Table 19

Appropriate Indications (Median Score 7–9)

IndicationAppropriate Use Score (1–9)
TTE for General Evaluation of Cardiac Structure and Function Suspected Cardiac Etiology—General
1.
  • Symptoms or conditions potentially related to suspected cardiac etiology including but not limited to chest pain, shortness of breath, palpitations, TIA, stroke, or peripheral embolic event

A (9)
2.
  • Prior testing that is concerning for heart disease or structural abnormality including but not limited to chest X-ray, baseline scout images for stress echocardiogram, ECG, or cardiac biomarkers

A (9)
TTE for General Evaluation of Cardiac Structure and Function Arrhythmias
4.
  • Frequent VPCs or exercise-induced VPCs

A (8)
5.
  • Sustained or nonsustained atrial fibrillation, SVT, or VT

A (9)
TTE for General Evaluation of Cardiac Structure and Function Lightheadedness/Presyncope/Syncope
7.
  • Clinical symptoms or signs consistent with a cardiac diagnosis known to cause lightheadedness/presyncope/syncope (including but not limited to aortic stenosis, hypertrophic cardiomyopathy, or HF)

A (9)
9.
  • Syncope when there are no other symptoms or signs of cardiovascular disease

A (7)
TTE for General Evaluation of Cardiac Structure and Function Pulmonary Hypertension
15.
  • Evaluation of suspected pulmonary hypertension including evaluation of right ventricular function and estimated pulmonary artery pressure

A (9)
17.
  • Routine surveillance (≥1 y) of known pulmonary hypertension without change in clinical status or cardiac exam

A (7)
18.
  • Re-evaluation of known pulmonary hypertension if change in clinical status or cardiac exam or to guide therapy

A (9)
TTE for Cardiovascular Evaluation in an Acute Setting Hypotension or Hemodynamic Instability
19.
  • Hypotension or hemodynamic instability of uncertain or suspected cardiac etiology

A (9)
TTE for Cardiovascular Evaluation in an Acute Setting Myocardial Ischemia/Infarction
21.
  • Acute chest pain with suspected MI and nondiagnostic ECG when a resting echocardiogram can be performed during pain

A (9)
22.
  • Evaluation of a patient without chest pain but with other features of an ischemic equivalent or laboratory markers indicative of ongoing MI

A (8)
23.
  • Suspected complication of myocardial ischemia/infarction, including but not limited to acute mitral regurgitation, ventricular septal defect, free-wall rupture/tamponade, shock, right ventricular involvement, HF, or thrombus

A (9)
TTE for Cardiovascular Evaluation in an Acute Setting Evaluation of Ventricular Function After ACS
24.
  • Initial evaluation of ventricular function following ACS

A (9)
25.
  • Re-evaluation of ventricular function following ACS during recovery phase when results will guide therapy

A (9)
TTE for Cardiovascular Evaluation in an Acute Setting Respiratory Failure
26.
  • Respiratory failure or hypoxemia of uncertain etiology

A (8)
TTE for Cardiovascular Evaluation in an Acute Setting Pulmonary Embolism
29.
  • Known acute pulmonary embolism to guide therapy (e.g., thrombectomy and thrombolytics)

A (8)
31.
  • Re-evaluation of known pulmonary embolism after thrombolysis or thrombectomy for assessment of change in right ventricular function and/or pulmonary artery pressure

A (7)
TTE for Cardiovascular Evaluation in an Acute Setting Cardiac Trauma
32.
  • Severe deceleration injury or chest trauma when valve injury, pericardial effusion, or cardiac injury are possible or suspected

A (9)
TTE for Evaluation of Valvular Function Murmur or Click
34.
  • Initial evaluation when there is a reasonable suspicion of valvular or structural heart disease

A (9)
37.
  • Re-evaluation of known valvular heart disease with a change in clinical status or cardiac exam or to guide therapy

A (9)
TTE for Evaluation of Valvular Function Native Valvular Stenosis
39.
  • Routine surveillance (≥3 y) of mild valvular stenosis without a change in clinical status or cardiac exam

