Referral of patients
Referral for exercise testing
- Comment: Referral for exercise testing will be influenced
by whether or not open access facilities are available locally. If they are not
then referral for exercise testing will have to be via a cardiologist (see
below).
Recommendations:
- exercise testing is effective in prognostically grouping patients and can provide information in addition to that obtained from invasive testing (B)
- all patients with clinically certain angina should have an exercise test (B)
- this will mean referral to an open access service where this is available and referral to a cardiologist where it is not (C)
Referral to a cardiologist
Recommendations:
all patients with clinically certain angina should be referred to
identify whether they fall into a group that would benefit from prognostic
investigation and treatment (B)
all patients in whom the diagnosis is uncertain should be considered for referral for clarification of the diagnosis (C)
all patients in whom management is currently sub-optimal, as judged by symptoms,
should be considered for referral for further treatment or investigation (C)
patients whose symptoms are uncontrolled on maximal medical therapy should be referred to a cardiologist for angiography not exercise testing (C)
for patients who are not adequately controlled on full doses of two drugs the remaining evidence based therapeutic options are very limited. Such patients should be referred rather than given a third drug (C)
reasons for not referring are: patients declining referral; patients currently having a more significant condition (C)
- Comment:
- Referral from a
general practitioner to a cardiologist will be for one of three reasons: to
identify whether they fall into a group that would benefit from prognostic
investigation and treatment; to establish a diagnosis; or for management advice.
Identifying whether patients fall into a group that would benefit from prognostic
investigation and treatment will apply in patients with a clear history of
angina; they will usually be on medical treatment. The purpose of referral is to
confirm the presence and severity of disease by further investigation with a view
to identifying those suitable for revascularisation. Patients in whom the
diagnosis is unclear should be referred to a cardiologist, not for an open access
exercise test. While referral of these patients may lead to coronary angiography
the purpose is to clarify the diagnosis, often ending up excluding significant
cardiac disease.
Referral for management advice will apply to
those patients in whom the diagnosis is certain but in whom symptom control is
sub-optimal. Patients uncontrolled on maximal medical therapy should be referred
for consideration for angiography not for open access exercise testing.
What influences the decision to refer?
In all patients considered for referral the decision will be influenced by:
- clinical factors: pain on minimal exertion, nocturnal pain, rapidly progressive symptoms, possible aortic stenosis, failure to respond to medical treatment, previous myocardial infarction
- age/duration of disease
- co-morbidities
- risk factors
- patient preference
- clinician factors (such as doctor uncertainty)
- threatened employment/unacceptable interference with lifestyle or recreation.
These factors
represent a spectrum for most patients and their effect on the decision to refer
will be additive.
The referral decision cannot be taken in
isolation and needs to be set in the current context of the patient. Not all
patients need to be referred.
Those who will benefit are:
- those with a clinically certain diagnosis who are seen as urgent by the criteria above
- those with an uncertain diagnosis: a small proportion of these will have coronary artery disease and will benefit from revascularisation; for the rest the reassurance that they do not have coronary artery disease can increase their quality of life and prevent their receiving treatment for a condition they do not have. If they have persisting symptoms it also allows their true diagnosis to be made.
Those who will not benefit are:
- those with other more significant co-morbid conditions
- those who make an informed decision that they do not wish referral.