Name: __________________________________________

Address: ________________________________________
________________________________________________
Phone: (h) _________________ (w) __________________
Health Card #: ____________________________________
Cardiology Referral Form D.O.B: _____________________ Gender: ______________
For Cath Lab Procedures or Inpatient Transfer Family Dr.: _______________________________________
Request for: Ref. Specialist: ___________________________________
□ Cardiac Catheterization, PCI, or Other Intervention (includes requests for 24h transfer)
□ Transfer for Ongoing Care Referral Date (yyyy/mm/dd) _________________
Patient Wait Location and Urgency Brief Clinical History and Special Instructions
Outpatient □ Urgent □ Semi-Urgent □ Scheduled
Inpatient □ Referring Hospital & Unit _____________
Reason for Referral
□ Coronary Artery Disease
□ Rule out CAD □ Stable Angina
-------------------------------------
□ NSTEACS ○Unstable Angina ○NSTEMI
○Low risk* ○Int risk* ○High risk*
GRACE Risk Score* _____ TIMI Risk Score* ____
----------------------------------------
□ STEMI ○ Primary PCI ○ Pharmacoinvasive
○ Rescue PCI ○Other ____________
□ Valvular Heart Disease
□ Aortic Stenosis □ Other Valvular ___________
Valve Area _________ MG________ PG _______
□ Congestive Heart Failure / Cardiomyopathy Comorbidity Assessment Allergies
□ Arrhythmia □ Congenital □ Other____________ □ Previous Cath/PCI Date ________________
□ None □ Contrast Dye
Requested Procedure □ Previous CABG Date________________
Date ________________ □ Latex □ ASA
□ Coronaries □ Grafts □ Right Heart Cath □ Previous Valve Surgery
□ Other _______________
□ Left Heart Cath ○ with LV Gram ○without LV Gram □ Bioprosthetic □ Mechanical
□ Diabetes □ Insulin Blood Work
□ PCI ○ Vessel(s) if known anatomy ____________
□ TAVI □ PFO/ASD Closure □ Biopsy □ Hypertension □ Dyslipidemia Date _________________
□ Smoking ○Yes ○No ○ Quit (date) ________________
□ Other ____________________________________ Hb ______ Cr ______
□ Family History Premature CAD
ECG eGFR ______ INR ______
□ Renal Insufficiency □ Dialysis
Ischemic Changes? □ Yes □ No □ Uninterpretable Other Details
□ Atrial Fibrillation
Exercise ECG □ Done □ Not Done Height ___________ cm
□ Cerbrovascular Disease ○ TIA ○ Stroke
High Risk Features □ Yes □ No □ Nondiagnostic
□ Peripheral Vascular Disease Weight ___________ kg
Perfusion Imaging □ Done □ Not Done
□ CHF □ COPD □ Asthma Carrier Status
High Risk Features □ Yes □ No □ Nondiagnostic □ Infective Endocarditis MRSA □ Contact □ Carrier
Stress Echo □ Done □ Not Done □ DVT/PE □ GI Bleed □ Other ________________________
VRE □ Contact □ Carrier
High Risk Features □ Yes □ No □ Nondiagnostic
Coronary CTA □ Done □ Not Done Medications
High Risk Features □ Yes □ No □ Nondiagnostic □ Warfarin □ Apixaban □ Dabigatran □ Edoxaban □ Rivaroxaban
Assessment of LV Function □ Yes □ No Bridging Anticoagulation Required ○Yes ○No
Method: □ Echo □ Perfusion Imaging □ Enoxaparin □ Fondaparinux □ Metformin □ IV NTG □ IV Amiodarone
□ Wall Motion Study □ Other _______________ Able to tolerate dual antiplatelet therapy ○Yes ○No
EF % ___________ Frailty Score* ________________ * Please see “Cardiology Referral Form – Definitions and Instructions for Use”

Printed Name: _____________________________________________ Signature: __________________________________________________

Booking Use Only

Pre-assessment Clinic Date _____________ / Time _____________ Procedure Date (yyyy/mm/dd) _____________
Fax completed page 1 and other relevant information to 902-473-2271 (Bed Management Coordinator)
For QEII and DGH inpatients only, please fax page 1 of completed form and other relevant information to 902-473-2871 (Cardiac Cath Lab)

CD0720MR_08_2017 Page 1 of 1
Cardiology Referral Form
For Cath Lab Procedures or Inpatient Transfer

Cardiology Referral Form – Definitions and Instructions for Use

1. For patients who require immediate / urgent attention, the triage cardiologist on call should be paged to
discuss the clinical scenario and arrange for expedited transfer as appropriate.

2. Please complete this form in addition to usual required documentation for requests for inpatient or outpatient
cardiac catheterization, PCI or other intervention(s) performed in the cardiac cath lab1. This form should also
be used for requests for inpatient transfer for ongoing care. Please indicate the type of request at the top of
the form and do not use this form for other requests (eg. ambulatory care consultation, outpatient HF or EP
evaluation, noninvasive imaging studies).

3. Patients will only be triaged once all pertinent documentation has been received, including a completed copy
of this form, a typed consultation / referral letter from the referring physician, relevant bloodwork, current
medication list, as well as copies of reports of relevant noninvasive tests1. It is also expected that changes in
the clinical status of the patient be communicated in a timely fashion, as this may impact on their triage
priority and / or suitability for the 24 hour transfer service or requested procedure.

4. In order to facilitate the appropriate triage of patients, and to ensure fairness, uniformity and timely access for
all patients, please justify the triage priority requested by indicating contributing clinical factors, pertinent
noninvasive findings and the GRACE or TIMI risk score where appropriate (see Appendix). Please refer to
the indicated references for guidance regarding appropriate triage priorities, definitions of high risk features
on noninvasive testing, and current national wait time benchmarks for cardiac services and procedures2,3,4.

