ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography

A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance Endorsed by the American College of Chest Physicians

Technical Panel

Steven R. Bailey, MD, FACC, FSCAI, FAHA, Moderator

Rory B. Weiner, MD, Writing Group Liaison

Peter Alagona, Jr, MD, FACC^⁎

Jeffrey L. Anderson, MD, FACC, FAHA, MACP^⁎∥

Jeanne M. DeCara, MD, FACC, FASE§

Rowena J. Dolor, MD, MHS

Reza Fazel, MD, FACC^⁎⁎

John A. Gillespie, MD, FACC‡‡

Paul A. Heidenreich, MD, FACC#

Luci K. Leykum, MD, MBA, MSc

Joseph E. Marine, MD, FACC, FHRS‡

Gregory J. Mishkel, MD, FACC, FSCAI, FRCPC††

Patricia A. Pellikka, MD, FACC, FAHA, FACP, FASE§

Gilbert L. Raff, MD, FACC, FSCCT†

Krishnaswami Vijayaraghavan, MD, FACC, FCCP§§

Neil J. Weissman, MD, FACC, FAHA^⁎

Katherine C. Wu, MD¶

Appropriate Use Criteria Task Force

Michael J. Wolk, MD, MACC, Chair

Steven R. Bailey, MD, FACC, FSCAI, FAHA

Pamela S. Douglas, MD, MACC, FAHA, FASE

Robert C. Hendel, MD, FACC, FAHA, FASNC

Christopher M. Kramer, MD, FACC, FAHA

James K. Min, MD, FACC

Manesh R. Patel, MD, FACC

Leslee Shaw, PhD, FACC, FASNC

Raymond F. Stainback, MD, FACC, FASE

Joseph M. Allen, MA

Table of Contents

• Abstract…...1128

• Preface…...1128

• 1. Introduction…...1129

• 2. Methods…...1129

• 3. General Assumptions…...1130

• 4. Definitions…...1131

• 5. Abbreviations…...1132

• 6. Results of Ratings…...1132

• 7. Echocardiography Appropriate Use Criteria (by Indication)…...1133

  • Table 1. TTE for General Evaluation of Cardiac Structure and Function…...1133

  • Table 2: TTE for Cardiovascular Evaluation in an Acute Setting…...1133

  • Table 3: TTE for Evaluation of Valvular Function…...1134

  • Table 4: TTE for Evaluation of Intracardiac and Extracardiac Structures and Chambers…...1135

  • Table 5: TTE for Evaluation of Aortic Disease…...1135

  • Table 6: TTE for Evaluation of Hypertension, HF, or Cardiomyopathy…...1135

  • Table 7: TTE for Adult Congenital Heart Disease…...1136

  • Table 8: TEE…...1137

  • Table 9: Stress Echocardiography for Detection of CAD/Risk Assessment: Symptomatic or Ischemic Equivalent…...1137

  • Table 10: Stress Echocardiography for Detection of CAD/Risk Assessment: Asymptomatic (Without Ischemic Equivalent)…...1138

  • Table 11: Stress Echocardiography for Detection of CAD/Risk Assessment: Asymptomatic (Without Ischemic Equivalent) in Patient Populations With Defined Comorbidities…...1138

  • Table 12: Stress Echocardiography Following Prior Test Results…...1139

  • Table 13: Stress Echocardiography for Risk Assessment: Perioperative Evaluation for Noncardiac Surgery Without Active Cardiac Conditions…...1140

  • Table 14: Stress Echocardiography for Risk Assessment: Within 3 Months of an ACS…...1140

  • Table 15: Stress Echocardiography for Risk Assessment: Postrevascularization (PCI or CABG)…...1140

  • Table 16: Stress Echocardiography for Assessment of Viability/Ischemia…...1141

  • Table 17: Stress Echocardiography for Hemodynamics (Includes Doppler During Stress)…...1141

