Chest Pain

• Suspected acute coronary syndrome
• Suspected pulmonary embolism or aortic dissection
• Suspected or confirmed endocarditis, myocarditis or pericarditis
• Suspected ischaemic chest pain within 24 hours with any of the following concerning features:
  • Chest pain that is:
    • severe or ongoing
    • lasting ten minutes or more
    • new at rest or with minimal activity
    • associated with severe dyspnoea
    • associated with syncope / pre-syncope
    • associated with any of the following signs:
      • respiratory rate > 30 breaths per minute
      • tachycardia >120
      • systolic BP <90mmHg
      • heart failure / suspected pulmonary oedema
      • ST elevation or depression
      • complete heart block
      • new left bundle branch block

Artrial Fibrillation

• Atrial fibrillation / flutter with any of the following concerning features
  • haemodynamic instability
  • shortness of breath
  • chest pain
  • syncope/pre syncope/dizziness
  • known Wolff-Parkinson-White
  • neurological deficit indicative of TIA/stroke

Heart Failure

• Acute or chronic heart failure with any of the following concerning features
  • NYHA Class IV heart failure
  • ongoing chest pain.
  • increasing shortness of breath.
  • oxygen saturation < 90%.
  • signs of acute pulmonary oedema
  • haemodynamic instability:
    • pre-syncope / syncope / severe dizziness
    • altered level of consciousness
    • heart rate > 120 beats per minute
    • systolic BP < 90mmHg
  • significant pulmonary or pedal oedema
  • recent myocardial infarction (within 2 weeks)
  • pregnant patient
  • sign of myocarditis
  • sign of acute decompensated heart failure

Hypertension

• Hypertensive emergency (BP >220/140)
• Severe Hypertensive with systolic BP >180mmHg with any of the following concerning features:
  • headache
  • confusion
  • blurred vision
  • retinal haemorrhage
  • reduced level of consciousness
  • seizures
  • proteinuria
  • papilloedema
• If suspected pregnancy include hypertension or pre-eclampsia refer patient to the emergency department of a facility that offers obstetrics services where possible.

Murmur

•  New murmur with any of the following concerning features:
  • haemodynamic instability
  • persistent or progressive shortness of breath (NYHA Class III - IV)
  • chest pain
  • syncope/pre-syncope/dizziness
  • neurological deficit indicative of TIA Stroke
  • abnormal ECG (e.g. LV hypertrophy, AF, LBBB, RBBB)
  • fever or constitutional symptoms suggestive of infection (e.g. endocarditis, acute rheumatic fever)
  • signs of heart failure

Palpitations

• Palpitations with any of the following concerning features:
  • chest pain
  • shortness of breath
  • loss of consciousness
  • syncope / pre-syncope
  • persisting tachyarrhythmia on ECG

Supraventricular tachycardia:

• Unresolved acute supraventricular tachycardia with any of the following concerning features:
  • syncope
  • severe dizziness
  • ongoing chest pain
  • increasing shortness of breath
  • hypotension
  • signs of cardiac failure
  • ventricular rate >120

Syncope/ Pre-syncope:

• Syncope with any of the following concerning features:
  • exertional onset
  • chest pain
  • persistent hypotension (systolic BP <90mmHg)
  • severe persistent headache
  • focal neurological deficits
  • preceded by or associated with palpitations
  • associated with SVT or paroxysmal atrial fibrillation
  • known ischaemic heart disease with reduced LV systolic function
  • pre-excited QRS (delta waves) on ECG
  • suspected malfunction of pacemaker or ICD
  • absence of prodrome
  • associated injury
  • occurs while supine or sitting

Other

• Pacemaker/ICD
  • Delivery of 2 or more shocks by ICD in 24 hours
  • Suspected pacemaker/defibrillator malfunction (with ECG evidence)
  • pacemaker/ICD device erosion
• Bradycardia including any of the following:
  • symptomatic bradycardia
  • PR interval on ECG exceeding 300ms
  • second degree or complete heart block
• Broad complex tachycardia
• Suspected or confirmed endocarditis, myocarditis or pericarditis

