What Cardiologists Want PCPs to Know About Referrals

Cardiologists want primary care providers (PCPs) to know that they are at the ready to assist with acute and complex cases and also to provide consultations. And yes, they know that sometimes a well-timed motivational interview in their office can be particularly compelling.

Yet, risk calculators have known flaws, and there aren’t clear-cut guidelines for what triggers a referral to cardiology and what can be managed in-house.

“What is really up to the primary is to work through the problem,” said Heba Wassif, MD, MPH, director of Inpatient Clinical Cardiology at Cleveland Clinic, Cleveland. “It’s not like: Chest pain, refer to cardiology. Palpitations, refer to cardiology.”

While those patients may end up being referred, doing so based on first impressions can lead to delays in care “because they’ve not had the workup that needs to be done ahead of time,” Wassif said.

Here are some tips on managing referrals from primary care to cardiology from the perspective of referral too early, referral just right, and referral too late.

Referral Too Early

When it comes to risk management, prevention, and treatment of conditions like straight-forward hyperlipidemia, hypertension, and even coronary artery disease with controlled cholesterol, these matters are best managed at the primary care level, said Janet Wei, MD, Southern California Governor of the California Chapter of the American College of Cardiology (ACC), Sacramento, and a cardiologist in the Smidt Heart Institute at Cedars-Sinai Medical Center, Los Angeles. She specializes in women’s heart health, with a particular interest in women with angina and no obstructed coronary arteries.

In the case of coronary artery disease with well-controlled cholesterol, the PCP would just see the patient more often, Wei said.

For prevention, risk management, and uncomplicated cases, PCPs are well-positioned to counsel on diet, physical activity, lifestyle, and smoking cessation, as well as serve as the ongoing prescriber for statins and one or two blood pressure medications. The American Academy of Family Physicians has published guidelines for hypertension.

Particularly with hypertension medications, PCPs should work with patients to develop a treatment plan.

“A close provider-patient relationship is important, as it may take some time to find the best drug or combination with minimal risks or side effects, said Mario Jorge Garcia, MD, chief of the Division of Cardiology and professor of medicine and radiology at Montefiore Medical Center’s Einstein Campus in New York City.

Be vigilant against feeling like it’s easier to prescribe or refer than talk about exercise and mobility, said Adam Moskowitz, MD, medical director of the UNC Cardiology Clinic at Eastowne in Chapel Hill, North Carolina.

“I really, truly believe as a geriatric cardiologist that exercise and mobility is the key to long-term health and independence and healthcare benefit. It is so often completely omitted because it’s not something that you can easily refer to,” he said. “For cardiologists, for PCPs, for anyone listening, please don’t forget to counsel your patients on mobility and exercise.”

Risk Calculators and Diagnostics

Diagnostic tests can be ordered before a referral on the basis of a PCP’s comfort level, and that decision should also take case details into consideration.

For example, Wassif recently saw a patient referred for palpitations who waited 2 months for an appointment and then had to schedule a return visit because diagnostics were needed.

Sometimes it may be in the patient’s best interest to wait for the PCP to interpret the test results. Physicians should consider whether a referral to cardiology is made out of fear of missing something when a cardiologist’s first step would be to order the same tests that the PCP can order and interpret.

“If the person is comfortable enough to order the test — which I do recommend, assuming they feel comfortable doing it from a knowledge perspective — you may want to just say, ‘OK, well, let’s just see what this looks like and then we’ll go from there,’” said Moskowitz.

“Of course, there are patients that you’re going to be severely worried about, people that have very high pretest probability of disease, and you know that you’re going to need that patient to see cardiology regardless,” he added. “But for the lower risk conditions — for instance, a young person with palpitations or a young person with chest pain — sometimes the test alone just to rule out life-threatening disease is all that you need.”

Imaging results can also help patients make lifestyle changes or choose a treatment, said Garcia, who says PCPs could more liberally use coronary calcium scoring and carotid intima-media thickness tests.

“Sometimes imaging can be powerful to convince a patient. Evidence of atherosclerosis converts ‘prevention’ into ‘treatment.’ Studies have shown improved compliance,” he said.

For those worried about missing something, “I would recommend just order the tests and then give the patient strong return precautions to let you know if something else is going on before they get that testing completed,” Moskowitz said.

It’s reasonable to be on alert, particularly because risk calculators don’t incorporate all known risk enhancers.

“The studies indicate that no matter what you choose, whether you choose the ACC risk estimator or the PREVENT calculator, at least you’re doing something because regardless of the type of equation you use, only half of the people who are felt to be high risk actually end up taking cholesterol medicine,” Wei said. “So we already are really under treating people for cholesterol or atherosclerosis to reduce stroke and heart attack risk.”

Referral Just Right

Cardiologists know that PCPs are fully capable of managing high cholesterol, high blood pressure, and traditional risk factors and of providing counseling, Wei said.

“We understand sometimes they just need the extra expertise for the patient to either direct them to be more aggressive with therapy or determining additional testing that might help with the risk assessment and determining whether the patient should be on cholesterol therapy or certain blood pressure medications,” she said.

Lifestyle changes can only get a patient so far, she said. When physicians need help to guide medication or more intensive counseling, “then certainly it’s a collaborative approach with cardiologists.”

Garcia described characteristics of a “referral just right” scenario as “stable typical conditions like chest pain, shortness of breath, and abnormal ECG.”

“A referral that is just right is someone that’s already had counseling and already had to some extent a preliminary diagnostic workup if it’s appropriate,” said Moskowitz. “Sometimes there’s going to be puzzling cases and ones that don’t necessarily require ordering some tests. But when there’s been an initial effort to treat, an initial attempt at primary care, and there’s a failure or there’s some obvious cardiac condition, that’s the right time to send a referral.”

High-risk situations also may bump some cases to an earlier referral than cases with otherwise similar workups. Although Moskowitz noted that with risk calculators, age is weighted so heavily that around age 70 it starts looking like everyone needs a statin.

Referral Too Late

Because cardiovascular problems are progressive, there are risks of delaying a referral, although most “referral too late” scenarios are access to care issues, Moskowitz said.

Garcia considers a referral too late as a situation in which “symptoms are established, and a patient has failed therapy.”

An article last year in the journal ESC Heart Failure found that people diagnosed with heart failure who experienced a delay in cardiology assistance after being referred faced a significantly increased risk in all-cause, cardiovascular, and heart failure mortality at the 1-year mark.

“Heart failure is a condition that requires close monitoring and frequent interventions. Delay in appropriate treatment leads to irreversible heart and kidney failure. This is a disease that should be considered as serious and complex as most cancers,” Garcia said.

When monitoring visits and checkpoints for lifestyle changes, like blood sugar checks or smoking cessation follow-ups, seem difficult to fit into a busy primary care schedule, PCPs should leverage other resources, said Juan Carlos Venis, MD, MPH, an assistant professor of clinical family medicine at the Indiana University School of Medicine in Indianapolis.

“It’s really important that we remember that primary care clinicians — if we’re family doctors out in the community or nurse practitioners and other folks who are doing primary care — that we are part of a team, Venis said. 

If a doctor has a patient with hypertension, they can collaborate with nurses or pharmacists to co-manage the condition and fine-tune medications.

Taking every opportunity and every visit to spend time on patient education is also important, he said.

“Maybe that’s kind of straightforward. Maybe it seems like very common sense. But sometimes, it’s just by necessity we have to operate as a team. And maybe in some settings folks forget that, or they feel like they’re alone and that they don’t have those resources at their disposal,” Venis said.