  • Table 18: Contrast Use in TTE/TEE or Stress Echocardiography…...1141

• 8. Echocardiography Appropriate Use Criteria (by Appropriate Use Rating)…...1142

  • Table 19. Appropriate Indications (Median Score 7–9)…...1142

  • Table 20. Uncertain Indications (Median Score 4–6)…...1146

  • Table 21. Inappropriate Indications (Median Score 1–3)…...1148

• 9. Discussion…...1154

• Appendix A: Additional Echocardiography Definitions…...1158

  • Figure A1. Stepwise Approach to Perioperative Cardiac Assessment…...1159

  • Table A1: Active Cardiac Conditions for Which the Patient Should Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I, Level of Evidence: B)…...1159

  • Table A2. Perioperative Clinical Risk Factors*…...1160

• Appendix B: Additional Methods…...1160

  • Relationships With Industry and Other Entities…...1160

  • Literature Review…...1160

• Appendix C: ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography Participants…...1160

• Appendix D: ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography Writing Group, Technical Panel, Indication Reviewers, and Task Force—Relationships With Industry and Other Entities (in Alphabetical Order Within Each Group)…...1163

• References…...1164

Abstract

The American College of Cardiology Foundation (ACCF), in partnership with the American Society of Echocardiography (ASE) and along with key specialty and subspecialty societies, conducted a review of common clinical scenarios where echocardiography is frequently considered. This document combines and updates the original transthoracic and transesophageal echocardiography appropriateness criteria published in 2007 (1) and the original stress echocardiography appropriateness criteria published in 2008 (2). This revision reflects new clinical data, reflects changes in test utilization patterns, and clarifies echocardiography use where omissions or lack of clarity existed in the original criteria.

The indications (clinical scenarios) were derived from common applications or anticipated uses, as well as from current clinical practice guidelines and results of studies examining the implementation of the original appropriate use criteria (AUC). The 202 indications in this document were developed by a diverse writing group and scored by a separate independent technical panel 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).

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

The AUC for echocardiography have the potential to impact physician decision making, healthcare delivery, and reimbursement policy. Furthermore, recognition of uncertain clinical scenarios facilitates identification of areas that would benefit from future research.

Preface

In an effort to respond to the need for the rational use of imaging services in the delivery of high-quality care, the ACCF has undertaken a process to determine the appropriate use of cardiovascular imaging for selected patient indications.

AUC publications reflect an ongoing effort by the ACCF to critically and systematically create, review, and categorize clinical situations where diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on current understanding of the technical capabilities of the imaging modalities examined. Although impossible to be entirely comprehensive given the wide diversity of clinical disease, the indications are meant to identify common scenarios encompassing the majority of situations encountered in contemporary practice. Given the breadth of information they convey, the indications do not directly correspond to the Ninth Revision of the International Classification of Diseases system as these codes do not include clinical information, such as symptom status.

The ACCF believes that careful blending of a broad range of clinical experiences and available evidence-based information will help guide a more efficient and equitable allocation of healthcare resources in cardiovascular imaging. The ultimate objective of AUC is to improve patient care and health outcomes in a cost-effective manner, but it is not intended to ignore ambiguity and nuance intrinsic to clinical decision making. AUC thus should not be considered substitutes for sound clinical judgment and practice experience.

The ACCF AUC process itself is also evolving. In the current iteration, technical panel members were asked to rate indications for echocardiography in a manner independent and irrespective of the prior published ACCF ratings for transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) (1) and stress echocardiography (2) as well as the prior ACCF ratings for diagnostic imaging modalities such as cardiac radionuclide imaging (RNI) (3) and cardiac computed tomography (CT) (4). Given the iterative and evolving nature of the process, readers are counseled that comparison of individual appropriate use ratings among modalities rated at different times over the past several years may not reflect the comparative utility of the different modalities for an indication, as the ratings may vary over time. A comparative evaluation of the appropriate use of multiple imaging techniques is currently being undertaken to assess the relative strengths of each modality for various clinical scenarios.

