset/offset, character of palpitation
etc).
Evidence of underlying cardiac/thyroid
disease/HT.
Drug history including caffeine and
alcohol.
Management Options
Referral Guidelines
If evaluation negative or suggests only
ectopic beats or sinus tachycardia –
reassurance.
In the presence of underlying cardiac
disease, significant symptoms,
abnormal ECG, or ongoing
palpitations, refer to Cardiologist –
Category 3 – routine.
Letter of referral for ECG if prolonged
or ECG to be sent/faxed from GP
practice for opinion.
(Category 2 – urgent if syncope
present.)
Associated symptoms, eg. syncope,
presyncope, chest pain and dyspnoea.
ECG (during if possible).
Thyroid Function Tests, FBC and U&E.
Consider 24 hour ambulatory ECG
recording and echocardiography.
Diagnosis / Symptomatology
Supraventricular Tachycardia (SVT)
Last updated February 2006
Evaluation
History – duration of symptoms.
Evidence of underlying cardiac/thyroid
disease.
Drug history.
Consider 24 hour ambulatory ECG
recording or event recorder if
paroxysmal.
ECG.
Thyroid function tests.
Echocardiography.
Management Options
If isolated in the absence of syncope/
haemodynamic compromise:
 Reassure.
 Consider vagolytic manoeuvres.
If recurrent or abnormal ECG – refer.
Referral Guidelines
In the presence of underlying cardiac
disease, significant symptoms,
abnormal ECG, or ongoing
palpitations, refer to cardiologist.
SVT – continuous – Category 1.
SVT – other – Category 3.
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REFREC001
Diagnosis / Symptomatology
Syncope or presyncope
Evaluation
History – duration of symptoms,
precipitants (eg. cough, micturition)
Evidence of underlying cardiac
disease/GI bleeding.
Drug history especially diuretics.
Associated symptoms, eg angina,
SOB, palpitations, neurological signs/
postural hypotension.
ECG.
Full blood count.
Consider 24 hour ambulatory ECG
recording or event recorder if
paroxysmal.
Thyroid function tests. UEC, Mg.
Management Options
Isolated event and negative findings –
reassure.
History suggests vaso-vagal event in
young and otherwise fit – reassure
(vasovagal or neurocardiogenic
syncope – recommend hydration,
liberal with salt intake and avoid
prolonged immobilistation).
(refer if recurrent).
Referral Guidelines
Syncope – Category 1 or 2.
Presyncope – Category 3 – routine.
If recurrent – refer.
Consider echocardiography.
Diagnosis / Symptomatology
Ventricular Tachyarrhythmias
Evaluation
History – duration of symptoms
Evidence of underlying cardiac
disease.
Drug history.
Associated symptoms, eg angina and
syncope, SOB.
ECG.
Management Options
Immediate phone referral for acute
admission (via ambulance).
Referral Guidelines
Admission – Category 1.
Draw blood for UEC, Mg, CK. (May be
useful if need DCV – send with
ambulance).
IV cannula.
Echocardiogram.
Last updated February 2006
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