When should I consider referring a patient with rheumatic heart disease to a cardiologist for further evaluation?

You should consider referring a patient with rheumatic heart disease to a cardiologist for further evaluation in several key situations, primarily based on the severity of their valve disease and the presence of symptoms ¹.

• Urgent Referral (within 2 weeks)
• If the patient has a systolic murmur and experiences exertional syncope, offer urgent specialist assessment that includes an echocardiogram or an urgent echocardiogram alone ¹.
• If the patient has a murmur and severe symptoms such as angina or breathlessness on minimal exertion or at rest, which are thought to be related to valvular heart disease, consider urgent specialist assessment that includes an echocardiogram ¹.
• If the patient experiences syncope or presyncope (unless clearly due to postural hypotension), refer to a cardiologist as this may indicate ventricular tachycardia, especially with reduced ejection fraction ².
• If the patient has palpitations accompanied by syncope or near syncope, or if palpitations are precipitated by exercise, refer urgently to cardiology ³.
• Routine Referral (after echocardiography)
• If echocardiography reveals moderate or severe valve disease of any type, offer referral to a specialist ¹.
• If the patient has heart failure that is due to valve disease, they should be referred for specialist assessment and advice regarding follow-up ².
• If the patient has heart valve conditions and heart failure with left ventricular dysfunction, refer to the NICE guideline on chronic heart failure in adults ¹.
• If the patient has palpitations with accompanying chest pain or lightheadedness, a history or physical symptoms of structural heart disease, heart failure, or hypertension, or a resting ECG abnormality (excluding second or third-degree atrioventricular block), refer routinely to cardiology ³.
• If underlying heart disease is suspected from clinical assessment or ECG, or if ventricular extrasystoles are frequent or ventricular tachycardia is suspected, refer to cardiology ³.
• Specific Considerations for Women
• Refer pregnant women or women who are considering pregnancy to a cardiologist with expertise in the care of pregnant women if they have moderate or severe valve disease, regardless of symptoms ¹.
• Asymptomatic but Severe Valve Disease
• Consider referring adults with asymptomatic severe aortic stenosis for intervention (which implies specialist evaluation) if they have specific echocardiographic findings such as peak aortic jet velocity (Vmax) more than 5 m/s, aortic valve area less than 0.6 cm², left ventricular ejection fraction (LVEF) less than 55%, or B-type natriuretic peptide (BNP) or N-terminal proBNP (NT-proBNP) level more than twice the upper limit of normal ¹.
• Consider referring adults with asymptomatic severe aortic regurgitation for intervention if they have LVEF less than 55% or end systolic diameter (ESD) of more than 50 mm (or end systolic diameter index (ESDI) more than 24 mm/m²) on echocardiography ¹.
• Consider referring adults with asymptomatic severe primary mitral regurgitation for intervention if they have LVEF less than 60%, ESD more than 45 mm (or ESDI more than 22 mm/m²) on echocardiography, or an increase of systolic pulmonary artery pressure to more than 60 mmHg on exercise testing ¹.