We are grateful to the technical panel and its chair, Steven Bailey, MD, FACC, FSCAI, FAHA, a professional group with a wide range of skills and insights, for their thoughtful and thorough deliberation of the merits of echocardiography for various indications. We would also like to thank the 27 individuals who provided a careful review of the draft of indications, the parent AUC Task Force ably led by Michael Wolk, MD, MACC, Rory Weiner, MD, and the ACC staff, John C. Lewin, MD, Joseph Allen, Starr Webb, Jenissa Haidari, and Lea Binder for their exceptionally skilled support in the generation of this document.

Pamela S. Douglas, MD, MACC, FAHA, FASE Chair, Echocardiography Writing Group

Michael J. Wolk, MD, MACC Chair, Appropriate Use Criteria Task Force

1 Introduction

This report addresses the appropriate use of TTE, TEE, and stress echocardiography. Improvements in cardiovascular imaging technology and an expanding armamentarium of noninvasive diagnostic tools and therapeutic options for cardiovascular disease have led to an increase in cardiovascular imaging. As the field of echocardiography continues to advance along with other imaging modalities and treatment options, the healthcare community needs to understand how to best incorporate this technology into daily clinical care.

All prior AUC publications from the ACCF and collaborating organizations reflect an ongoing effort to critically and systematically create, review, and categorize the appropriate use of cardiovascular procedures and diagnostic tests. The ACCF recognizes the importance of revising these criteria in a timely manner in order to provide the cardiovascular community with the most accurate indications. Understanding the background and scope of this document are important before interpreting the rating tables.

This document presents a combination and revision of the 2007 ACCF AUC for Transthoracic and Transesophageal Echocardiography (1) and the 2008 ACCF AUC for Stress Echocardiography (2). Appropriate echocardiograms are those that are likely to contribute to improving patients' clinical outcomes, and importantly, inappropriate use of echocardiography may be potentially harmful to patients and generate unwarranted costs to the healthcare system.

2 Methods

The indications included in this publication cover a wide array of cardiovascular signs and symptoms as well as clinical judgments as to the likelihood of cardiovascular findings. Within each main disease category, a standardized approach was used to capture the majority of clinical scenarios without making the list of indications excessive. The approach was to create 5 broad clinical scenarios regarding the possible use of echocardiography: 1) for initial diagnosis; 2) to guide therapy or management, regardless of symptom status; 3) to evaluate a change in clinical status or cardiac exam; 4) for early follow-up without change in clinical status; and 5) for late follow-up without change in clinical status. Certain specific clinical scenarios were addressed with additional focused indications.

The indications were constructed by experts in echocardiography and in other fields and were modified on the basis of discussions among the task force and feedback from independent reviewers and the technical panel. Wherever possible, indications were mapped to relevant clinical guidelines and key publications/references (Online Appendix).

An important focus during the indication revision process was to harmonize the indications across noninvasive modalities, such that the wording of the indications are similar with other AUC (3) whenever it was feasible to do so. New indications as well as indication tables were created, although it remains likely that several clinical scenarios are not covered by these revised AUC for echocardiography. Once the revised indications were written, they were reviewed and critiqued by the parent AUC Task Force and by 27 external reviewers representing all cardiovascular specialties and primary care before being finalized.

A detailed description of the methods used for ranking the selected clinical indications is found in a previous publication, “ACCF Proposed Method for Evaluating the Appropriateness of Cardiovascular Imaging” (5). Briefly, this process combines evidence-based medicine and practice experience by engaging a technical panel in a modified Delphi exercise. Since the original TTE/TEE (1) and stress echocardiography (2) documents and methods paper (5) were published, several important processes have been put in place to further enhance the rigor of this process. They include convening a formal writing group with diverse expertise in imaging and clinical care, circulating the indications for external review prior to rating by the technical panel, ensuring appropriate balance of expertise and practice area of the technical panel, development of a standardized rating package, and establishment of formal roles for facilitating panel interaction at the face-to-face meeting.

