When should a patient with heart failure be referred to a cardiologist?

From the Guidelines

Patients with heart failure should be referred to a cardiologist when they have severe heart failure class III/IV, unknown etiology, relative contraindications, intolerance to low dose beta-blockade, or previous use of beta-blocker and discontinuation because of symptoms, as indicated by the European Society of Cardiology guidelines 1. When considering referral to a cardiologist, several key factors come into play, including the severity of heart failure, the presence of complex comorbidities, and the need for advanced therapies.

• Severe heart failure, classified as NYHA class III/IV, necessitates immediate referral due to the high risk of morbidity and mortality associated with this condition.
• Unknown etiology of heart failure also warrants referral to a cardiologist, as determining the underlying cause is crucial for guiding treatment and improving outcomes.
• Relative contraindications, such as bradycardia or low blood pressure, require careful evaluation by a cardiologist to ensure safe and effective management.
• Intolerance to low dose beta-blockade or previous discontinuation of beta-blockers due to symptoms are also indications for referral, as these patients may require alternative therapies or closer monitoring. The American College of Cardiology Foundation/American Heart Association guidelines also emphasize the importance of referral for patients at risk for heart failure, including those with hypertension, atherosclerotic disease, diabetes, and obesity 1. However, the most recent and highest quality evidence prioritizes the referral criteria outlined by the European Society of Cardiology 1, which focuses on the severity of heart failure and the presence of complex comorbidities.
• Key considerations for referral include:
  • Severe heart failure class III/IV
  • Unknown etiology
  • Relative contraindications
  • Intolerance to low dose beta-blockade
  • Previous use of beta-blocker and discontinuation because of symptoms By prioritizing these factors and referring patients to a cardiologist accordingly, healthcare providers can improve outcomes and reduce the risk of morbidity and mortality associated with heart failure.

From the Research

Referral to a Cardiologist

When considering referral to a cardiologist for heart failure, several factors should be taken into account:

• The presence of symptoms such as dyspnea or limited exertion due to impaired cardiac ventricular filling and/or blood ejection 2
• The patient's ejection fraction, as treatment options may vary for heart failure with reduced ejection fraction (HFrEF) versus heart failure with preserved ejection fraction (HFpEF) 3
• The patient's response to initial treatment, as optimization of guideline-directed chronic HF therapy is crucial for improving quality of life, mortality, and HF hospitalizations 3

Timing of Referral

Referral to a cardiologist should be considered when:

• Initial treatment is not effective in managing symptoms or improving cardiac function 3
• The patient has a history of acute decompensated HF, acute myocardial infarction with reduced ejection fraction, or other comorbidities that may impact treatment 3
• The patient requires specialized care, such as device therapy or advanced heart failure management 4

Guideline Recommendations

The 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure provides recommendations for the referral of patients to a cardiologist, including:

• Referral to a cardiologist for patients with new-onset HF or worsening symptoms 4
• Consideration of referral to a heart failure specialist for patients with advanced HF or those requiring specialized care 4