When should a patient with suspected myocarditis be referred to a cardiologist for further evaluation and management?

Patients with suspected myocarditis should be referred to a cardiologist for further evaluation and management if they present with symptoms or signs suggestive of structural heart disease, heart failure, arrhythmias, or syncope. This includes those with palpitations accompanied by chest pain, lightheadedness, or syncope, or with abnormal ECG findings such as second or third degree atrioventricular block or ventricular tachycardia. Referral is also indicated if there is evidence of reduced left ventricular function (ejection fraction ≤35%), heart failure symptoms, or if myocarditis is suspected to be causing arrhythmias or syncope, as these may indicate a risk of ventricular tachycardia or other serious complications. Additionally, urgent referral is warranted if there is exertional syncope or severe symptoms related to cardiac dysfunction. Echocardiography and specialist assessment should be considered promptly in these cases to guide diagnosis and management.

In summary, refer patients with suspected myocarditis to cardiology if they have:

• Syncope or near syncope not clearly due to other causes.
• Palpitations precipitated by exercise or associated with chest pain or lightheadedness.
• Abnormal ECG findings such as high-grade AV block or ventricular arrhythmias.
• Signs or symptoms of heart failure or reduced left ventricular ejection fraction (≤35%).
• Severe or worsening symptoms suggestive of cardiac dysfunction.

Patients without these features and with normal ECG and no structural heart disease may not require urgent referral but should be monitored and investigated appropriately.

This approach aligns with recommendations for referral in palpitations, heart failure, and structural heart disease contexts, which are relevant to myocarditis management.