Point-of-Care Tool: Emergency Medicine Care for Patients with Congenital Heart Defects

The emergency department (ED) is an important point of contact for patients with congenital heart defects (CHDs) who present with complaints either directly or indirectly related or unrelated to their CHD.

• Clinicians, and ultimately the patients, should be educated about the potential signs and symptoms that herald a progression of their underlying heart condition.
• Careful screening on the part of physicians to identify a previous CHD diagnosis, previous cardiac procedure (e.g. surgical scar), or red flag symptoms during history taking or upon physical exam, will enable recognition and opportunities to refer patients to appropriate outpatient congenital cardiology care.
• When patients appear to have been lost to cardiac follow up care, physicians should be familiar with the avenues for referral of patients to congenital cardiologists.

• Thorough history and physical examination, including targeted questioning, such as “Have you had any heart problems before — even as a child? For example, did you ever have heart surgery or take medicine for your heart?”
• Patients may not mention pertinent medical history unless questioned directly.
• A complete review of systems, including, but not limited to the following:
  • Shortness of breath with activity or when lying down
  • Reduced ability to exercise
  • Fatigue and weakness
  • Swelling in the abdomen, legs, ankles and feet
  • Rapid or irregular heartbeat
  • Persistent cough or wheezing with white or pink blood-tinged mucus
  • Very rapid weight gain from fluid buildup
  • Nausea and lack of appetite
  • Difficulty concentrating or decreased alertness
  • Chest pain
  • Lower oxygen than a previous baseline
• Survey for potential complications following repair, such as arrhythmias, heart failure, etc.

Patients with CHDs may sometimes be lost to cardiac follow-up care. It is vital to stress the importance and need for lifetime care under a congenital cardiologist. If you encounter a patient lost to cardiac follow-up care, it is essential to suggest they contact their cardiologist if they have one.

You may also want to perform appropriate questioning and refer the patient to a cardiologist if they do not have one. In some cases, a cardiology consultation in the ED may be appropriate.

• Link adults to adult congenital cardiology care through the ACHD Clinic Directory.
• Each program processes referrals differently but many large regional programs have satellite clinics in smaller areas.
  
  • Utilize social work, case management and contact adult and pediatric cardiology specialists at major regional centers to ensure expedited follow-up.
• Establish a Digital Emergency Care Plan Letter, listing the CHD condition, prior surgeries (with dates), highlighting symptoms to watch for, immediate emergency care steps and contact information for the patient’s cardiologist.