5. For patients who are on oral anticoagulation, please indicate if they will require bridging anticoagulation and
arrange as appropriate. If patients are being referred for possible PCI, it is expected that the potential need
for dual antiplatelet therapy in addition to oral anticoagulation has been discussed5.

6. For patients referred for cardiac catheterization with chronic kidney disease and eGFR < 60, please refer to
the NS Renal Protocol3.

7. Please indicate the clinical frailty score for all patients (see attached).

References

1. QEII Health Sciences Centre Cardiac Catheterization Laboratory 24 Hour Transfer Service Guide (last
updated October 2013).

2. Mancini GB, Gosselin G, Chow B et al. Canadian Cardiovascular Society Guidelines for Diagnosis and
Management of Stable Ischemic Heart Disease. Can J Cardiol 2014;30:837-49.

3. http://www.cdha.nshealth.ca/cardiovascular-health-nova-scotia-2

4. http://www.waittimealliance.ca/benchmarks/cardiac-care/

5. Macle L, Cairns J, Leblanc K et al. 2016 Focused Update of the Canadian Cardiovascular Society Guidelines
for the Management of Atrial Fibrillation. Can J Cardiol 2016;32:1170-85.

CD0720MR_08_2017
 TIMI Risk Score for Non-ST Elevation ACS GRACE Risk Score
One point each for: GRACE (the Global Registry of Acute Coronary Events)
� >65 years of age is an international observational programme of outcomes for patients who were
hospitalized with an ACS in the 10 years from 1999.
� >3 risk factors for CADa
The GRACE 2.0 ACS Risk Calculator implements the revised GRACE algorithms
� significant coronary stenosisb for predicting death or death/myocardial infarction following an initial acute
� ST deviation on presentation coronary syndrome (ACS).
� severe anginal symptomsc
� use of aspirin in last 7 days Online web calculator can be found here:
� elevated troponin http://www.gracescore.org/website/WebVersion.aspx

a family history of CAD, hypertension, dyslipidemia, diabetes Mobile App available for download:
or current smoking http://www.gracescore.org/website/Default.aspx
b prior coronary stenosis > 50%
c > two anginal episodes in last 24 hours

Non-ST Elevation ACS Triage Category High-Risk Features of Noninvasive Test Results Associated
2
with > 3% Annual Rate of Death or MI

Exercise treadmill
High Risk (catheterization ± PCI within 24-48 hours)
a o ≥ 2 mm of ST-segment depression at low (< 5 metabolic equivalents)
o hypotension or definite evidence of heart failure workload or persisting into recovery
o recurrent ventricular arrhythmias o Exercise-induced ST segment elevation
o transient ST elevation o Exercise-induced VT/VF
o new ST depression equal to or greater than o Failure to increase systolic blood pressure to > 120 mm Hg or sustained
2mm in 3 or more leads decrease > 10 mm Hg during exercise
o recurrent or refractory ischemia despite initial Myocardial perfusion imaging
b
therapy o Severe resting LV dysfunction (LVEF ≤ 35%) not readily explained by
o TIMI Risk Score 5-7 noncoronary causes
o GRACE Risk Score > 140 o Resting perfusion abnormalities ≥ 10% of the myocardium in patients without
previous history or evidence of MI
Intermediate Risk (catheterization ± PCI within 3-5 o Severe stress-induced LV dysfunction (peak exercise LVEF < 45% or
days) decrease in LVEF with stress ≥ 10%)
o NSTEACS with no high risk features but known o Stress-induced perfusion abnormalities encumbering ≥ 10% myocardium or
LVEF less than 40% stress segmental scores indicating multiple vascular territories with
o TIMI Risk Score 3-4 abnormalities
o GRACE Risk Score 109-140 o Stress-induced LV dilation
o Increased lung uptake
Low Risk (catheterization ± PCI within 5-7 days) Stress echocardiography
o NSTEACS with no high or intermediate risk o Inducible wall motion abnormality involving > 2 segments or 2 coronary beds
features o Wall motion abnormality developing at low dose of dobutamine (≤ 10
o TIMI Risk Score 1-2 μg/kg/min) or at a low heart rate (< 120 beats per minute)
o GRACE Risk Score <=108 Coronary computed tomographic angiography
a with other supportive evidence of ischemia o Multivessel obstructive CAD or left main stenosis on CCTA
b definite new or dynamic ST changes needed to justify CAD, coronary artery disease; CCTA, cardiac computed tomography angiography; LV, left
urgent status in troponin negative patient ventricular; LVEF, left ventricular ejection fraction; MI, myocardial infarction; VF, ventricular
fibrillation; VT, ventricular tachycardia.

CFS – Clinical Frailty Scale Rockwood et al. CMAJ 2005;173(5):489-95.

Item Description Details
1 Very Fit Robust, active, energetic, well-motivated, and among fittest for their age
2 Well Without active disease but less fit than category 1
3 Managing well Disease symptoms are well-controlled compared with those in category 4
4 Apparently vulnerable Although not frankly dependent, commonly complain of symptoms that limit activities
5 Mildly frail Some dependence on others for IADLs
6 Moderately frail Help is needed with BADLs and IADLs
7 Severely frail Completely dependent for all BADLs and IADLs
8 Very severely frail Completely dependent, approaching end of life and could not recover from a minor illness
9 Terminally ill Life expectancy <6 months but not otherwise frail
IADLs = instrumental activities of daily living: banking, transportation, cooking, cleaning, medication management, shopping.
BADLs = basic activities of daily living: feeding, dressing, toileting, and ambulation.

CD0720MR_08_2017