When should a patient be referred to a cardiologist?

When to Refer a Patient to a Cardiologist

Patients with established cardiac disease (coronary heart disease, heart failure, valvular disease, severe pulmonary hypertension with PASP >60mmHg or >50mmHg with abnormal right ventricle, or significant arrhythmia) should be referred to a cardiologist for evaluation and management. 1

Immediate/Urgent Referral Indications

Refer immediately for:

• Suspected myocarditis requiring emergency intervention 2
• Hemodynamically unstable new-onset atrial fibrillation 2
• Severe coronary artery disease with refractory symptoms despite medical treatment 2
• Deteriorating left ventricular systolic function without reversible cause 2
• Significant worsening cardiac symptoms requiring expedited evaluation 2

Symptomatic Patients Requiring Referral

Any patient with chest pain or angina-equivalent symptoms (even without known coronary disease) should be evaluated by a cardiologist, with strong consideration for noninvasive and/or invasive imaging. 1

Additional symptomatic indications include:

• Characteristic episodic resting angina with ST-segment changes that resolve with nitrates and/or calcium antagonists 2
• Severe angina despite antianginal drug treatment 2
• Clinical signs or symptoms concerning for cardiac dysfunction in any patient, particularly cancer survivors 1, 2

Heart Failure-Specific Referrals

Patients with advanced heart failure who wish to prolong survival should be referred to a team specializing in heart failure for review of management and assessment of suitability for advanced therapies (left ventricular assist devices, cardiac transplantation, palliative care). 1

Additional heart failure referral criteria:

• LVEF <50% 1
• LVEF persistently <40% (cardiomyopathy) - consider heart failure specialty clinic 1
• Evidence of ischemic left ventricular dilation 1
• Exercise-induced hypotension 1
• Demonstrable ischemia in multiple coronary artery distributions 1
• Asymptomatic cardiac dysfunction detected during surveillance 1, 2
• Abnormal cardiac biomarkers and/or abnormal echocardiogram findings 2

Valvular Heart Disease Referrals

Refer patients with:

• Bicuspid aortic valve with ascending aorta diameter ≥4.0 cm for serial imaging 2
• Moderate to severe aortic stenosis or regurgitation 2
• Subaortic stenosis with peak Doppler gradient ≥30 mmHg 2
• Women with aortic stenosis contemplating pregnancy 2
• Women with bicuspid aortic valve and ascending aorta diameter >4.5 cm due to high pregnancy risks 2

Congenital Heart Disease Referrals

Adults with moderate or complex congenital lesions, or simple lesions with associated cyanosis, pulmonary hypertension, or significant valve disease should be evaluated at an Adult Congenital Heart Disease (ACHD) center annually. 2

• Newly diagnosed coronary artery anomalies require evaluation by ACHD team with expertise in imaging, CAD management, intervention, and surgical revascularization 2

Pulmonary Hypertension Referrals

For patients with sickle cell disease:

• Peak tricuspid regurgitant jet velocity (TRJV) ≥2.5 m/s with reduced 6-minute walk distance and/or elevated NT-BNP 2
• TRJV >2.9 m/s with normal 6-minute walk distance and NT-BNP but other concerning echocardiographic findings - consult pulmonary hypertension expert 2

Special Populations

Cancer Patients

Baseline cardiovascular risk assessment is recommended in patients starting potentially cardiotoxic cancer therapies, with cardiology consultation when appropriate for multiple cardiovascular risk factors or established cardiovascular disease. 2

Specific cancer-related referral indications:

• Diagnosed atrial fibrillation or AF risk factors before starting cardiotoxic treatments 2
• Abnormal baseline cardiac investigations before starting immune checkpoint inhibitor therapy 2
• Concerning cardiac symptoms or abnormal cardiac tests during immune checkpoint inhibitor therapy 2

Transplant Candidates

Participation of a dedicated cardiologist in multidisciplinary candidate selection committees facilitates evaluation, improves testing efficiency, and supports standardized protocols. 1

For kidney transplant candidates:

• Cardiomyopathy (LVEF persistently <40%) for heart failure specialty clinic referral 1
• Known coronary disease with new/inadequately controlled cardiac symptoms for invasive coronary angiography consideration 1

Cardiac Testing Abnormalities

Diabetes Patients

Refer for diagnostic cardiac stress testing if:

• Typical or atypical cardiac symptoms 1
• Abnormal resting electrocardiogram 1

Consider screening cardiac stress testing for:

• History of peripheral or carotid occlusive disease 1
• Sedentary lifestyle, age >35 years, planning vigorous exercise 1
• Two or more cardiovascular risk factors (dyslipidemia, hypertension, smoking, family history of premature coronary disease, micro- or macroalbuminuria) 1

Patients with abnormal exercise ECG or inability to perform exercise ECG require additional testing (stress nuclear perfusion or stress echocardiography) and cardiology consultation. 1

QT Interval Prolongation

In cases of structural heart disease, QT prolongation, or cardiac symptoms, referral to a cardiologist should be considered. 1

Coordination of Care Considerations

It may be reasonable for each program to identify a primary cardiology consultant for questions related to potential transplant candidates or complex cardiac management. 1

Common Pitfalls to Avoid

• Delaying cardiology referral for suspected myocarditis can lead to rapid deterioration 2
• Failing to refer congenital heart disease patients to specialized ACHD centers results in suboptimal management 2
• Relying solely on invasive coronary angiography without appropriate non-invasive testing first is not recommended 2
• Underutilizing ASCVD risk scores in primary care chest pain patients - less than 8% of chest pain patients are referred, and ASCVD risk tools could help identify those most in need 3

Evidence Supporting Cardiology Referral Benefits

Follow-up with both a primary care physician and cardiologist after emergency department discharge for low-risk chest pain was associated with significantly reduced risk of death or MI at 1 year (adjusted HR 0.81,95% CI 0.72-0.91) compared to no follow-up. 4 This demonstrates measurable mortality and morbidity benefits from appropriate cardiology involvement, even in lower-risk populations.