The technical panel first rated indications independently. Then, the panel was convened for a face-to-face meeting for discussion of each indication. At this meeting, panel members were provided with their scores and a blinded summary of their peers' scores. After the meeting, panel members were then asked to independently provide their final scores for each indication.

Although panel members were not provided explicit cost information to help determine their appropriate use ratings, they were asked to implicitly consider cost as an additional factor in their evaluation of appropriate use. In rating these criteria, the technical panel was asked to assess whether the use of the test for each indication is appropriate, uncertain, or inappropriate, and was provided the following definition of appropriate use:

An appropriate imaging study is one in which the expected incremental information, combined with clinical judgment, exceeds the expected negative consequences^⁎by a sufficiently wide margin for a specific indication that the procedure is generally considered acceptable care and a reasonable approach for the indication.

The technical panel scored each indication as follows:

• Median Score 7 to 9

• Appropriate test for specific indication (test is generally acceptable and is a reasonable approach for the indication).

• Median Score 4 to 6

• Uncertain for specific indication (test may be generally acceptable and may be a reasonable approach for the indication). Uncertainty also implies that more research and/or patient information is needed to classify the indication definitively.

• Median Score 1 to 3

• Inappropriate test for that indication (test is not generally acceptable and is not a reasonable approach for the indication).

The division of these scores into 3 levels of appropriateness is somewhat arbitrary, and the numeric designations should be viewed as a continuum. Further, there is diversity in clinical opinion for particular clinical scenarios, such that scores in the intermediate level of appropriate use should be labeled “uncertain,” as critical patient or research data may be lacking or discordant. This designation should be a prompt to the field to carry out definitive research investigations whenever possible. It is anticipated that the AUC reports will continue to be revised as further data are generated and information from the implementation of the criteria is accumulated.

To prevent bias in the scoring process, the technical panel was deliberately comprised of a minority of specialists in echocardiography. Specialists, although offering important clinical and technical insights, might have a natural tendency to rate the indications within their specialty as more appropriate than nonspecialists. In addition, care was taken in providing objective, nonbiased information, including guidelines and key references, to the technical panel.

The level of agreement among panelists as defined by RAND (6) was analyzed based on the BIOMED rule for a panel of 14 to 16 members. As such, agreement was defined as an indication where 4 or fewer panelists' ratings fell outside the 3-point region containing the median score.

Disagreement was defined as where at least 5 panelists' ratings fell in both the appropriate and the inappropriate categories. Any indication having disagreement was categorized as uncertain regardless of the final median score. Indications that met neither definition for agreement or disagreement are in a third, unlabeled category.

3 General Assumptions

To prevent any inconsistencies in interpretation, specific assumptions were considered by the writing group in developing the indications and by the technical panel when rating the clinical indications for the appropriate use of inpatient and outpatient adult TTE/TEE and stress echocardiography.

• 1. A TTE and a TEE examination and report will include the use and interpretation of 2-dimensional/M-mode imaging, color flow Doppler, and spectral Doppler as important elements of a comprehensive TTE/TEE (7–9) evaluating relevant cardiac structures and hemodynamics. Stress echocardiography will include rest and stress 2-dimensional imaging at a minimum unless performed for hemodynamics, when Doppler must be included (10).

• 2. All standard echocardiographic techniques for image acquisition, including standard rest imaging and stress protocols (10), are available for each indication and have a sensitivity and specificity similar to those found in the published literature. Selection for and monitoring of contrast use is assumed to be in accord with practice guidelines (11).

• 3. The test is performed and interpreted by qualified individual(s) in a facility that is proficient in the echocardiographic technique (12,13).

