Ensure referral to Cardiology consultation for possible coronary angiography.

With only a few exceptions, coronary angiography is generally not indicated in asymptomatic or mildly symptomatic patients with either known or suspected CAD, unless non-invasive testing reveals findings that suggest a high risk for adverse outcomes. Some patients with extenuating circumstances should not be routinely referred to cardiology. These general circumstances include the following:

• Review of prior coronary angiogram by current clinician shows disease not amenable to revascularization by current standards.
• Patient refusal of catheterization and/or revascularization and/or patient and physician prefer medical therapy alone, without further evaluation.
• Noncardiac disease with projected life expectancy <6 months or quality of life unlikely to be improved by revascularization.

The following indications for referral to a cardiologist apply only to patients with stable IHD, and not to those with a current or recent ACS, in whom different criteria apply.

• Patients with Canadian Class 3 to 4 symptoms of ischemia or heart failure on medical therapy.
• Patients dissatisfied with symptoms despite maximal medical therapy.
• Patients with recurrent symptoms following recent (<6 months) revascularization.
• Patients at increased risk for sudden cardiac death
• Patients with high-risk findings on non-invasive testing
• Patients with non-invasive test results that are inadequate for management.