When should a patient be referred to a cardiologist?

When to Consult Cardiology

Patients should be referred to a cardiologist when they have abnormal cardiac test results, significant cardiovascular risk factors, or symptoms suggestive of cardiac disease that require specialized evaluation and management beyond primary care capabilities. 1

Urgent/Immediate Cardiology Referral Indications

• Patients with suspected or documented myocarditis, as this condition can rapidly lead to death and requires emergency intervention with high-dose corticosteroids and immediate discontinuation of immunotherapy 1
• Patients with severe coronary artery disease, particularly if symptoms are refractory to medical treatment or if they have a high-risk clinical profile 1
• Patients with deteriorating left ventricular systolic function that cannot be attributed to a reversible cause 1
• Patients with significant worsening of cardiac symptoms that require expedited evaluation 1
• Patients with new-onset atrial fibrillation who are hemodynamically unstable 1

Cardiovascular Disease-Specific Referral Indications

Heart Failure

• Patients with abnormal cardiac biomarkers (troponin, BNP, NT-proBNP) and/or abnormal echocardiogram findings 1
• Patients identified to have asymptomatic cardiac dysfunction during routine surveillance 1
• Patients with heart failure who would benefit from specialized care to improve medication adherence and reduce mortality and readmission rates 2, 3

Coronary Artery Disease

• Patients with characteristic episodic resting angina and ST-segment changes that resolve with nitrates and/or calcium antagonists 1
• Patients with severe angina despite treatment with antianginal drugs 1
• Patients with multivessel coronary artery disease who may benefit from a heart team approach for revascularization decisions 4

Valvular Heart Disease

• Patients with bicuspid aortic valve and ascending aorta diameter ≥4.0 mm for serial imaging assessment 1
• Patients with moderate to severe aortic stenosis or regurgitation 1
• Patients with subaortic stenosis with peak Doppler gradient across the obstruction of ≥30 mm Hg 1

Congenital Heart Disease

• Adults with moderate or complex congenital lesions or those with simple lesions with associated cyanosis, pulmonary hypertension, or significant valve disease should be evaluated at an Adult Congenital Heart Disease (ACHD) center annually 1
• Patients with newly diagnosed coronary artery anomalies should be evaluated by an ACHD team with expertise in imaging, CAD management, intervention, and surgical revascularization 1

Pulmonary Hypertension

• Patients with sickle cell disease and a peak tricuspid regurgitant jet velocity (TRJV) of ≥2.5 m/s who also have reduced 6-minute walk distance and/or elevated NT-BNP 1
• Consultation with a pulmonary hypertension expert for patients with TRJV >2.9 m/s who have normal 6-minute walk distance and NT-BNP but other concerning findings on echocardiography 1

Special Population Considerations

Cancer Patients

• Baseline cardiovascular risk assessment in patients starting potentially cardiotoxic cancer therapies 1
• Cancer patients with diagnosed atrial fibrillation or risk factors for developing AF before starting potentially cardiotoxic treatments 1
• Cancer survivors with clinical signs or symptoms concerning for cardiac dysfunction 1

Immune Checkpoint Inhibitor Therapy

• Patients with abnormal baseline cardiac investigations before starting immune checkpoint inhibitor therapy 1
• Patients who develop concerning cardiac symptoms or abnormal cardiac test results during immune checkpoint inhibitor therapy 1

Pregnancy Planning

• Women with aortic stenosis who are contemplating pregnancy 1
• Women with bicuspid aortic valve and ascending aorta diameter >4.5 cm due to high risks associated with pregnancy 1

Practical Considerations for Referral

• General practitioners tend to manage older, female heart failure patients with fewer diagnostic tests and less evidence-based medications compared to cardiologists 5
• Cardiologist care is associated with higher adherence to evidence-based medications and potentially lower mortality and readmission rates in heart failure patients 2, 3
• A heart team approach (involving cardiologists, cardiac surgeons, and other specialists) may change treatment decisions in up to 30% of cases compared to decisions made by a single interventional cardiologist 4
• An accurate baseline cardiovascular risk assessment should include consultation with a cardiologist when appropriate for any patient with multiple cardiovascular risk factors or established cardiovascular disease 1

Common Pitfalls to Avoid

• Delaying cardiology referral for patients with suspected myocarditis, as this condition can rapidly deteriorate 1
• Relying solely on invasive coronary angiography for risk stratification without appropriate non-invasive testing first 1
• Failing to refer patients with congenital heart disease to specialized ACHD centers, resulting in suboptimal management 1
• Underutilizing cardiology consultation for heart failure patients, which may lead to lower rates of evidence-based medication use and potentially worse outcomes 2, 3, 5