• 4. The range of potential indications for echocardiography is quite large, particularly in comparison with other cardiovascular imaging tests. Thus, the indications are, at times, purposefully broad to cover an array of cardiovascular signs and symptoms as well as the ordering physician's best judgment as to the presence of cardiovascular abnormalities. Additionally, there are likely clinical scenarios that are not covered in this document.

• 5. A complete clinical history and physical exam has been completed by a qualified clinician such that the clinical status of the patient can be assumed to be valid as stated in the indication (e.g., an asymptomatic patient is truly asymptomatic for the condition in question and that sufficient questioning of the patient has been undertaken).

• 6. If the reason for a test can be assigned to more than 1 indication, it should be classified under the most appropriate indication.

• 7. Cost should be considered implicitly in the appropriate use determination.

• 8. For each indication, the rating should reflect whether the echocardiogram is reasonable for the patient according to the appropriate use definition, not whether the test is preferred over another modality. It should not be assumed that for each indication the decision to perform a diagnostic test has already been made. It also should not consider issues of local availability or skill for any modality or attempt in any way to compare 2 tests with each other.

• 9. The category of “uncertain” should be used when insufficient clinical data are available for a definitive categorization or there is substantial disagreement regarding the appropriateness of that indication. The designation of “uncertain” should not be used as grounds for denial of reimbursement.

• 10. Indications that describe routine or surveillance echocardiograms imply that the test is being considered for a “periodic” evaluation since a certain period of time has elapsed. The test is not being ordered due to the anticipation of changing clinical decision making or guiding therapy.

• 11. Prosthetic valves and native valves are to be considered together, except where specifically mentioned otherwise in this document. The severity of valve stenosis or regurgitation is defined in clinical guidelines (14,15).

• 12. In general, it is assumed that TEE is most appropriately used as an adjunct or subsequent test to TTE when indicated, such as when suboptimal TTE images preclude obtaining a diagnostic study. The indications for which TEE may reasonably be the test of first choice include, but are not limited to, the indications presented in Table 8 of this document.

• 13. Intraoperative TEE is an important use of cardiovascular ultrasound. However, this application is outside the scope of this document and thus is not addressed here.

• 14. For all stress imaging, the mode of stress testing is assumed to be exercise (e.g., treadmill, bicycle) for patients able to exercise. For patients unable to exercise, it is assumed that dobutamine is used for echocardiographic stress testing. Any indications requiring a specific mode of stress (e.g., when hemodynamic information is required) are labeled as such.

• 15. Doppler hemodynamic assessment during stress echocardiography includes both right and left heart hemodynamics (e.g., valvular gradients, pulmonary artery pressure, mitral regurgitation severity).

• 16. The indications for the perioperative evaluation for noncardiac surgery were modeled after the ACCF/AHA guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery (16). If a patient has signs/symptoms of suspected cardiac etiology, the clinical scenario should be considered in the symptomatic category (e.g., Indication 1) and not in the perioperative section.

• 17. As with other surgeries, the need for coronary artery disease (CAD) assessment prior to solid organ transplantation is related to patient and surgical risk. In general, solid organ transplantation should be considered in the vascular surgery category given that CAD is common in patients with diabetes mellitus who have end-stage renal disease.

4 Definitions

Definitions of terms used throughout the indication set are listed here. Additional definitions are listed in Appendix A. These definitions were provided to and discussed with the technical panel prior to ratings of indications.

• 1. Ischemic Equivalent: Chest Pain Syndrome, Anginal Equivalent, or Ischemic Electrocardiographic Abnormalities: Any constellation of clinical findings that the physician feels is consistent with CAD. Examples of such findings include, but are not limited to, chest pain, chest tightness, chest burning, shoulder pain, palpitations, jaw pain, new electrocardiographic abnormalities, or other symptoms/findings suggestive of CAD. Nonchest pain symptoms (e.g., dyspnea or reduced/worsening effort tolerance) that are thought to be consistent with CAD may also be considered to be an ischemic equivalent.

