The appropriateness criteria for echocardiography were published in 2007 and classified potential procedural indications as appropriate, uncertain, or inappropriate. The appropriate use rates for outpatient transthoracic echocardiography (TTE) by cardiologists have not been well defined. The objective of the present study was to prospectively determine the appropriate use rate of outpatient TTE in a large private practice group of >40 cardiologists (Cardiovascular Consultants, PA, Kansas City, Missouri). For each transthoracic echocardiographic study, we classified the stated reason for the examination into one of the 59 indications specified in the 2007 Appropriateness Criteria for Echocardiography publication. During the study period, 772 transthoracic echocardiographic studies were performed. Adequate information was available to classify 716 (92.7%) of these studies. The transthoracic echocardiographic studies were appropriately ordered for 533 patients (74%). Symptoms of potential cardiac origin (eg, dyspnea) was the most common reason for TTE (n = 156, 21.8%). The most common inappropriate use was routine repeat evaluation of patients with heart failure and no change in clinical status (n = 74, 10.3%). In conclusion, the appropriateness criteria for echocardiography were easily applied to real-world patients. Most patients in our series had undergone TTE for an appropriate indication.
Recent studies have demonstrated a temporal increase in the use patterns of cardiac testing without a similar increase in underlying disease prevalence. In 2007, the American College of Cardiology and the American Society of Echocardiography, in association with other professional societies, published appropriateness criteria for echocardiography. This publication has classified potential procedural indications as follows: appropriate, uncertain, and inappropriate. These classifications were determined by combining evidence-based medicine and expert consensus opinion from the appropriateness panel. We, and others, have recently published single-center data regarding the appropriate use of transesophageal echocardiography. Few data are available regarding the appropriate use of transthoracic echocardiography (TTE), and, to our knowledge, no previous reports have evaluated the appropriate use of TTE by private practice cardiologists. The objective of the present study was to prospectively evaluate the appropriate use of TTE in a large consecutive series of patients referred for TTE by private practice cardiologists.
Methods
This was a prospective observational study of all transthoracic echocardiographic studies ordered for clinically indicated reasons for outpatient visits in February 2008 by cardiologists of Cardiovascular Consultants, PA (Kansas City, Missouri). A detailed review of the electronic medical record was performed for preprocedural clinical documentation. All transthoracic echocardiographic studies were performed in the outpatient offices of Cardiovascular Consultants for patients aged ≥18 years. From this information, the stated reason for performing the transthoracic echocardiographic studies was classified into one of the 59 indications, as described in the 2007 appropriateness criteria publication. A consensus opinion was used when the indication was not obvious or when multiple indications were applicable. The transthoracic echocardiographic studies were excluded if they were performed for research purposes or if classification was not possible because of insufficient preprocedural clinical documentation.
Results
During the study period, 813 transthoracic echocardiographic studies were ordered by cardiologists in the outpatient setting. Of these, 6 (0.7%) transthoracic echocardiographic studies were performed for research purposes and 35 (4.3%) had insufficient clinical documentation and were excluded. For an additional 56 transthoracic echocardiographic studies, adequate clinical documentation was present, but the studies were not classifiable using the appropriateness criteria. The indications for these 56 studies included routine follow-up of patients who had undergone cardiac transplantation (n = 30), evaluation of left ventricular function in patients with recent percutaneous coronary intervention (n = 5), initial evaluation of known or suspected aortic root pathologic features in patients with no evidence of Marfan syndrome (n = 8), preoperative risk stratification in patients without a change in clinical status (n = 5), and other (n = 8). The remaining 716 patients constituted the study group ( Table 1 ). The transthoracic echocardiographic studies were appropriately ordered for 533 patients (74.4%). The most common indication for outpatient TTE (n = 156, 21.8%) was “symptoms potentially due to suspected cardiac etiology, including but not limited to dyspnea, shortness of breath, lightheadedness, syncope, transient ischemic attack, cerebrovascular events” (indication 1, appropriateness score 9). Of these, 35% were performed for the evaluation of dyspnea ( Figure 1 ). Transthoracic echocardiographic studies were performed for the evaluation of heart failure in 153 patients (21.4%; indications 41, 42, and 43). Of these, nearly 1/2 were classified as inappropriate. For example, 74 (10.3%) were performed for “routine (yearly) re-evaluation of patients with heart failure (systolic or diastolic) in whom there is no change in clinical status” (indication 42, appropriateness score 3). The second most common inappropriate use (n = 24, 3.4%) was “routine (yearly) evaluation of a patient with a prosthetic valve in whom there is no suspicion of valvular dysfunction and no change in clinical status” (indication 29, appropriateness score 3).
