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Coronary Artery Disease – When to Refer

When to Refer

Regional and national organizations may provide guidance on specialist cardiology referral from primary care. For example the Scottish Intercollegiate Guidelines Network (SIGN) in the United Kingdom suggests that for patients with stable angina:1

  • early referral to secondary care should be considered if patients have new onset angina or established coronary heart disease (CHD) with an increase in symptoms
  • the majority of patients with suspected angina will be referred for exercise tolerance testing.
  • coronary angiography requires referral to a cardiologist
  • if symptoms are not controlled on maximum therapeutic doses of two drugs, referral to a cardiologist should be considered
  • referral for rehabilitation is recommended in the case of limiting symptoms and after revascularization
     

The European Society of Cardiology (ESC) states in their guidelines for the management of stable angina2 that many individuals with stable angina are not referred for functional testing to confirm the diagnosis and determine prognosis, which they consider a gap between best practice and usual care. They also suggest that high-risk candidates for revascularization on prognostic grounds should be identified and appropriately referred. 



An acute coronary syndrome (ACS) is a life-threatening state of atherothrombotic disease3 and may be considered a medical emergency. The ESC do not specifically state referral recommendations related to ACS;3,4 however, they recommend an algorithm for first medical contact and emergency care in the case of acute ST-segment elevation myocardial infarction (STEMI).4
 

References

  1. Scottish Intercollegiate Guidelines Network. Guideline 96: Management of Stable Angina. Accessed 4 May 2011.
  2. Guidelines on the Management of Stable Angina Pectoris. The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology, 2007. Accessed 3 May 2011.
  3. European Society of Cardiology Full Guidelines and Pocket Guidelines on Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation (2007). Accessed 3 May 2011.
  4. European Society of Cardiology Full Guidelines and Pocket Guidelines on Management of Acute Myocardial Infarction in Patients Presenting with ST-Segment Elevation (2008). Accessed 3 May 2011.