• 2. Global CAD Risk: It is assumed that clinicians will use current standard methods of global risk assessment such as those presented in the National Heart, Lung, and Blood Institute report on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III [ATP III]) (18) or similar national guidelines.

   Absolute risk is defined as the probability of developing CAD over a given time period. The ATP III report specifies absolute risk for CAD over the next 10 years. CAD risk refers to 10-year risk for any hard cardiac event (e.g., myocardial infarction or CAD death). However, acknowledging that global absolute risk scores may be miscalibrated in certain populations (e.g., women, younger men), clinical judgment must be applied in assigning categorical risk thresholds in such subpopulations.

  • • Low global CAD risk

     Defined by the age-specific risk level that is below average. In general, low risk will correlate with a 10-year absolute CAD risk <10%. However, in women and younger men, low risk may correlate with 10-year absolute CAD risk <6%.

  • • Intermediate global CAD risk

     Defined by the age-specific risk level that is average. In general, moderate risk will correlate with a 10-year absolute CAD risk range of 10% to 20%. Among women and younger age men, an expanded intermediate risk range of 6% to 20% may be appropriate.

  • • High global CAD risk

     Defined by the age-specific risk level that is above average. In general, high risk will correlate with a 10-year absolute CAD risk of >20%. CAD equivalents (e.g., diabetes mellitus, peripheral arterial disease) can also define high risk.

• 3. Pretest Probability of CAD: Symptomatic (Ischemic Equivalent) Patients: Once the physician determines that symptoms are present that may represent CAD, the pretest probability of CAD should be assessed. There are a number of risk algorithms (19,20) available that can be used to calculate this probability. Clinicians should be familiar with those algorithms that pertain to the populations they encounter most often. In scoring the indications, the following probabilities, as calculated from any of the various available validated algorithms, should be applied.

• • Very low pretest probability: <5% pretest probability of CAD

• • Low pretest probability: Between 5% and 10% pretest probability of CAD

• • Intermediate pretest probability: Between 10% and 90% pretest probability of CAD

• • High pretest probability: >90% pretest probability of CAD

The method recommended by the ACC/AHA guidelines for chronic stable angina (21) is provided as one example of a method used to calculate pretest probability and is a modification of a previously published literature review (22). Please refer to Table A and the definition of angina in Appendix A. It is important to note that other historical factors or electrocardiographic findings (e.g., prior infarction) can affect pretest probability, although these factors are not accounted for in Table A. Similarly, although not incorporated into the algorithm, other CAD risk factors may also affect pretest likelihood of CAD. Detailed nomograms are available that incorporate the effects of a history of prior infarction, electrocardiographic Q waves and ST- and T-wave changes, diabetes, smoking, and hypercholesterolemia (23).

5 Abbreviations

• ACS = acute coronary syndrome

• APC = atrial premature contraction

• CABG = coronary artery bypass grafting surgery

• CAD = coronary artery disease

• CMR = cardiovascular magnetic resonance

• CRT = cardiac resynchronization therapy

• CT = computed tomography

• ECG = electrocardiogram

• HF = heart failure

• ICD = implantable cardioverter-defibrillator

• LBBB = left bundle-branch block

• LV = left ventricular

• MET = estimated metabolic equivalents of exercise

• MI = myocardial infarction

• PCI = percutaneous coronary intervention

• RNI = radionuclide imaging

• SPECT MPI = single-photon emission computed tomography myocardial perfusion imaging

• STEMI = ST-segment elevation myocardial infarction

• SVT = supraventricular tachycardia

• TEE = transesophageal echocardiogram

• TIA = transient ischemic attack

• TIMI = Thrombolysis In Myocardial Infarction

• TTE = transthoracic echocardiogram

• UA/NSTEMI = unstable angina/non–ST-segment elevation myocardial infarction

• VPC = ventricular premature contraction

• VT = ventricular tachycardia

6 Results of Ratings

The final ratings for echocardiography are listed by indication in Tables 1 to 18. The final score reflects the median score of the 15 technical panel members and has been labeled according to the 3 appropriate use categories of appropriate (median 7 to 9), uncertain (median 4 to 6), and inappropriate (median 1 to 3). Tables 19 to 21 present the indications by the appropriate use categories.