A (7)
41.
  • Routine surveillance (≥1 y) of moderate or severe valvular stenosis without a change in clinical status or cardiac exam

A (8)
46.
  • Routine surveillance (≥1 y) of moderate or severe valvular regurgitation without change in clinical status or cardiac exam

A (8)
TTE for Evaluation of Valvular Function Prosthetic Valves
47.
  • Initial postoperative evaluation of prosthetic valve for establishment of baseline

A (9)
49.
  • Routine surveillance (≥3 y after valve implantation) of prosthetic valve if no known or suspected valve dysfunction

A (7)
50.
  • Evaluation of prosthetic valve with suspected dysfunction or a change in clinical status or cardiac exam

A (9)
51.
  • Re-evaluation of known prosthetic valve dysfunction when it would change management or guide therapy

A (9)
TTE for Evaluation of Valvular Function Infective Endocarditis (Native or Prosthetic Valves)
52.
  • Initial evaluation of suspected infective endocarditis with positive blood cultures or a new murmur

A (9)
55.
  • Re-evaluation of infective endocarditis at high risk for progression or complication or with a change in clinical status or cardiac exam

A (9)
TTE for Evaluation of Intracardiac and Extracardiac Structures and Chambers
57.
  • Suspected cardiac mass

A (9)
58.
  • Suspected cardiovascular source of embolus

A (9)
59.
  • Suspected pericardial conditions

A (9)
61.
  • Re-evaluation of known pericardial effusion to guide management or therapy

A (8)
62.
  • Guidance of percutaneous noncoronary cardiac procedures including but not limited to pericardiocentesis, septal ablation, or right ventricular biopsy

A (9)
TTE for Evaluation of Aortic Disease
63.
  • Evaluation of the ascending aorta in the setting of a known or suspected connective tissue disease or genetic condition that predisposes to aortic aneurysm or dissection (e.g., Marfan syndrome)

A (9)
64.
  • Re-evaluation of known ascending aortic dilation or history of aortic dissection to establish a baseline rate of expansion or when the rate of expansion is excessive

A (9)
65.
  • Re-evaluation of known ascending aortic dilation or history of aortic dissection with a change in clinical status or cardiac exam or when findings may alter management or therapy

A (9)
TTE for Evaluation of Hypertension, HF, or Cardiomyopathy Hypertension
67.
  • Initial evaluation of suspected hypertensive heart disease

A (8)
TTE for Evaluation of Hypertension, HF, or Cardiomyopathy HF
70.
  • Initial evaluation of known or suspected HF (systolic or diastolic) based on symptoms, signs, or abnormal test results

A (9)
71.
  • Re-evaluation of known HF (systolic or diastolic) with a change in clinical status or cardiac exam without a clear precipitating change in medication or diet

A (8)
73.
  • Re-evaluation of known HF (systolic or diastolic) to guide therapy

A (9)
TTE for Evaluation of Hypertension, HF, or Cardiomyopathy Device Evaluation (Including Pacemaker, ICD, or CRT)
76.
  • Initial evaluation or re-evaluation after revascularization and/or optimal medical therapy to determine candidacy for device therapy and/or to determine optimal choice of device

A (9)
78.
  • Known implanted pacing device with symptoms possibly due to device complication or suboptimal pacing device settings

A (8)
TTE for Evaluation of Hypertension, HF, or Cardiomyopathy Ventricular Assist Devices and Cardiac Transplantation
81.
  • To determine candidacy for ventricular assist device

A (9)
82.
  • Optimization of ventricular assist device settings

A (7)
83.
  • Re-evaluation for signs/symptoms suggestive of ventricular assist device-related complications

A (9)
84.
  • Monitoring for rejection in a cardiac transplant recipient

A (7)
85.
  • Cardiac structure and function evaluation in a potential heart donor

A (9)
TTE for Evaluation of Hypertension, HF, or Cardiomyopathy Cardiomyopathies
86.
  • Initial evaluation of known or suspected cardiomyopathy (e.g., restrictive, infiltrative, dilated, hypertrophic, or genetic cardiomyopathy)

A (9)
87.
  • Re-evaluation of known cardiomyopathy with a change in clinical status or cardiac exam or to guide therapy