Essential information (Referral will be declined without this)

• General Referral Information
• As much detail as possible about the patient’s personal history of disease including the following:

• clear indication of clinical need for urgency (see above)
• clinical diagnosis and features
• age at diagnosis
• treatment (completed and planned)
• relevant pathology (if results are available on Auslab please indicate this on referral)
• relevant organ specific diagnostic investigations and/or imaging results (especially ECG, MRI and echocardiogram) (if results are available within ieMR please indicate this on referral)
• details and results of genetic testing if performed

• Presence or absence of relevant family (blood relatives) history

Additional referral information (useful for processing the referral)

• Known details of relevant family history (first and second degree blood relatives including:
  • clinical diagnosis/features and age at diagnosis
  • relation to patient including whether maternal or paternal
  • autopsy reports (where relevant and available)

• If the family is known to GHQ, the GHQ reference number (GF)
• If the family are known to another genetic service, the name of the service and family reference number (if available)

Other useful information for management (not an exhaustive list)

• • The offer of an appointment by GHQ does NOT guarantee that the patient will be offered a publicly funded genetic test.
  • If there are any queries regarding the appropriateness of a referral please contact GHQ.
  • If the patient is an UNTESTED blood relative of a person with an identified gene mutation/chromosomal anomaly, please refer to the following CPC:
    • Unaffected (predictive/presymptomatic testing)
    • Affected (confirmatory testing)
  • Patients will be asked to provide detailed family information either during a telephone consultation or via a family history questionnaire. One or more ‘Consent to Release information’ forms may be provided to forward to family members to obtain their consent to confirm details of the reported family history.
  • The Queensland Cardiac Genetics Service is a collaborative multidisciplinary clinical service with both cardiology and clinical genetics staff in attendance. The clinics are primarily based at the Royal Brisbane and Women's Hospital (adult) and Queensland Children’s Hospital (children), however regional clinics and telehealth appointments are also available.
  • Examples of conditions where individuals might be referred include a confirmed or suspected diagnosis/family history of:
    • ascending aortic aneurysm/aortopathy/vasculopathy
    • hypertrophic cardiomyopathy
    • arrhythmogenic right ventricular cardiomyopathy (ARVC)
    • left ventricular non-compaction (LVNC)
    • dilated cardiomyopathy
    • long QT syndrome
    • catecholaminergic polymorphic ventricular tachycardia (CPVT)
    • Brugada syndrome
    • sudden unexplained death in a young relative (less than 40 years of age)
    • familial hypercholesterolaemia
    • paediatric pulmonary hypertension
    • Marfan syndrome (please ensure an echocardiogram and ophthalmology review has been requested)
    • congenital heart defect

Clinical resources

• NSW Centre for Genetics Education

Patient resources

• NSW Centre for Genetics Education
• Australian Genetic Heart Disease Registry Information sheets
  • Familial dilated cardiomyopathy
  • Hypertrophic cardiomyopathy (HCM)
  • Arrhythmogenic right ventricular cardiomyopathy
  • Long QT syndrome
  • Catecholaminergic polymorphic ventricular tachycardia
  • Left ventricular noncompaction
  • Brugada syndrome

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information (Referral will be declined without this)

• General Referral Information
• Details of relevant signs and symptoms
• Details of all treatments offered and efficacy
• Past medical history and comorbidities
• Patient’s functional status
• Family history of premature cardiac disease or sudden cardiac death
• FBC, ELFTs, fasting lipids, HbA1c (if diabetic) results
• ECG

Additional referral information (useful for processing the referral)

• Investigations relevant to significant comorbidities
• Cardiovascular risk assessment score
• Other investigations (if available) including CXR, cardiac imaging: stress ECG, stress echo or myocardial perfusion scan
• History of smoking, alcohol intake and drug use (including recreational drugs)

Other useful information for management (not an exhaustive list)

• No additional information

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information (Referral will be declined without this)

