Table 21

Inappropriate Indications (Median Score 1–3)

IndicationAppropriate Use Score (1–9)
TTE for General Evaluation of Cardiac Structure and Function Arrhythmias
3.
  • Infrequent APCs or infrequent VPCs without other evidence of heart disease

I (2)
6.
  • Asymptomatic isolated sinus bradycardia

I (2)
TTE for General Evaluation of Cardiac Structure and Function Lightheadedness/Presyncope/Syncope
8.
  • Lightheadedness/presyncope when there are no other symptoms or signs of cardiovascular disease

I (3)
TTE for General Evaluation of Cardiac Structure and Function Evaluation of Ventricular Function
10.
  • Initial evaluation of ventricular function (e.g., screening) with no symptoms or signs of cardiovascular disease

I (2)
11.
  • Routine surveillance of ventricular function with known CAD and no change in clinical status or cardiac exam

I (3)
12.
  • Evaluation of LV function with prior ventricular function evaluation showing normal function (e.g., prior echocardiogram, left ventriculogram, CT, SPECT MPI, CMR) in patients in whom there has been no change in clinical status or cardiac exam

I (1)
TTE for General Evaluation of Cardiac Structure and Function Perioperative Evaluation
13.
  • Routine perioperative evaluation of ventricular function with no symptoms or signs of cardiovascular disease

I (2)
TTE for General Evaluation of Cardiac Structure and Function Pulmonary Hypertension
16.
  • Routine surveillance (<1 y) of known pulmonary hypertension without change in clinical status or cardiac exam

I (3)
TTE for Cardiovascular Evaluation in an Acute Setting Pulmonary Embolism
28.
  • Suspected pulmonary embolism in order to establish diagnosis

I (2)
30.
  • Routine surveillance of prior pulmonary embolism with normal right ventricular function and pulmonary artery systolic pressure

I (1)
TTE for Cardiovascular Evaluation in an Acute Setting Cardiac Trauma
33.
  • Routine evaluation in the setting of mild chest trauma with no electrocardiographic changes or biomarker elevation

I (2)
TTE for Evaluation of Valvular Function Murmur or Click
35.
  • Initial evaluation when there are no other symptoms or signs of valvular or structural heart disease

I (2)
36.
  • Re-evaluation in a patient without valvular disease on prior echocardiogram and no change in clinical status or cardiac exam

I (1)
TTE for Evaluation of Valvular Function Native Valvular Stenosis
38.
  • Routine surveillance (<3 y) of mild valvular stenosis without a change in clinical status or cardiac exam

I (3)
40.
  • Routine surveillance (<1 y) of moderate or severe valvular stenosis without a change in clinical status or cardiac exam

I (3)
TTE for Evaluation of Valvular Function Native Valvular Regurgitation
42.
  • Routine surveillance of trace valvular regurgitation

I (1)
43.
  • Routine surveillance (<3 y) of mild valvular regurgitation without a change in clinical status or cardiac exam

I (2)
TTE for Evaluation of Valvular Function Prosthetic Valves
48.
  • Routine surveillance (<3 y after valve implantation) of prosthetic valve if no known or suspected valve dysfunction

I (3)
TTE for Evaluation of Valvular Function Infective Endocarditis (Native or Prosthetic Valves)
53.
  • Transient fever without evidence of bacteremia or a new murmur

I (2)
54.
  • Transient bacteremia with a pathogen not typically associated with infective endocarditis and/or a documented nonendovascular source of infection

I (3)
56.
  • Routine surveillance of uncomplicated infective endocarditis when no change in management is contemplated

I (2)
TTE for Evaluation of Intracardiac and Extracardiac Structures and Chambers
60.
  • Routine surveillance of known small pericardial effusion with no change in clinical status

I (2)
TTE for Evaluation of Aortic Disease
66.
  • Routine re-evaluation for surveillance of known ascending aortic dilation or history of aortic dissection without a change in clinical status or cardiac exam when findings would not change management or therapy

