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