• General Referral Information
• Details of relevant signs and symptoms
• Details of all treatments offered and efficacy
• Past medical history and comorbidities
• Family history of sudden cardiac death
• FBC, ELFTs, TSH
• All available ECGs (including ECG showing arrhythmia)

Additional referral information (useful for processing the referral)

• Any investigations relevant to any co-morbidities
• Other investigations (if available) eg echocardiogram report, CXR report, holter monitor report, sleep study report
• History of smoking, alcohol intake and drug use (including recreational drug use)
• Coagulation studies, fasting lipid results
• CHADS VASC score

Other useful information for management (not an exhaustive list)

• Not all patients have to be seen by a cardiologist if the general practitioner is comfortable caring for the patient
• In patients with new onset atrial arrhythmias (<48 hours), consider a fast track approach via telephone contact with the nearest cardiology service for consideration of earlier cardioversion to minimize the burden of atrial arrhythmia.

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information (Referral will be declined without this)

• General Referral Information
• Cardiac history
• Symptoms e.g. syncope, pre-syncope, palpitations, clamminess
• Relevant imaging
• Previously performed cardiac investigations (ECG, ECHO, stress test, chest x-ray)
• Pregnancy Details
  • gestational age
  • expected date of delivery
  • previous pregnancies

Additional referral information (useful for processing the referral)

• Nil additional information

Other useful information for management (not an exhaustive list)

• Nil additional information

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information (Referral will be declined without this)

• General Referral Information
• Details of relevant signs and symptoms
• Details of all treatments offered and efficacy
• Relevant previous medical history and co-morbidities
• BP
• Weight, height & BMI
• Recent fluctuations in weight indicative of cardiac dysfunction (if known)
• New York Heart Association (NYHA) class
• FBC, ELFTs, fasting lipids, HbA1c (if diabetic), TSH,
• ECG
• CXR report

Additional referral information (useful for processing the referral)

• Sleep study report if OSA suspected
• Stress test report (if performed)
• Investigations relevant to co-morbidities
• Respiratory function tests if patient a smoker, has COPD or asthma
• Echocardiogram report
• BNP or NT-pro-BNP results
• History of smoking, alcohol intake and drug use (including recreational drugs)
• Aboriginal or Torres Strait Islander or Maori / Pacific Islander / Refugee status (increased risk of acute rheumatic fever and rheumatic heart disease)
• Iron studies 

Other useful information for management (not an exhaustive list)

• The Heart Foundation’s Heart Failure Guidelines and the European Society of Cardiology guidelines provide some additional information regarding patient management

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information (Referral will be declined without this)

• General Referral Information
• Details of relevant signs and symptoms
• Details of all treatments offered and efficacy
• BP (BP measurements on both arms preferable)
• Relevant previous medical history and co-morbidities
• FBC, ELFTs, eGFR, fasting lipids results
• Urinalysis results
• Urinary protein estimation results or albumin creatinine ratio
• CXR report
• ECG

Additional referral information (useful for processing the referral)

• Any investigations relevant to co-morbidities
• Stress test report (if available)
• Renal duplex report if renal artery stenosis suspected
• Smoking, alcohol intake and drug use (including recreational drugs)

Other useful information for management (not an exhaustive list)

• Consider testing for primary hyperaldosteronism, and phaeochromocytoma
• Refer to HealthPathways for assessment and management information if available.
• The Heart Foundation’s Hypertension Guidelines provide some additional guidance for patient management

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information (Referral will be declined without this)

• General Referral Information
• Details of all treatments offered and efficacy
• Relevant previous medical history and co-morbidities (especially cardiovascular disease)
• BP
• ELFTs, HbA1c, TSH
• Recent (within 3 months) fasting lipid results (cholesterol/ triglyceride/ HDL-cholesterol/ LDL-cholesterol)

Additional referral information (useful for processing the referral)

• Smoking and alcohol history
• Family history of hyperlipidaemia
• Previous lipid results (serial if available)
• CK results
• Any imaging confirming presence of cardiovascular disease
• Coronary artery calcium score

Other useful information for management (not an exhaustive list)

• Consider commencing statins depending on  other cardiac risk factors
• The Heart Foundation’s Lipid Management Guidelines provide some additional guidance for patient management
• The QRISK®2 calculator is helpful in assessing cardiovascular disease risk
• Patients with moderate hyperlipidaemia (total cholesterol 5 – 10mmol/L and/or triglycerides < 4mmol/L) may be referred to a general physician rather than a cardiologist depending on local services.

