Cardiology

• 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

• 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

• 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

• 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
  • 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

• 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.

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

• 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 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 or sitting
  • Seizures

• 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