DIAGNOSIS
Hypertension (HTN)
Murmur (New or Changing)
Chest Pain/Pressure
Lipid Management
CONSIDERATIONS
Primary prevention:

Management per PCP

Specialist (Nephrology or Cardiology depending on the specifics of the case) consult if uncontrolled on 3 or more BP classes after initial work-up by PCP; including H&P, blood pressure check in both arms and tests (TSH, CBC, renal chemistry panel, UA, fasting lipid panel and chest X-ray, ECG)
Secondary prevention (MI, SCHF or prior admit for DCHF, arrhythmia, moderate or severe pulmonary hypertension-PASP greater than 50, stroke, CRI 3 or higher, other structural heart disease**):

Management per PCP

Specialist (Nephrology or Cardiology depending on the specifics of the case) consult as desired by the PCP if uncontrolled with 2 BP medications
Echocardiogram as directed by the PCP:

See Cardiology Referral Guidelines for Cardiologist Self-Referral
With stigmata of unstable angina, MI, PE, GI bleed, aortic aneurysm or other life threatening conditions:

Stat cardiology consult, send to ER/hospital or call 911 per PCP direction
Persistent/recurrent:

H&P, office ECG, Chest X-ray, labs (CBC, CMP, TSH fasting lipids)

Consider non-cardiac cause

Refer for MPS or stress echo, if not clearly non-cardiac

Cardiology consult if cardiac causes suspected after initial work-up
Not persistent/recurrent:

Without DM or less than 2 non-diabetic risk factors* then work-up per PCP as stated above without cardiology consult

DM, strong tobacco history, premature family history (male less than 55, female less than 65), or greater than or equal to 2 non-diabetic risk factors* then treat as persistent/recurrent above
Primary prevention:

Management per PCP

Specialist (Endocrinology or Cardiology depending on the specifics of the case) consult if uncontrolled on maximum lipid lowering efforts, after initial workup
(TSH, CBC, renal chemistry panel, UA, H&P, lipid panel & A1C)
Secondary prevention: (history of MI, stroke, DM or other arterial occlusive disease):

Management per PCP

Cardiology consult as desired by PCP, if fasting lipid panel shows poor control on one or more lipid lowering medications, if DM is controlled
Post Hospital / ER Discharge with
Suspected or Proven Cardiac
Symptoms
Refer to Cardiology Referral Guidelines for Cardiologist Self-Referral, for any specific postdischarge diagnosis

Cardiology consult as directed by PCP or hospital based physician

Cardiology follow-up if seen by the Cardiologist in the ER or the hospital
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DIAGNOSIS
Shortness of Breath
(Cardiac causes suspected)
Syncope/Pre-Syncope
Palpitations (without associated symptoms such as diaphoresis, SOB,
CP)
New Exercise Program
Pre-Op Evaluation
CONSIDERATIONS
With unstable signs and symptoms:

Stat specialist consult, send to ER/hospital, or 911 per PCP direction
Persistent/recurrent:

H&P, office ECG, Chest X-ray, labs (CBC, CMP) Consider non-cardiac cause

MPS or stress echo or 2D echo and/or holter monitor if not clearly non-cardiac

Specialist (Cardiology or Pulmonology depending on the specifics of the case) consult as desired by the PCP after initial work-up
Not persistent/recurrent and low risk factors:

Work-up per PCP as stated above (without specialist consult)
With unstable signs and symptoms:

Stat cardiology consult, send to ER/hospital or 911 per PCP direction
PCP work-up:

ECG, CBC, CMP, Glucose, H&P

Review of medications, as possible cause

Consider orthostatic hypotension, vasovagal, or seizure disorder

Stress echocardiogram if CAD risk factors or echocardiogram, if not getting a stress echocardiogram and if this is primary work-up for first syncope event

Consider holter, event monitor, loop recorder or other recording device, as appropriate to the specifics of the case

Cardiology consult if persistent/recurrent and after above work-up
Cardiology consult, after above work-up, if high risk: (associated with exertion or syncope induced trauma, high risk occupation, structural heart disease**, known CAD, history of arrhythmias, known cardiomyopathy, pacemaker, prior ablation procedure, previously or presently on antiarrhythmic medication)
PCP work-up:

ECG, TSH, CMP, CBC, H&P (to include screen for alcohol, caffeine, and substance abuse)

Review of medications, as possible cause

Consider work-up for sleep apnea, as indicated (screening ROS to be documented)

Consider holter, event monitor, loop recorder or other recording device, as appropriate to the specifics of the case

Consider echocardiogram or stress echocardiogram, if CAD risk factors or suspected CAD

Cardiology consult after above work-up, if persistent/recurrent or interferes with
ADLs
Cardiology consult, after above work-up, if high risk: (history of CAD, history of cardiomyopathy, prior ablation procedure, antiarrhythmic medication history, associated with exercise, pacemaker, structural heart disease**)
Blood work & ECG, if desired by the PCP without cardiology consult.
Treadmill stress test if any 1 of 5 cardiac risk factors*, as directed by the PCP, if 1 has not been done within the last 2 years. Stress echocardiogram if abnormal baseline ECG
Cardiology consult if positive for pre-op evaluation for non-vascular surgery criteria (see below)
For vascular surgery:

As directed by the Vascular Surgeon

For major vascular surgery such as carotid, aortic, ileo-femoral, consider cardiology consultation or stress test if one has not been done within the last year.
Non vascular surgery:

PCP may elect stress test and/or other work-up as desired if patient falls under
American Heart Association ( http://circ.ahajournals.org/ ) pre-op evaluation algorithm
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DIAGNOSIS CONSIDERATIONS
Pre-Op Evaluation
(cont.)

Patient can receive a cardiology consult if: o CHF or chronic angina with either class 3/4 symptoms OR worsening frequency, duration or severity within the last 6 months o LVEF less than or equal to 40% o History of MI or Stent o New ECG changes consistent with ischemia (see InterQual criteria) o Symptomatic MS/AS OR valve area of less than or equal to 1.5 CM 2 o MR/AR – severity grade 3+/4+ o Prosthetic valve(s) o Pacemaker or defibrillator o A fib, Aflutter, antiarrhythmic RX, multiform PVC, greater than or equal to 5 PVC’s per minute, tachycardia or heart rate less than or equal to 45 o Second degree heart block o Pulmonary artery pressures of 50 or greater AND need for general anesthesia o Abdominal or thoracic surgery WITH one of the following:
 Age over 70, known CAD, history of stroke/TIA, renal insufficiency, DM or poor exercise tolerance (unable to walk one flight of stairs)
In order to do more than one pre-op cardiology evaluation per a 12-month period, the patient must have documented change in condition.
Note:
All follow up and test schedules stated in this guideline assumes sign and symptom stability. Medication changes by a Cardiologist are expected to be followed by the Primary Care Providers. Exception to this would be anti-arrhythmic medication changes and patients with unstable symptoms
(example A Fib with RVR or worsening SOB). All cardiology consultation notes and test / lab results are expected to be sent to the Primary Care
Provider as soon as possible.
* HTN, lipid, tobacco, family history (DM would be the 5th of 5 main cardiac risk factors)
**LVH (greater than 1.2 CM), RVE, septal hypertrophy, reduce EF, moderate to severe aortic or mitral valvular HD, congenital HD
The use of the Cardiology Referral Guidelines for Primary Care Physicians and the Cardiology Referral Guidelines for Cardiologist Self-Referral are not restricted by the title of the guideline, both can be used by the PCP and treating specialist.
04/16/20
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