What are the appropriate use criteria for echocardiography (echo-cardiography)?

Appropriate Use Criteria for Echocardiography

The Appropriate Use Criteria (AUC) for echocardiography provide a framework to determine when echocardiography is reasonable based on specific clinical scenarios, with indications classified as appropriate (median score 7-9), uncertain (median score 4-6), or inappropriate (median score 1-3). 1

Core Principles of Appropriate Use

• A complete echocardiographic examination includes 2D/M-mode imaging, color flow Doppler, and spectral Doppler to evaluate cardiac structures and hemodynamics 1
• Tests should be performed and interpreted by qualified individuals in facilities proficient in echocardiographic techniques 1
• A complete clinical history and physical examination should be completed before ordering an echocardiogram 1
• Cost considerations are implicitly included in appropriateness determinations 1
• The "uncertain" designation should not be used as grounds for denial of reimbursement 1

Generally Appropriate Indications

• Initial evaluation of cardiac structure and function when there is a change in clinical status 2
• Evaluation of symptoms potentially due to suspected cardiac etiology (dyspnea, syncope, TIA, cerebrovascular events) 1
• Initial evaluation of known or suspected valvular stenosis or regurgitation 1
• Evaluation of hypotension or hemodynamic instability of uncertain or suspected cardiac etiology 1
• Assessment of suspected complications of myocardial ischemia/infarction 1
• Initial evaluation of left ventricular function following acute myocardial infarction 1
• Re-evaluation of patients with severe valvular regurgitation with no change in clinical status 1
• Evaluation of known or suspected adult congenital heart disease 1

Generally Inappropriate Indications

• Routine (yearly) evaluation of asymptomatic patients with mild valvular disease and no change in clinical status 1
• Routine (yearly) evaluation of asymptomatic patients with corrected congenital heart defects more than 1 year after successful correction 1
• Evaluation of left ventricular function with prior normal evaluation within the past year in patients with no change in clinical status 1
• Evaluation of isolated premature atrial or ventricular contractions without other evidence of heart disease 1
• Initial evaluation for a murmur/click without symptoms/signs of structural heart disease 3

Clinical Scenario Categories

• Cardiovascular symptoms: Chest pain, dyspnea, palpitations, syncope 1
• Valvular heart disease: Initial evaluation and follow-up of native and prosthetic valves 1
• Heart failure: Evaluation of ventricular function and potential causes 1
• Cardiomyopathies: Diagnosis and classification of hypertrophic, dilated, arrhythmogenic, restrictive, and unclassified types 1
• Perioperative evaluation: Assessment before non-cardiac surgery 1
• Acute settings: Evaluation of chest pain, hypotension, respiratory failure 1

Special Considerations

• For surveillance echocardiograms, the test should not be ordered simply because a certain period of time has elapsed 1
• If a test can be assigned to multiple indications, it should be classified under the most appropriate one 1
• Global CAD risk assessment should be considered when evaluating appropriateness for certain indications 1
• Angina definitions are important for determining appropriateness: typical angina (substernal pain, provoked by exertion/stress, relieved by rest/nitroglycerin), atypical angina (lacks one characteristic), and nonanginal chest pain (meets one or none) 1

Implementation Considerations

• It is neither anticipated nor desirable that all physicians or facilities will have 100% of their echocardiograms deemed appropriate 1
• AUC are useful as educational tools for both echocardiography providers and referring physicians 1
• Incorporation of AUC into echocardiography laboratory accreditation requirements encourages their use 1
• The greatest opportunity to optimize echocardiography use is in improving individual patient decision making 1

Common Pitfalls to Avoid

• Using echocardiography for routine annual follow-up in stable patients with mild disease 1
• Ordering repeat studies when there is no change in clinical status 1
• Failing to consider the impact of test results on clinical decision-making or patient management 1
• Using the "uncertain" designation as grounds for denial of reimbursement 1
• Comparing echocardiography to other imaging modalities rather than focusing on whether it is reasonable for the specific patient scenario 1