Cardiology outpatient referrals

COVID-19 and cardiology outpatient referrals

In common with most other specialties, we are changing the way we work over the next few months and in particular who we see in outpatient clinics.
The elderly, the immunocompromised, those with IHD or heart failure, men and smokers appear to be at higher risk of infection with COVID-19, and these demographics are highly pertinent to our cardiovascular patients. Elective intervention and arrhythmia procedures are being significantly curtailed. We, therefore, plan to restrict outpatients to urgent referrals.
All referrals will be vetted using the following criteria:

• Symptoms suggestive of angina on minimal exertion (marked limitation of ordinary physical activity, walking one or two blocks on the level and climbing one flight of stairs at a reasonable pace) despite optimal medical therapy with a minimum of 2 anti-anginal agents (b-blockers or ivabradine and nitrates or ranolazine): REFER
• Symptoms suggestive of crescendo angina: REFER
• Recurrence of symptoms suggestive of angina in patients who have had PCI or CABG in the past 12 months: REFER

• Palpitations with red flags (significant family history of SCD / arrhythmic syndrome, with syncope, on exertion, with known structural heart disease, abnormal ECG): REFER
• Palpitations in the otherwise fit and well – DO NOT REFER

• Syncope with injury, with known cardiac disease / red flags (significant family history of SCD / arrhythmic syndrome, preceded by palpitation, on exertion, with known structural heart disease, abnormal ECG): REFER
• Pre-syncope with known cardiac disease: REFER
• Typical vasovagal, postural or situational syncope in the absence of red flags and presyncope without cardiac history – DO NOT REFER
Asymptomatic / minimally symptomatic bradycardia: DEFER
Shortness of breath on exertion:
Minimum of ECG, CXR and NT-ProBNP
If suggestive of heart failure, initiate treatment with a diuretic, ACE-I/ARB, beta-blockers,
spironolactone. If rendered asymptomatic, DEFER REFERRAL
• If ongoing symptoms despite medical management: REFER
• If significant murmur or known valvular heart disease with worsening / disabling
symptoms: REFER
Shortness of breath with normal investigations: DO NOT REFER
Inherited Cardiac Conditions:
• Known or suspected ICC with palpitations, syncope or heart failure: REFER
• Genuinely suspected ICC, index case with symptoms: REFER
ICC family screening: referrals not being accepted and should be DEFERRED
Grown-up/Adult Congenital Heart Disease
• Known or suspected GUCH patients with new palpitations, heart failure: REFER
• Dr Head and Dr Freeman happy to DISCUSS by phone – mainly lost to follow up of complex GUCH with new symptoms
• All existing patients have access to the GUCH Cardiac nurse specialist telephone service
Pregnancy and Heart Disease
• Palpitations/ectopics common in 3rd Trimester: DO NOT REFER
• sustained rhythm disturbances in patients with a previous GUCH/ICC/VHD/IHD:
• Breathlessness lying flat is NOT normal in pregnancy or postpartum period – refer. Dr Head or Dr Freeman happy to DISCUSS by phone – particularly in known GUCH patients
If your patients do not fit into the above criteria and you still think they need to be seen urgently, write to us via the advice and guidance service and we will endeavour to guide you accordingly.