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Murmur (Cardiology)

PAEDIATRIC

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.


Chest pain (adult)

  • 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:
    • severe or ongoing chest pain
    • chest pain lasting ten minutes or more
    • chest pain that is new at rest or with minimal activity
    • chest pain that is associated with severe dyspnoea
    • chest pain that is associated with syncope / pre-syncope
    • chest pain that is 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 

 Atrial fibrillation

  • Atrial fibrillation / flutter with any of the following concerning features:
    • haemodynamic instability
    • shortness of breath
    • chest pain
    • syncope/pre syncope/dizziness
    • known Wolff-Parkinson-White
    • neurological deficit indicative of TIA/stroke

 Chest pain (paediatric)

  • Current chest pain with haemodynamic compromise
  • Acute onset chest pain from a potential cardiac cause

Heart failure

  • Acute or chronic heart failure with any of the following concerning features:
    • NYHA Class IV heart failure
    • ongoing chest pain
    • increasing shortness of breath
    • oxygen saturation < 90%
    • 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
    • significant pulmonary or pedal oedema
    • recent myocardial infarction (within 2 weeks)
    • pregnant patient
    • signs of myocarditis
    • signs of acute decompensated heart failure

Hypertension

  • Hypertensive emergency (BP>220/140)
  • Severe hypertensive with systolic BP >180mmHg with any of the following concerning features:
    • headache
    • confusion
    • blurred vision
    • retinal haemorrhage
    • reduced level of consciousness
    • seizures
    • proteinuria
    • papilloedema
  • If suspected pregnancy induced hypertension or pre-eclampsia refer patient to the emergency department of a facility that offers obstetric services where possible.

Murmur (adults or children)

  •  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

Murmur (Infant)

  •  Infant <3 months with newly noted murmur and any of the following concerning features:
    • poor feeding
    • slow weight gain
    • weak or absent femoral pulses
    • post ductal (foot) oxygen saturation < 95%
    • respiratory signs (wheeze, recession or tachypnoea)
  • Suspected heart failure or endocarditis

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         

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
    • pre-excited QRS (delta waves) on ECG
    • suspected malfunction of pacemaker or ICD
    • absence of prodrome
    • associated injury
    • occurs while supine or sitting 

Other

  • 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

  • If structural heart disease is suspected an echocardiogram should be arranged.
  • If you have a reason to suspect a child in Queensland is experiencing harm, or is at risk of experiencing harm, you need to contact Child Safety Services: https://www.communities.qld.gov.au/
  • In the majority of cases it is thought inappropriate for children to wait more than 6 months for an outpatient initial appointment

Minimum Referral Criteria

  • Category 1
    (appointment within 30 calendar days)
    • Asymptomatic murmur in a baby from birth to 3 months
    • Asymptomatic murmur at any age in association with acute rheumatic fever
    • Murmur with cyanosis, heart failure, syncope or seizures
    • Children already diagnosed with a condition with known cyanosis or heart failure

  • Category 2
    (appointment within 90 calendar days)

    • Asymptomatic murmur in a child aged 4 months to 2 years
    • Murmur at any age with a past history of rheumatic fever
  • Category 3
    (appointment within 365 calendar days)
    •  Asymptomatic murmur in a child over 2 years old

1. Reason for request Indicate on the referral

  • 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

2. Essential referral information Referral will be returned without this

 

  • Physical findings including colour assessment or oxygen saturation
  • Report presence or absence of the following:
    • History of exercise intolerance
    • Cyanotic episodes or blue spells
    • Weak or absent femoral pulses
    • Clubbing

3. Additional referral information Useful for processing the referral

Highly desirable information – may change triage category

  • Known other congenital abnormalities
  • Family history of congenital cardiac disease
  • Aboriginal or Torres Strait Islander or Maori status (acute rheumatic fever / rheumatic heart disease risk)

Desirable information- will assist at consultation

  • Other past medical history
  • Immunisation history
  • Developmental history
  • Medication history
  • Significant psychosocial risk factors (especially parent’s mental health, family violence, housing and financial stress, department of child safety involvement)
  • Height/weight/head circumference and growth charts with prior measurements if available.
  • Other physical examination findings inclusive of CNS, birth marks or dysmorphology
  • Any relevant laboratory results or medical imaging reports, urinalysis result

4. Request

Patient's Demographic Details

  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander

Referring Practitioner Details

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature

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
  • 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
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use

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

Clinical modifiers

  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and/or Torres Strait Islander

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.)
  • Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service.  Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.

  • A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.

  • Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.