Guidelines for Referral to a Cardiovascular Specialist for the California Chapter of the American College of Cardiology

Managed care poses challenges to primary care physicians and specialists alike.

The primary care provider is charged with providing quality care to patients with many diverse ailments, requesting consultation from specialists when indicated. The specialist. by focusing almost entirely on a single organ system, should be able to provide precise diagnosis, prognosis and optimal management in the most economical way. In a rapidly evolving managed care environment it is appropriate to reevaluate the coordination between the generalist and the cardiovascular specialist that would best serve patient needs and result in ultimate cost savings.

In an effort to help primary care providers with different educational emphases practice patterns, and geographic locations decide when to refer patients to a cardiovascular specialist. the California Chapter of the American College of Cardiology has prepared these guidelines.

It is our hope that primary care providers will find these guidelines useful in their everyday practice. We realize that guidelines for heart failure and unstable angina are available from the Agency for Health Care Policy and Research (AHCPR) and more are on the way. We believe, however, that as good as these guidelines are. of necessity they are simplistic and cannot replace direct patient evaluation by a trained specialist.

In general, our guidelines are based on the premise that caring for the patient with cardiovascular disease is an expensive and frequently challenging process and that a cardiovascular specialist can best risk-stratify patients in the most timely. efficient and cost-effective manner.

Active collaboration between the primary care physician and the cardiovascular specialist is often necessary to improve out-comes and frequently will result in ultimate cost savings.

The guidelines are divided into seven general categories: Hyperlipidemia, Hypertension. Congestive Heart Failure. Arrhythmias, Chest Discomfort, Cardiac Murmurs, and Children With Suspected Cardiovascular Disease.

When lists of conditions or symptoms are provided, these lists are not meant to be all inclusive. Rather, they reflect the more common conditions that are recognized and referred. Less common conditions such as pulmonary embolism, pulmonary hyper-tension, the various arteritides, pericarditis, etc., are not specifically discussed. However. we suggest that whenever an ailment is suspected as being cardiovascular in origin and cannot be ascribed to another condition. consultation with a cardiovascular specialist is appropriate. Since there are significant differences in the pathophysiology, diagnosis and therapy of the same condition in children and adults. separate guidelines for pediatric patients are provided.

The issue of when to order special diagnostic tests is a difficult one.

Studies such as echocardiograms and nuclear perfusion scans need not necessarily be ordered prior to consultation with a cardiovascular specialist. Since in many instances, the specialist will find them to be unnecessary. Furthermore, specialized diagnostic studies must be performed in suitable facilities by appropriately trained tech-nical personnel and properly interpreted by appropriateIy trained specialists.

We have also attempted to describe the appropriate continuing care roles of specialists and generalists.

In general. referral back to the generalist is appropriate when the patient is stable. or when a diagnostic workup is completed and no specialist follow up is deemed necessary. Most of the time, however, the cardiovascular specialist will need to participate to some degree in continued follow up. Rather than presenting new concepts, these guidelines summarize the patterns of referral that have been developed over the past decades and have resulted in the highest quality of health care Americans have come to expect. This partnership between the primary care provider and the specialist must be preserved. The extent to which these guidelines will be utilized by primary care physicians will obviously vary depending upon the generalist's level of training and experience in internal medicine and specifically in cardiovascular diseases.

Gabriel Gregoratos, MD, FACC
Past President, California Chapter, American College of Cardiology