I (3)
TTE for Evaluation of Hypertension, HF, or Cardiomyopathy Hypertension
68.
  • Routine evaluation of systemic hypertension without symptoms or signs of hypertensive heart disease

I (3)
TTE for Evaluation of Hypertension, HF, or Cardiomyopathy HF
74.
  • Routine surveillance (<1 y) of HF (systolic or diastolic) when there is no change in clinical status or cardiac exam

I (2)
TTE for Evaluation of Hypertension, HF, or Cardiomyopathy Device Evaluation (Including Pacemaker, ICD, or CRT)
79.
  • Routine surveillance (<1 y) of implanted device without a change in clinical status or cardiac exam

I (1)
80.
  • Routine surveillance (≥1 y) of implanted device without a change in clinical status or cardiac exam

I (3)
TTE for Evaluation of Hypertension, HF, or Cardiomyopathy Cardiomyopathies
88.
  • Routine surveillance (<1 y) of known cardiomyopathy without a change in clinical status or cardiac exam

I (2)
TTE for Adult Congenital Heart Disease
95.
  • Routine surveillance (<2 y) of adult congenital heart disease following complete repair

    • without a residual structural or hemodynamic abnormality

    • without a change in clinical status or cardiac exam

I (3)
TEE as Initial or Supplemental Test—General Uses
100.
  • Routine use of TEE when a diagnostic TTE is reasonably anticipated to resolve all diagnostic and management concerns

I (1)
102.
  • Surveillance of prior TEE finding for interval change (e.g., resolution of thrombus after anticoagulation, resolution of vegetation after antibiotic therapy) when no change in therapy is anticipated

I (2)
105.
  • Routine assessment of pulmonary veins in an asymptomatic patient status post pulmonary vein isolation

I (3)
TEE as Initial or Supplemental Test—Valvular Disease
107.
  • To diagnose infective endocarditis with a low pretest probability (e.g., transient fever, known alternative source of infection, or negative blood cultures/atypical pathogen for endocarditis)

I (3)
TEE as Initial or Supplemental Test—Embolic Event
111.
  • Evaluation for cardiovascular source of embolus with a known cardiac source in which a TEE would not change management

I (1)
TEE as Initial Test—Atrial Fibrillation/Flutter
113.
  • Evaluation when a decision has been made to anticoagulate and not to perform cardioversion

I (2)
Stress Echocardiography for Detection of CAD/Risk Assessment: Symptomatic or Ischemic Equivalent Evaluation of Ischemic Equivalent (Nonacute)
114.
  • Low pretest probability of CAD

  • ECG interpretable and able to exercise

I (3)
Stress Echocardiography for Detection of CAD/Risk Assessment: Symptomatic or Ischemic Equivalent Acute Chest Pain
123.
  • Definite ACS

I (1)
Stress Echocardiography for Detection of CAD/Risk Assessment: Asymptomatic (Without Ischemic Equivalent) General Patient Populations
124.
  • Low global CAD risk

I (1)
125.
  • Intermediate global CAD risk

  • ECG interpretable

I (2)
Stress Echocardiography for Detection of CAD/Risk Assessment: Asymptomatic (Without Ischemic Equivalent) in Patient Populations With Defined Comorbidities Arrhythmias
131.
  • Infrequent PVCs

I (3)
Stress Echocardiography for Detection of CAD/Risk Assessment: Asymptomatic (Without Ischemic Equivalent) in Patient Populations With Defined Comorbidities Syncope
133.
  • Low global CAD risk

I (3)
Stress Echocardiography Following Prior Test Results Asymptomatic: Prior Evidence of Subclinical Disease
136.
  • Coronary calcium Agatston score <100

I (2)
Stress Echocardiography Following Prior Test Results
Asymptomatic or Stable Symptoms
Normal Prior Stress Imaging Study
142.
  • Low global CAD risk

