When should I consider referring a patient with dilated cardiomyopathy to a cardiologist?

Consider referring a patient with dilated cardiomyopathy to a cardiologist if they have:

• Severe heart failure symptoms (New York Heart Association [NYHA] class IV) or heart failure that does not respond to treatment in primary care or cannot be managed at home.
• A left ventricular ejection fraction of 35% or less, as these patients may be candidates for specialist treatments such as implantable cardioverter defibrillators (ICDs) or cardiac resynchronization therapy (CRT).
• Elevated N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) levels above 2000 ng/L (236 pmol/L), which warrants urgent specialist assessment and echocardiography within 2 weeks.
• NT-pro-BNP levels between 400 and 2000 ng/L (47–236 pmol/L), which should prompt specialist assessment and echocardiography within 6 weeks.
• Syncope or presyncope not clearly due to postural hypotension, as this may indicate ventricular arrhythmias requiring specialist evaluation.
• Heart failure resulting from valvular heart disease or significant comorbidities that complicate management.
• Women with heart failure and reduced ejection fraction who are planning pregnancy or are pregnant, for specialist pre-conceptual advice and management.

Referral should be made to a specialist multidisciplinary heart failure team, usually led by a cardiologist, for diagnosis confirmation, optimization of treatment, initiation of specialist therapies, and ongoing management of complex or advanced cases.

Regular follow-up and monitoring should be individualized based on symptom severity, treatment changes, and comorbidities, with urgent referral if clinical condition worsens.

These recommendations align with NICE guidelines on chronic heart failure and heart valve disease management in adults.

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