Can Physician Assistants (PAs) perform level 1 echocardiography on adult patients with atrial fibrillation or those requiring basic cardiac assessment?

Can Physician Assistants Perform Level 1 Echocardiography?

Physician Assistants can perform Level 1 echocardiography if they complete the required training (minimum 3 months, performing 75 studies and interpreting 150 studies), but they cannot independently perform or interpret echocardiograms—Level 1 training is explicitly insufficient for independent practice and requires physician supervision. 1

Understanding Level 1 Training Limitations

Level 1 training represents only introductory competence and is designed as the minimal training for all cardiovascular medicine trainees to understand echocardiography basics. 1 The key limitations are:

• Level 1 training is NOT sufficient for independent performance or interpretation of echocardiograms 1
• This level enables practitioners to expand on or clarify data acquired by a sonographer and understand technical limitations and artifacts 1
• It provides basic understanding of ultrasound physics, fundamental technical aspects, cardiovascular anatomy/physiology, and recognition of cardiac pathology 1

Minimum Requirements for Independent Practice

Level 2 training is the absolute minimum for independent echocardiography performance and interpretation, requiring: 1

• 6 months cumulative training (3 additional months beyond Level 1)
• 150 examinations personally performed (75 additional)
• 300 examinations interpreted (150 additional)
• Maintenance requires 300 studies per year 1

Who Can Perform Echocardiography in Emergency Settings

The European Association of Cardiovascular Imaging guidelines explicitly address non-cardiologists performing emergency echocardiography: 1

• Non-cardiologists (including emergency physicians, anesthesiologists, intensive care specialists) can perform emergency echocardiography if they complete the same training requirements as cardiologists
• Minimum 350 TTE examinations performed to achieve basic echocardiography competence 1
• Additional education/training is mandatory for non-cardiologists (versus "highly recommended" for cardiologists) 1
• Properly trained sonographers may provide crucial life-saving information using TTE in emergency cases 1

Critical Supervision Requirements

All emergency echocardiography, if not personally performed and interpreted by an expert, must be supervised by a physician with advanced level competence (Level 3 training). 1 This means:

• PAs performing Level 1 echocardiography must have immediate access to Level 3-trained physician oversight
• The supervising physician should be available for consultation during the examination 1
• Level 3 competence requires 12 months training, 300 studies performed, and 750 studies interpreted 1

Practical Application for Atrial Fibrillation Patients

For patients with atrial fibrillation requiring basic cardiac assessment: 1

• Transthoracic echocardiography (TTE) can detect underlying cardiac disorders in approximately 10% of AF patients with no clinically suspected cardiac disease 1
• 60% of AF patients with equivocal evidence of heart disease will have detectable cardiac disorders 1
• A PA with Level 1 training could assist in acquiring images under physician supervision but cannot independently interpret findings or make clinical decisions based on the study 1

Common Pitfalls to Avoid

• Do not confuse Level 1 training with independent competence—this is the most critical error 1
• Do not assume sonographer training equals physician training—while sonographers can perform studies, physician oversight for interpretation remains mandatory 1
• Do not perform echocardiography without appropriate supervision structure in place—patient safety depends on immediate access to expert consultation 1
• For AF patients specifically, recognize that TEE (not basic TTE) is required for thrombus exclusion before cardioversion, which requires additional specialized training beyond Level 2 1