A (9)
90.
  • Screening evaluation for structure and function in first-degree relatives of a patient with an inherited cardiomyopathy

A (9)
91.
  • Baseline and serial re-evaluations in a patient undergoing therapy with cardiotoxic agents

A (9)
TTE for Adult Congenital Heart Disease
92.
  • Initial evaluation of known or suspected adult congenital heart disease

A (9)
93.
  • Known adult congenital heart disease with a change in clinical status or cardiac exam

A (9)
94.
  • Re-evaluation to guide therapy in known adult congenital heart disease

A (9)
98.
  • Routine surveillance (≥1 y) of adult congenital heart disease following incomplete or palliative repair

    • with residual structural or hemodynamic abnormality

    • without a change in clinical status or cardiac exam

A (8)
TEE as Initial or Supplemental Test—General Uses
99.
  • Use of TEE when there is a high likelihood of a nondiagnostic TTE due to patient characteristics or inadequate visualization of relevant structures

A (8)
101.
  • Re-evaluation of prior TEE finding for interval change (e.g., resolution of thrombus after anticoagulation, resolution of vegetation after antibiotic therapy) when a change in therapy is anticipated

A (8)
103.
  • Guidance during percutaneous noncoronary cardiac interventions including but not limited to closure device placement, radiofrequency ablation, and percutaneous valve procedures

A (9)
104.
  • Suspected acute aortic pathology including but not limited to dissection/transsection

A (9)
TEE as Initial or Supplemental Test—Valvular Disease
106.
  • Evaluation of valvular structure and function to assess suitability for, and assist in planning of, an intervention

A (9)
108.
  • To diagnose infective endocarditis with a moderate or high pretest probability (e.g., staph bacteremia, fungemia, prosthetic heart valve, or intracardiac device)

A (9)
TEE as Initial or Supplemental Test—Embolic Event
109.
  • Evaluation for cardiovascular source of embolus with no identified noncardiac source

A (7)
TEE as Initial Test—Atrial Fibrillation/Flutter
112.
  • Evaluation to facilitate clinical decision making with regards to anticoagulation, cardioversion, and/or radiofrequency ablation

A (9)
Stress Echocardiography for Detection of CAD/Risk Assessment: Symptomatic or Ischemic Equivalent Evaluation of Ischemic Equivalent (Nonacute)
115.
  • Low pretest probability of CAD

  • ECG uninterpretable or unable to exercise

A (7)
116.
  • Intermediate pretest probability of CAD

  • ECG interpretable and able to exercise

A (7)
117.
  • Intermediate pretest probability of CAD

  • ECG uninterpretable or unable to exercise

A (9)
118.
  • High pretest probability of CAD

  • Regardless of ECG interpretability and ability to exercise

A (7)
Stress Echocardiography for Detection of CAD/Risk Assessment: Symptomatic or Ischemic Equivalent Acute Chest Pain
119.
  • Possible ACS

  • ECG: no ischemic changes or with LBBB or electronically paced ventricular rhythm

  • Low-risk TIMI score

  • Negative troponin levels

A (7)
120.
  • Possible ACS

  • ECG: no ischemic changes or with LBBB or electronically paced ventricular rhythm

  • Low-risk TIMI score

  • Peak troponin: borderline, equivocal, minimally elevated

A (7)
121.
  • Possible ACS

  • ECG: no ischemic changes or with LBBB or electronically paced ventricular rhythm

  • High-risk TIMI score

  • Negative troponin levels

A (7)
122.
  • Possible ACS

  • ECG: no ischemic changes or with LBBB or electronically paced ventricular rhythm

  • High-risk TIMI score

  • Peak troponin: borderline, equivocal, minimally elevated

A (7)
Stress Echocardiography for Detection of CAD/Risk Assessment: Asymptomatic (Without Ischemic Equivalent) in Patient Populations With Defined Comorbidities New-Onset or Newly Diagnosed HF or LV Systolic Dysfunction
128.
  • No prior CAD evaluation and no planned coronary angiography