| Indication | Description ⁎ | Frequency | Cumulative Frequency | Appropriateness Score (1–9) |
|---|---|---|---|---|
| 1 | Symptoms potentially due to suspected cardiac etiology, including but not limited to dyspnea, shortness of breath, lightheadedness, syncope, transient ischemic attack, cerebrovascular events | 156 (21.8%) | 156 (21.8%) | Appropriate (9) |
| 42 | Routine (yearly) re-evaluation of patients with heart failure (systolic or diastolic) in whom there is no change in clinical status | 74 (10.3%) | 230 (32.1%) | Inappropriate (3) |
| 43 | Re-evaluation of known heart failure (systolic or diastolic) to guide therapy in a patient with a change in clinical status | 61 (8.5%) | 291 (40.6%) | Appropriate (9) |
| 17 | Initial evaluation of murmur in patients for whom there is a reasonable suspicion of valvular or structural heart disease | 36 (5%) | 327 (45.7%) | Appropriate (9) |
| 2 | Previous testing that is concerning for heart disease (ie, chest X-ray, baseline scout images for stress echocardiography, electrocardiography, elevation of serum brain natriuretic peptide) | 31 (4.3%) | 358 (50%) | Appropriate (8) |
| 6 | Patients who have sustained or nonsustained supraventricular tachycardia or ventricular tachycardia | 29 (4.1%) | 387 (54.1%) | Appropriate (8) |
| 3 | Assessment of known or suspected adult congenital heart disease, including anomalies of great vessels and cardiac chambers and valves or suspected intracardiac shunt (atrial septal defect, ventricular septal defect, patent ductus arteriosus) either in unoperated patients or after repair/operation | 28 (3.9%) | 415 (58%) | Appropriate (9) |
| 29 | Routine (yearly) evaluation of patient with prosthetic valve in whom there is no suspicion of valvular dysfunction and no change in clinical status | 24 (3.4%) | 439 (61.3%) | Inappropriate (3) |
| 36 | Evaluation of pericardial conditions, including, but not limited to, pericardial mass, effusion, constrictive pericarditis, effusive-constrictive conditions, patients after cardiac surgery, or suspected pericardial tamponade | 23 (3.2%) | 462 (64.5%) | Appropriate (9) |
| 9 | Re-evaluation of left ventricular function after myocardial infarction during recovery phase when results will guide therapy | 18 (2.5%) | 480 (67%) | Appropriate (8) |
| 41 | Initial evaluation of known or suspected heart failure (systolic or diastolic) | 18 (2.5%) | 498 (69.6%) | Appropriate (9) |
| 25 | Routine (yearly) re-evaluation of native valvular regurgitation in asymptomatic patient with mild regurgitation, no change in clinical status, and normal left ventricular size | 17 (2.4%) | 515 (71.9%) | Inappropriate (2) |
| 5 | Patients who have isolated atrial premature contraction or premature ventricular contraction without other evidence of heart disease | 13 (1.8%) | 528 (73.7%) | Inappropriate (2) |
| 39 | Routine evaluation of patients with systemic hypertension without suspected hypertensive heart disease | 12 (1.7%) | 540 (75.4%) | Inappropriate (3) |
| 21 | Routine (yearly) re-evaluation of asymptomatic patient with mild native aortic stenosis or mild-moderate native mitral stenosis and no change in clinical status | 11 (1.5%) | 551 (77%) | Inappropriate (2) |
| 27 | Re-evaluation of native valvular regurgitation in patients with a change in clinical status | 11 (1.5%) | 562 (78.5%) | Appropriate (9) |
| 26 | Routine (yearly) re-evaluation of an asymptomatic patient with severe native valvular regurgitation with no change in clinical status | 10 (1.4%) | 572 (79.9%) | Appropriate (8) |
| 28 | Initial evaluation of prosthetic valve for establishment of baseline after placement | 10 (1.4%) | 582 (81.3%) | Appropriate (9) |
| 30 | Re-evaluation of patients with prosthetic valve with suspected dysfunction or thrombosis or a change in clinical status | 9 (1.3%) | 591 (82.5%) | Appropriate (9) |
| 38 | Initial evaluation of suspected hypertensive heart disease | 9 (1.3%) | 600 (83.8%) | Appropriate (8) |
| 19 | Routine (yearly) re-evaluation of mitral valve prolapse in patients with no or mild mitral regurgitation and no change in clinical status | 6 (0.8%) | 606 (84.6%) | Inappropriate (2) |
| 18 | Initial evaluation of patient with suspected mitral valve prolapse | 5 (0.7%) | 611 (85.3%) | Appropriate (9) |
| 22 | Routine (yearly) evaluation of an asymptomatic patient with severe native valvular stenosis | 5 (0.7%) | 616 (86%) | Appropriate (7) |
| 24 | Initial evaluation of known or suspected native valvular regurgitation | 5 (0.7%) | 621 (86.7%) | Appropriate (9) |
| 23 | Re-evaluation of patient with native valvular stenosis who has had a change in clinical status | 4 (0.6%) | 625 (87.3%) | Appropriate (9) |
| 47 | Routine (yearly) evaluation of hypertrophic cardiomyopathy in patient with no change in clinical status | 4 (0.6%) | 629 (87.8%) | Inappropriate (3) |
| 4 | Routine (yearly) evaluation of asymptomatic patients with corrected atrial septal defect, ventricular septal defect, or patent ductus arteriosus >1 year after successful correction | 3 (0.4%) | 632 (88.3%) | Inappropriate (3) |
| 40 | Re-evaluation of patient with known hypertensive heart disease without a change in clinical status | 2 (0.3%) | 634 (88.5%) | Inappropriate (3) |
| 20 | Initial evaluation of known or suspected native valvular stenosis | 1 (0.1%) | 635 (88.7%) | Appropriate (9) |
| 32 | Evaluation of native and/or prosthetic valves in patients with transient fever but without evidence of bacteremia or new murmur | 1 (0.1%) | 636 (88.8%) | Inappropriate (2) |
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