  • Last stress imaging study <2 y ago

I (1)
143.
  • Low global CAD risk

  • Last stress imaging study ≥2 y ago

I (2)
144.
  • Intermediate to high global CAD risk

  • Last stress imaging study <2 y ago

I (2)
Stress Echocardiography Following Prior Test Results
Asymptomatic or Stable Symptoms
Abnormal Coronary Angiography or Abnormal Prior Stress Study
No Prior Revascularization
146.
  • Known CAD on coronary angiography or prior abnormal stress imaging study

  • Last stress imaging study <2 y ago

I (3)
Stress Echocardiography Following Prior Test Results
Treadmill ECG Stress Test
148.
  • Low-risk treadmill score (e.g., Duke)

I (1)
Stress Echocardiography for Risk Assessment: Perioperative Evaluation for Noncardiac Surgery Without Active Cardiac Conditions
Low-Risk Surgery
154.
  • Perioperative evaluation for risk assessment

I (1)
Stress Echocardiography for Risk Assessment: Perioperative Evaluation for Noncardiac Surgery Without Active Cardiac Conditions
Intermediate-Risk Surgery
155.
  • Moderate to good functional capacity (≥4 METs)

I (3)
156.
  • No clinical risk factors

I (2)
158.
  • Asymptomatic <1 y post normal catheterization, noninvasive test, or previous revascularization

I (1)
Stress Echocardiography for Risk Assessment: Perioperative Evaluation for Noncardiac Surgery Without Active Cardiac Conditions
Vascular Surgery
159.
  • Moderate to good functional capacity (≥4 METs)

I (3)
160.
  • No clinical risk factors

I (2)
162.
  • Asymptomatic <1 y post normal catheterization, noninvasive test, or previous revascularization

I (2)
Stress Echocardiography for Risk Assessment: Within 3 Months of an ACS
STEMI
163.
  • Primary PCI with complete revascularization

  • No recurrent symptoms

I (2)
165.
  • Hemodynamically unstable, signs of cardiogenic shock, or mechanical complications

I (1)
Stress Echocardiography for Risk Assessment: Within 3 Months of an ACS
ACS—Asymptomatic Postrevascularization (PCI or CABG)
167.
  • Prior to hospital discharge in a patient who has been adequately revascularized

I (1)
Stress Echocardiography for Risk Assessment: Within 3 Months of an ACS
Cardiac Rehabilitation
168.
  • Prior to initiation of cardiac rehabilitation (as a stand-alone indication)

I (3)
Stress Echocardiography for Risk Assessment: Postrevascularization (PCI or CABG)
Asymptomatic
171.
  • <5 y after CABG

I (2)
173.
  • <2 y after PCI

I (2)
Stress Echocardiography for Risk Assessment: Postrevascularization (PCI or CABG)
Cardiac Rehabilitation
175.
  • Prior to initiation of cardiac rehabilitation (as a stand-alone indication)

I (3)
Stress Echocardiography for Hemodynamics (Includes Doppler During Stress)
Chronic Valvular Disease—Asymptomatic
177.
  • Mild mitral stenosis

I (2)
180.
  • Mild aortic stenosis

I (3)
183.
  • Mild mitral regurgitation

I (2)
186.
  • Mild aortic regurgitation

I (2)
Stress Echocardiography for Hemodynamics (Includes Doppler During Stress)
Chronic Valvular Disease—Symptomatic
191.
  • Severe mitral stenosis

I (3)
192.
  • Severe aortic stenosis

I (1)
196.
  • Severe mitral regurgitation

  • Severe LV enlargement or LV systolic dysfunction

I (3)
Stress Echocardiography for Hemodynamics (Includes Doppler During Stress)
Acute Valvular disease
197.
  • Acute moderate or severe mitral or aortic regurgitation

I (3)
Stress Echocardiography for Hemodynamics (Includes Doppler During Stress)
Pulmonary Hypertension
199.
  • Routine evaluation of patients with known resting pulmonary hypertension

I (3)
Contrast Use in TTE/TEE or Stress Echocardiography
201.
  • Routine use of contrast

  • All LV segments visualized on noncontrast images

I (1)

I indicates inappropriate.