Appropriateness Criteria for Cardiac Ultrasound Issued

June 22, 2007 — Appropriateness criteria for two of the most commonly used cardiac ultrasound techniques — transthoracic (TTE) and transesophageal (TEE) echocardiography have been published to co-incide with the American Society of Echocardiography (ASE) meeting which is currently taking place in Seattle.
The criteria have been produced by the American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography in partnership with several other organizations to help guide physicians in determining when and how often to use the cardiac ultrasound tests. They are now available online on the websites of the American Society of Echocardiography and the American College of Cardiology and will be published in print in the July 2007 issue of The Journal of the American Society of Echocardiography and the July 10, 2007, issue of The Journal of the American College of Cardiology.
The publication notes that it is anticipated that these new criteria will have a significant impact on physician decision making and performance and reimbursement policy and will help guide future research.
The appropriateness criteria review common scenarios found in clinical practice and address the appropriateness of ordering echocardiograms for each situation. These include patients presenting with signs and symptoms that could represent heart disease, such as murmurs and palpitations, and conditions such as hypertension, stroke, heart-valve disease, and suspected or known congenital heart disease.
The ACCF and the ASE explain that echocardiography has long been recognized in the broader medical community as a valuable diagnostic test for the evaluation of cardiac structure and function. As both TTE and TEE are relatively easy on the patient, low risk (no radiation is involved), and provide comprehensive diagnostic information, the opportunity exists for inappropriate use in patients who may not benefit from having the exam. The article addresses 14 scenarios that were found to be inappropriate for cardiac ultrasound. It adds that, in general, use of TTE/TEE for the initial evaluation of structure and function was viewed favorably, while routine repeat testing and general-screening uses in certain clinical scenarios were viewed less favorably.
Dr Michael Picard (Massachusetts General Hospital, Boston), outgoing ASE president and a member of the panel that formulated the criteria, told heartwire that the American College of Cardiology is drafting a series of appropriateness criteria for different technologies, with nuclear imaging and cardiac MRI/CT already having been covered and cardiac ultrasound representing the third in the series.
He says the new criteria will be helpful to doctors who order echocardiograms. While these include practicing cardiologists, about 70% of echocardiograms are actually ordered by noncardiologists — mainly internists and primary-care doctors, Picard noted. He said that the ASE is developing initiatives to widely disseminate the new appropriateness criteria to all medical professionals who are responsible for ordering echocardiograms, but cardiologists could assist in this process by educating their colleagues about the criteria.
Will Curb Inappropriate Use of Cardiac Ultrasound
Picard said one goal of the new criteria is to reduce the overuse of cardiac ultrasound technology. "There is the perception that echocardiography is being overused," he told heartwire. "The use of all cardiac imaging is growing at a substantial rate, with echocardiography no exception, increasing at about 8% per year. It is hard to say whether this growth is appropriate or not. While it is true that access to these new technologies has allowed great strides, there are some situations where its use is not appropriate, and we have tried to spell this out in this document."
Picard explained that the appropriateness criteria document lists many common scenarios that the average practitioner would encounter, and each scenario has been given a score based on a scale of 1-9 to signify its appropriateness for cardiac ultrasound. "The score was reached by a committee of experts voting. If most thought a particular scenario was appropriate for cardiac ultrasound, it was given a high score — 8 or 9. And if most thought it did not justify cardiac ultrasound, it was given a low score. If there was disagreement, it was ranked as uncertain — and given a midrange score of 5 or 6," he said.
Picard gives as an example a patient who has a murmur but no pathological features and who had an echo within the past year. "If there had been no change in clinical status, we would say that another echo was not appropriate for this patient, but if the patient had recently developed hypertension, then yes, another echo would be appropriate," he commented.
Picard emphasized to heartwire that these new appropriateness criteria are there to help doctors decide which patients to send for an echo, but they are not set in stone and are not supposed to be used in isolation but combined with clinical judgment to make the decision.
J Am Coll Cardiol. Published online June 15, 2007.