A (7)
Stress Echocardiography for Detection of CAD/Risk Assessment: Asymptomatic (Without Ischemic Equivalent) in Patient Populations With Defined Comorbidities Arrhythmias
129.
  • Sustained VT

A (7)
130.
  • Frequent PVCs, exercise-induced VT, or nonsustained VT

A (7)
Stress Echocardiography for Detection of CAD/Risk Assessment: Asymptomatic (Without Ischemic Equivalent) in Patient Populations With Defined Comorbidities Syncope
134.
  • Intermediate or high global CAD risk

A (7)
Stress Echocardiography for Detection of CAD/Risk Assessment: Asymptomatic (Without Ischemic Equivalent) in Patient Populations With Defined Comorbidities Elevated Troponin
135.
  • Troponin elevation without symptoms or additional evidence of ACS

A (7)
Stress Echocardiography Following Prior Test Results Asymptomatic: Prior Evidence of Subclinical Disease
139.
  • Coronary calcium Agatston score >400

A (7)
Stress Echocardiography Following Prior Test Results Coronary Angiography (Invasive or Noninvasive)
141.
  • Coronary artery stenosis of unclear significance

A (8)
Stress Echocardiography Following Prior Test Results Treadmill ECG Stress Test
149.
  • Intermediate-risk treadmill score (e.g., Duke)

A (7)
150.
  • High-risk treadmill score (e.g., Duke)

A (7)
Stress Echocardiography Following Prior Test Results New or Worsening Symptoms
151.
  • Abnormal coronary angiography or abnormal prior stress imaging study

A (7)
Stress Echocardiography Following Prior Test Results Prior Noninvasive Evaluation
153.
  • Equivocal, borderline, or discordant stress testing where obstructive CAD remains a concern

A (8)
Stress Echocardiography for Risk Assessment: Perioperative Evaluation for Noncardiac Surgery Without Active Cardiac Conditions Vascular Surgery
161.
  • ≥1 clinical risk factor

  • Poor or unknown functional capacity (<4 METs)

A (7)
Stress Echocardiography for Risk Assessment: Within 3 Months of an ACS STEMI
164.
  • Hemodynamically stable, no recurrent chest pain symptoms, or no signs of HF

  • To evaluate for inducible ischemia

  • No prior coronary angiography since the index event

A (7)
Stress Echocardiography for Risk Assessment: Within 3 Months of an ACS UA/NSTEMI
166.
  • Hemodynamically stable, no recurrent chest pain symptoms, or no signs of HF

  • To evaluate for inducible ischemia

  • No prior coronary angiography since the index event

A (8)
Stress Echocardiography for Risk Assessment: Postrevascularization (PCI or CABG) Symptomatic
169.
  • Ischemic equivalent

A (8)
Stress Echocardiography for Risk Assessment: Postrevascularization (PCI or CABG) Asymptomatic
170.
  • Incomplete revascularization

  • Additional revascularization feasible

A (7)
Stress Echocardiography for Assessment of Viability/Ischemia Ischemic Cardiomyopathy/Assessment of Viability
176.
  • Known moderate or severe LV dysfunction

  • Patient eligible for revascularization

  • Use of dobutamine stress only

A (8)
Stress Echocardiography for Hemodynamics (Includes Doppler During Stress) Chronic Valvular Disease—Asymptomatic
179.
  • Severe mitral stenosis

A (7)
185.
  • Severe mitral regurgitation

  • LV size and function not meeting surgical criteria

A (7)
188.
  • Severe aortic regurgitation

  • LV size and function not meeting surgical criteria

A (7)
Stress Echocardiography for Hemodynamics (Includes Doppler During Stress) Chronic Valvular Disease—Symptomatic
190.
  • Moderate mitral stenosis

A (7)
193.
  • Evaluation of equivocal aortic stenosis

  • Evidence of low cardiac output or LV systolic dysfunction (“low gradient aortic stenosis”)

  • Use of dobutamine only

A (8)
195.
  • Moderate mitral regurgitation

A (7)
Contrast Use in TTE/TEE or Stress Echocardiography
202.
  • Selective use of contrast

  • ≥2 contiguous LV segments are not seen on noncontrast images

A (8)

A indicates appropriate.