What are the appropriate use criteria for echocardiography (echo) in patients with suspected or known cardiac disease?

Appropriate Use Criteria for Echocardiography

Echocardiography is highly appropriate for initial evaluation of suspected cardiac conditions, assessment of valvular disease, and evaluation of acute cardiac presentations, but should not be routinely performed for annual follow-up in stable patients with mild disease or when there is no change in clinical status. 1, 2

General Appropriate Indications

• Evaluation of symptoms potentially due to suspected cardiac etiology, including dyspnea, shortness of breath, lightheadedness, syncope, TIA, and cerebrovascular events (highest appropriateness score of 9) 1
• Prior testing that raises concern for heart disease (e.g., abnormal chest X-ray, ECG, elevated BNP) 1
• Initial evaluation of known or suspected valvular stenosis or regurgitation 1
• Assessment of known or suspected adult congenital heart disease 1
• Evaluation of sustained or non-sustained supraventricular or ventricular tachycardia 1
• Initial evaluation of left ventricular function following acute myocardial infarction 1, 3
• Evaluation of known or suspected pulmonary hypertension 1

Appropriate Use in Acute Settings

• Evaluation of hypotension or hemodynamic instability of uncertain or suspected cardiac etiology 1
• Assessment of acute chest pain with suspected myocardial ischemia when laboratory markers and ECG are non-diagnostic and echocardiogram can be performed during pain 1
• Evaluation of suspected complications of myocardial ischemia/infarction (e.g., acute mitral regurgitation, ventricular septal defect, free-wall rupture, tamponade) 1, 3
• Evaluation of respiratory failure with suspected cardiac etiology 1
• Assessment of patients with known or suspected acute pulmonary embolism to guide therapy 1

Valvular Disease Evaluation

• Initial evaluation of murmur when there is reasonable suspicion of valvular or structural heart disease 1
• Initial evaluation of suspected mitral valve prolapse 1
• Annual evaluation of asymptomatic patients with severe native valvular stenosis 1
• Re-evaluation of patients with valvular stenosis who have had a change in clinical status 1
• Annual re-evaluation of asymptomatic patients with severe native valvular regurgitation 1
• Initial evaluation of prosthetic valve for baseline assessment after placement 1
• Re-evaluation of patients with prosthetic valve with suspected dysfunction or change in clinical status 1

Inappropriate Use Indications

• Routine yearly evaluation of asymptomatic patients with corrected congenital heart defects more than 1 year after successful correction 1, 2
• Evaluation of patients with isolated premature atrial or ventricular contractions without other evidence of heart disease 1
• Evaluation of left ventricular function when prior evaluation within the past year showed normal function and there has been no change in clinical status 1, 2
• Initial evaluation of suspected pulmonary embolism to establish diagnosis (echocardiography is not recommended for this purpose) 1
• Routine yearly re-evaluation of mitral valve prolapse in patients with no or mild regurgitation and no change in clinical status 1
• Routine yearly re-evaluation of asymptomatic patients with mild native aortic stenosis or mild-moderate mitral stenosis with no change in clinical status 1
• Routine yearly evaluation of patients with prosthetic valves when there is no suspicion of dysfunction and no change in clinical status 1

Special Clinical Scenarios

• Takotsubo cardiomyopathy: Echocardiography is valuable for diagnosis, typically showing LV apical akinesia that doesn't correspond to typical coronary artery territories 1
• Myocarditis: Echocardiography can detect LV dysfunction, regional wall motion abnormalities, and pericardial involvement 1
• Acute aortic syndromes: Echocardiography serves as an initial imaging modality for suspected aortic dissection in emergency settings 1

Implementation Considerations

• Tests should be performed and interpreted by qualified individuals in facilities proficient in echocardiographic techniques 2
• A complete clinical history and physical examination should precede ordering an echocardiogram 2
• Surveillance echocardiograms should not be ordered simply because a certain period of time has elapsed 2
• The greatest opportunity to optimize echocardiography use is in improving individual patient decision-making 2

Common Pitfalls to Avoid

• Ordering routine annual follow-up studies in stable patients with mild disease 2
• Ordering repeat studies when there is no change in clinical status 2
• Failing to consider how test results will impact clinical decision-making or patient management 2
• Using echocardiography for initial evaluation of suspected pulmonary embolism to establish diagnosis 1
• Performing echocardiography for chest pain evaluation when a non-cardiac etiology is apparent 1

By following these appropriate use criteria, clinicians can ensure that echocardiography is utilized effectively to improve patient outcomes while avoiding unnecessary testing.