When Should You Refer for Cardiac Ultrasound and When Should You Scan In-House?
Referral is a core part of general practice. Knowing your limits, acting on them quickly, and getting patients to the right level of expertise at the right time is good medicine, not a failure.
But over-referring is also a problem. It costs clients money, creates delays in treatment, reduces your practice's diagnostic capability, and, if it's happening because of a confidence gap rather than a genuine complexity gap, it's a problem that training can fix.
The question "should I scan this myself or refer?" is one every GP vet faces regularly. This post offers a framework for thinking through it, honest about where GP echo ends and specialist input begins.
The GP vet's echo toolkit: what's genuinely within reach
With solid foundational training, a GP vet should be able to:
Detect and quantify pleural and pericardial effusion
Assess left atrial size and left ventricular dimensions
Identify obvious left ventricular hypertrophy
Make a subjective assessment of contractility
Stage preclinical MMVD using LA:Ao and LVIDDN
Recognise the echo features of dilated cardiomyopathy
Identify significant valve thickening and regurgitation
Perform emergency cardiac assessment (TFAST/EEC) in the collapsed patient
That's a meaningful toolkit. It covers the majority of cardiac cases presenting to general practice.
Scan in-house: these presentations are within GP reach
MMVD staging in dogs (including CKCSs) If you can reliably acquire a right parasternal short-axis view for LA:Ao and a right parasternal long-axis view for left ventricular measurements, you can make the EPIC trial prescribing decision without referring. This is the single most common cardiac echo task in GP practice and the one with the highest return on learning.
First-line assessment of the dyspnoeic cat Is there pleural effusion? Is the left atrium obviously enlarged? A five-minute echo in a dyspnoeic cat can completely change the initial treatment plan. You don't need a cardiology report to justify draining a chest or starting furosemide.
Pericardial effusion in the acute/collapsed dog If you can see fluid around the heart and evidence of tamponade, you have the information you need. Act on it.
Monitoring of known DCM or MMVD cases between specialist reviews Basic ventricular dimension measurements and fractional shortening are achievable at GP level and clinically useful for tracking disease progression.
Ruling out gross structural disease in a young dog with a murmur Not every puppy murmur needs a cardiologist on first presentation. A basic echo to check for obvious structural abnormalities is reasonable at GP level, with referral if findings are equivocal or concerning.
Refer: where specialist input genuinely adds value
Complex congenital disease Subaortic stenosis, pulmonic stenosis, ventricular septal defects, patent ductus arteriosus, these require Doppler quantification of pressure gradients and flow velocities that go beyond basic GP echo. The management decisions hinge on measurements that need to be accurate.
Equivocal echo findings where the treatment decision is high stakes If you've scanned and you're not sure, and the next step involves a significant intervention or expensive long-term medication, a second opinion from a cardiologist is appropriate. That's not a confidence failure, it's good clinical judgement.
Cats with suspected HCM requiring detailed characterisation Basic echo can flag significant HCM. But characterising severity, identifying dynamic outflow tract obstruction, and guiding treatment in complex feline cardiomyopathy cases is specialist territory.
Any case where Doppler quantification is essential for the decision Pulmonary hypertension estimation, aortic velocity measurements for SAS grading, mitral regurgitation jet characterisation, these require clean Doppler windows and accurate technique. If you're not yet confident in Doppler, refer or upskill.
Second opinions on your own equivocal findings There's no shame in scanning, finding something that might be significant, and sending the case for confirmation. That's the correct pathway. Your in-house scan gave the cardiologist useful context; it didn't replace them.
The honest middle ground
Most GP vets exist in a middle ground where some scans they should be doing in-house, some they're right to refer, and some they're genuinely unsure about. The goal of good echo training isn't to replace cardiology referral, it's to pull the line in the right direction, so cases that clearly belong in-house stay there, and cases that genuinely need a specialist get there faster because you've already done useful preliminary work.
A GP vet who has done a solid basic echo and documented their findings before referring is a more useful referral than one who hasn't scanned at all. You've given the cardiologist a head start.
Closing the confidence gap
If the framework above left you feeling that most of your current referrals are in the "within GP reach" category, that's useful information. The gap between what you can currently do and what you should be able to do is almost always a training gap, and it's a fixable one.
Our Echocardiography CPD course is designed precisely to move GP vets into the "confident to scan in-house" column for the presentations above. We work in your practice, on your machine, at your pace.
