When should a patient be referred to cardiology?

When to Refer a Patient to Cardiology

Patients with chest pain who have high-risk features, evidence of acute coronary syndrome (ACS), or abnormal ECG findings should be immediately referred to cardiology through the emergency department, ideally via emergency medical services. 1

Immediate Referral Indications (Emergency Department)

High-Risk Clinical Presentations

• Continuing chest pain with characteristics suggestive of ischemia (central, pressure-like, squeezing, heaviness, tightness) 1
• Severe dyspnea
• Syncope or presyncope
• Palpitations
• Patients ≥75 years with shortness of breath, syncope, acute delirium, or unexplained fall 1
• Any patient with clinical evidence of ACS 1

ECG Findings Requiring Immediate Referral

• ST-segment elevation
• ST-segment depression
• New T-wave inversions
• Any new conduction abnormalities 1

Office-Based Evaluation

• If ECG is unavailable in the office setting, refer to ED for immediate ECG 1
• Avoid delayed transfer to ED for cardiac troponin or other diagnostic testing 1
• For patients with acute chest pain, ECG should be acquired and reviewed within 10 minutes of arrival 1

Referral for Non-Emergency Cardiology Evaluation

Stable Angina Patients

• Patients with typical angina symptoms not responding to initial pharmacotherapy 1
• Patients with stable angina requiring further risk stratification 1
• Patients with high pre-test probability of coronary artery disease based on:
  • Age (risk increases with age)
  • Male gender
  • Typical angina characteristics (retrosternal, exertional, relieved by rest/nitroglycerin)
  • Multiple cardiovascular risk factors 1

Risk Factors Warranting Cardiology Referral

• History of coronary artery disease
• History of heart failure
• Diabetes mellitus
• Hypercholesterolemia
• Multiple cardiovascular risk factors 1, 2

Special Populations

• Women with chest pain should be evaluated with attention to accompanying symptoms that are more common in women with ACS 1
• Patients with diabetes, who may present with atypical symptoms 1

Evaluation Algorithm Before Referral

1. Assess chest pain characteristics:

   • Central location, pressure-like quality, exertional nature suggest cardiac origin
   • Sharp, pleuritic, positional pain suggests non-cardiac origin 1

2. Perform focused cardiovascular examination:

   • Look for signs of heart failure (S3, crackles)
   • Assess for murmurs suggesting valvular disease
   • Check for pulse differentials suggesting aortic dissection 1

3. Obtain ECG:

   • If normal but high clinical suspicion, consider serial ECGs
   • Consider supplemental leads V7-V9 if posterior MI suspected 1

4. Risk stratify patient:

   • Age, gender, cardiovascular risk factors
   • Nature and pattern of symptoms
   • Previous cardiovascular disease 1

Common Pitfalls to Avoid

1. Underdiagnosing cardiac disease in women

   • Women are at risk for underdiagnosis and should always be considered for cardiac causes of chest pain 1

2. Misattributing symptoms in elderly patients

   • Older patients may present with atypical symptoms like shortness of breath rather than chest pain 1

3. Premature reassurance

   • Patients diagnosed with "non-cardiac chest pain" without adequate evaluation have poor outcomes and continued disability 3

4. Overlooking anxiety and depression

   • While these conditions may contribute to symptoms, they should not prevent appropriate cardiac evaluation 4

5. Failure to recognize high-risk features

   • Even when initial impression is "non-cardiac chest pain," patients with traditional cardiovascular risk factors or history of coronary disease should receive further evaluation 2

Rapid access cardiology services have been shown to accurately diagnose cardiac disease and identify high-risk patients, with very low rates of missed cardiac diagnoses (2%) 5. Implementing structured referral pathways based on risk stratification can ensure appropriate utilization of cardiology services.