There was less variation in ratings for the indications labeled as either appropriate or inappropriate, with 92% and 90%, respectively, showing agreement as defined in Methods Section 2. There was greater variability (less agreement) in the rating scores for indications defined as uncertain, with 21% showing agreement as defined previously. Two indications, 182 and 189, were distributed into each extreme such that the panel was classified as being in disagreement. However, the median scores for these indications were already placed in the uncertain category, so no changes were required to reflect disagreement. Across all categories, 40 indications did not meet the definition of agreement; however, the scores were not so divergent (as defined by disagreement) as to necessitate a change in the final score.

7 Echocardiography Appropriate Use Criteria (by Indication)

8 Echocardiography Appropriate Use Criteria (by Appropriate Use Rating)

Tables 19 to 21

Visual representations (flow diagrams) for all indications are included in the Online Appendix.

Selected flow diagrams for several categories of indications are included here (Figs. 1 to 6).⇓⇓⇓⇓⇓⇓

• Download figure
• Open in new tab
• Download powerpoint

Figure 1

Stress Echocardiography for Detection of CAD/Risk Assessment: Symptomatic or Ischemic Equivalent

• Download figure
• Open in new tab
• Download powerpoint

Figure 2

Stress Echocardiography for Detection of CAD/Risk Assessment: Asymptomatic (Without Ischemic Equivalent)

• Download figure
• Open in new tab
• Download powerpoint

Figure 3

Stress Echocardiography Following Prior Treadmill ECG, Coronary Calcium Scoring, or Carotid Intimal Medial Thickness Test Results

• Download figure
• Open in new tab
• Download powerpoint

Figure 4

Stress Echocardiography Following Prior Stress Imaging or Coronary Angiogram Test Results

• Download figure
• Open in new tab
• Download powerpoint

Figure 5

Stress Echocardiography for Risk Assessment—Perioperative Evaluation for Noncardiac Surgery Without Active Cardiac Conditions

• Download figure
• Open in new tab
• Download powerpoint

Figure 6

Stress Echocardiography for Risk Assessment—Postrevascularization (PCI or CABG)

9 Discussion

Appropriate use criteria define patient subgroups where the available medical evidence supplemented by expert opinion are combined to assess whether the net benefit or risks of a test or procedure make it reasonable to perform testing (in this document, echocardiography) in a particular clinical situation. The intent of these criteria is to guide the rational use of a procedure, namely avoidance of either under- or over-utilization, and thereby lead to improved outcomes, more optimal healthcare delivery, and justifiable healthcare expenditures.

This document is a revision and combination of the original AUC for transthoracic and transesophageal echocardiography (1) and stress echocardiography (2). The revision adds insight provided by interim clinical data and standards documents recently published in the literature and clarifies areas in which omissions or lack of clarity existed in the original criteria. Additionally, since publication of the original AUC, several studies have assessed the application of these criteria in clinical practice; results from these studies were incorporated into this revision and will be briefly summarized here.

Staff

American College of Cardiology Foundation

John C. Lewin, MD, Chief Executive Officer

Joseph M. Allen, MA, Director, TRIP (Translating Research Into Practice)

Starr Webb, MPH, Senior Specialist, Appropriate Use Criteria

Jenissa Haidari, MPH, Senior Specialist, Appropriate Use Criteria

Lea Binder, MA, Specialist, Appropriate Use Criteria

Erin A. Barrett, MPS, Senior Specialist, Science and Clinical Policy