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 (systolic BP >180) with known ischaemic heart disease or cardiomyopathy AND any of the following concerning features:
  • headache
  • confusion
  • blurred vision
  • retinal haemorrhage
  • reduced level of consciousness
  • seizures
  • proteinuria
  • papilloedema
  • signs of heart failure
  • chest pain
• 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