Angina / myocardial ischaemia / chest pain

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

Atrial fibrillation / flutter

• Atrial fibrillation / flutter with any of the following concerning features:
  • Haemodynamic instability
  • Shortness of breath
  • Chest pain
  • Syncope/pre-syncope/dizziness
  • Evidence of pre-excited QRS (delta waves)
  • Neurological deficit indicative of TIA/stroke
  • Uncontrolled Tachycardia/heart rate despite medical therapy

Aortic Disease

• Suspected chest pain within 24 hours that is associated with any of the following concerning features:
  
  • Severe or ongoing chest pain
  • Ischemic chest pain lasting ten minutes or more
  • Recurrent chest pain that is new at rest or occurring with minimal activity
    
  • Chest pain accompanied by severe dyspnoea
  • 
    Chest pain associated with any of the following clinical signs:
    • syncope / pre-syncope
      
    • respiratory rate > 30 breaths per minute
    • tachycardia >120 bpm
      
    • systolic BP < 90mmHg
      
    • heart failure / suspected pulmonary oedema
    • ST elevation or depression
    • complete heart block
    • new left bundle branch block

Heart Failure

• Acute or chronic heart failure with any of the following concerning features:
  • 
    NYHA Class IV heart failure
  • 
    Ongoing chest pain
  • Significant orthopnoea/PND
  • Oxygen saturation < 90%
  • Clinical and/or radiographic 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 with symptoms of hypoperfusion
    • systolic BP < 80mmHg irrespective of symptoms
• 
  Significant pulmonary or pedal oedema
• Recent myocardial infarction (within 2 weeks)
• Pregnant patient
• Signs of myocarditis
• Signs of acute decompensated heart failure

NB: Early discussion with the patient’s usual heart failure team would be advised for local care protocols

Hypertension

• Hypertensive emergency (BP>220/140)
• Severe hypertension with systolic BP >180mmHg with any of the following concerning features:
  • Headache
  • Confusion
    
  • Blurred vision
  • Retinal haemorrhage
  • Reduced level of consciousness
  • Seizures
  • Proteinuria
  • Papilloedema
  • Signs of heart failure
  • Chest pain

If suspected pregnancy induced hypertension or pre-eclampsia refer patient to the emergency department of a facility that offers obstetric 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 (eg 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 bpm

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
  • Known ischaemic heart disease or reduced LV systolic function
  • Associated with SVT or paroxysmal atrial fibrillation
    
  • Evidence of pre-excited QRS (delta waves) on ECG
  • Suspected malfunction of pacemaker or ICD
  • Absence of prodrome
  • Associated injury
    
  • Occurs while supine
  • Seizures

Reason for request

• To establish a diagnosis
• For treatment or intervention
• For advice and management
• For specialist to take over management
• Reassurance for GP/second opinion
• For a specified test/investigation the GP can't order, or the patient can't afford or access
• Reassurance for the patient/family
• For other reason (e.g. rapidly accelerating disease progression)
• Clinical judgement indicates a referral for specialist review is necessary

Relevant clinical information about the condition

• Presenting symptoms (evolution and duration)
• Physical findings
• Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
• All conservative options that have been pursued unsuccessfully prior to referral
• Body mass index (BMI)
• Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
• Any special care requirements where relevant (e.g tracheostomy in place, oxygen required)
• Current medications and dosages
• Drug allergies
• Alcohol, tobacco and other drugs use

Patient's Demographic Details

• Full name (including aliases)
• Date and country of birth
• Residential and postal address including whether patient resides at an aged care facility
• Telephone contact number/s – home, mobile and alternative
• Medicare number (where eligible)
• Name of the parent or caregiver (if appropriate)
• Name of delegate and contact details (Department of Corrective Services)
• Preferred language and interpreter requirements
• Identifies as Aboriginal and/or Torres Strait Islander
• Any special needs, access requirements and/or disability relevant to the referral

Referring Practitioner Details

• Full name
• Full address
• Contact details – telephone, fax, email
• Provider number
• Date of referral
• Signature
• Nominated general practitioner’s details (if known), if the nominated general practitioner is different from the referring practitioner

Other relevant information

• Willingness to have surgery (where surgery is a likely intervention)
• Choice to be treated as a public or private patient
• Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)