Appropriate uses considered for echocardiography in common clinical scenarios

In the face of new evidence and new technologies, 10 medical specialty and subspecialty societies reviewed common clinical scenarios where echocardiography is frequently considered.

The review combines and updates the original transthoracic and transesophageal echocardiography appropriateness criteria published in 2007 and the original stress echocardiography appropriateness criteria published in 2008. New to the report are:

• new clinical data, changes in test utilization patterns, and clarifications to echocardiography use,expanded tables with more comprehensive coverage of various clinical situations,revised or new clinical scenarios such as valvular heart disease, perioperative evaluation and evaluation of thoracic aortic disease, andindications to better address evolving therapeutic options such as cardiac resynchronization therapy or treatment/follow-up of pulmonary hypertension.

Also, writers tried to harmonize the indications across noninvasive modalities, and also added sections of specific assumptions and definitions to clarify interpreting the review.

The complete review was published online Nov. 19 by the Journal of the American College of Cardiology. The 202 indications (clinical scenarios) were derived from common applications or anticipated uses, as well as from current clinical practice guidelines and results of studies.

Indications were scored on a scale of 1 to 9, to designate appropriate use (median, 7 to 9), uncertain use (median, 4 to 6), and inappropriate use (median, 1 to 3). Authors acknowledged that the division was somewhat arbitrary, and the numbers should be viewed as a continuum.

Ninety-seven indications were rated as appropriate, 34 were rated as uncertain, and 71 were rated as inappropriate. In general, echocardiography is appropriate for initial diagnosis when there is a change in clinical status or when the results of the echocardiogram are anticipated to change patient management. Routine testing when there is no change in clinical status or when results of testing are unlikely to modify management was more likely to be inappropriate.

In the report, 18 tables document appropriate use by test and condition (such as "TTE [Transthoracic Echocardiogram] for Cardiovascular Evaluation in an Acute Setting" or "Stress Echocardiography for Assessment of Viability/Ischemia"), while three more tables break down all tests into their indications of appropriate, uncertain or inappropriate.

Also new, one table specifically covers contrast use as applied to all of the echocardiographic modalities and another covers indications related to patients with adult congenital heart disease, a growing population.