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information (Referral will be declined without this)

• General Referral Information
• Details of relevant signs and symptoms
• Details of all treatments offered and efficacy
• Past medical history (including rheumatic fever) and comorbidities
• Family history of cardiac disease or sudden cardiac death
• FBC, ELFTs, TSH, fasting lipids results

Additional referral information (useful for processing the referral)

• Echocardiogram report
• CXR report
• Include if appropriate gestational and development history
• History of smoking, alcohol intake and drug use (including recreational drugs)
• ECG
• Aboriginal or Torres Strait Islander or Maori / Pacific Islander / Refugee status (increased risk of acute rheumatic fever and rheumatic heart disease)
• Functional class NYHA Class

Other useful information for management (not an exhaustive list)

• If structural heart disease is suspected an echocardiogram should be arranged 

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information (Referral will be declined without this)

• General Referral Information
• Details of relevant signs and symptoms including duration and frequency of episodes
• History of underlying cardiac disease
• Family history of sudden cardiac death
• ELFTs, TSH 
• All available ECGs (during episodes if possible)

Additional referral information (useful for processing the referral)

• Holter monitor report and all ECG tracings (useful if symptoms are present on almost a daily basis) 
• Echocardiogram report
• Stress test report
• Magnesium  results 
• Caffeine intake, alcohol intake and drug use (including recreational drugs)
• Aboriginal or Torres Strait Islander or Maori / Pacific Islander / Refugee status (increased risk of acute rheumatic fever and rheumatic heart disease)

Other useful information for management (not an exhaustive list)

• ECG at the time of palpitation (even if normal) may have important diagnostic clues

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information (Referral will be declined without this)

• General Referral Information
• Medical history
• ELFTs, FBC, TSH results
• All available ECGs (including an ECG showing SVT if possible)

Additional referral information (useful for processing the referral)

• Details of relevant signs and symptoms
• Details of all treatments offered and efficacy
• Relevant previous medical history and co-morbidities
• Caffeine intake, alcohol intake and drug use (including recreational drugs)
• Echocardiogram report
• Stress test report
• CXR report

Other useful information for management (not an exhaustive list)

• If isolated in the absence of syncope/ haemodynamic compromise:
  • reassure
  • consider vagolytic manoeuvres
• Consider holter monitor if frequent (daily or second daily)
• Consider event recorder if infrequent

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information (Referral will be declined without this)

• General Referral Information
• Details of all treatments offered and efficacy
• Relevant medical history
• Description of syncopal / pre-syncopal events (consider timeline, precipitating factors, any warning pre-syncopal symptoms, complete LOC or partial, duration of LOC, nature of recovery, witnessed signs, seizures, pallor, incontinence, cyanosis, irregular or absent pulse during attack, associated injury).
• Lying / standing or sitting / standing BP
• Family history of sudden cardiac death or premature coronary artery disease
• Presence of impaired LV function by any imaging modality (MRI, echo or MPS) if known
• FBC, TSH, ELFTs, magnesium results
• All available ECGs       

Additional referral information (useful for processing the referral)

• Holter monitor report (only useful if frequent symptoms)
• Echocardiogram report
• CXR report    
• History of drug use (including recreational drugs) 

Other useful information for management (not an exhaustive list)

• The NICE (UK) Guidelines for transient loss of consciousness may provide guidance on assessment and management.
• Syncope may impact on a patient’s medical fitness to drive.  Queensland Government’s Transport and Motoring website has advice about managing driving.
• Syncope that is suspected to be of non-cardiac origin may be referred to a general physician rather than a cardiologist depending on local services.     

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.