In an effort to ensure quality cardiac ultrasound imaging and to avoid unnecessary use of the technology, the American Society of Echocardiography (ASE; Raleigh, North Carolina) and the American College of Cardiology Foundation (ACCF; Washington), in partnership with five other groups, have released Appropriateness Criteria for two of the most commonly used cardiac ultrasound techniques — transthoracic (TTE) and transesophageal (TEE) echocardiography — just in time for the 18th annual Scientific Sessions of ASE in Seattle, beginning last Saturday and running through tomorrow.

The TTE/TEE Appropriateness Criteria review common scenarios found in clinical practice and address the appropriateness of ordering echocardiograms for each situation. The criteria address a range of clinical situations in which TTE/TEE might be used, such as for patients presenting with signs and symptoms that could represent heart disease — like murmurs and palpitations — and conditions such as hypertension, stroke, heart valve disease and suspected or known congenital heart disease.

According to the report discussing the new criteria, the rising costs of healthcare and concern on the part of payers are among the primary reasons development of the criteria.

Michael Picard, MD, outgoing president of ASE and leader of the Appropriateness Guidelines Committee, told Diagnostics & Imaging Week: "The really big issue that both private payers and the government are concerned about is obviously the rising cost of healthcare. Then, if you look at the rising cost of healthcare, the concern is that medical imaging is a big component of that rise, because we are relying more on technology as we care for our patients."

Family practitioners, he said, order more of these TTEs/TEEs than any other physician group, so the new criteria are really directed at them. And the ASE will be undertaking educational efforts directed at family practitioners to inform them of the instances in which TTEs/TEEs are appropriate for use.

The criteria score each indication for which a TTE/TEE might be used:

A score of 7 to 9 indicates that the test is appropriate for a specific indication;

a score of 4 to 6 would mean that reasonableness of the test is "uncertain" — that is, the "test may be generally acceptable and may be a reasonable approach for the indication";

a score of 1 to 3 would signal that a test is inappropriate for the indication.

According to the report, the "relative ease of use and low risk" — meaning that no radiation is involved and it is non-invasive — not only provides "many advantages" to physicians, but it also "create[s] opportunities for overuse and misuse in patients who may not obtain a benefit, or who could have achieved a similar benefit without the addition of the test."

However, Picard said the issue is "not so much misuse as a concern about overuse or stemming the tide . . ."

"If," he said, "we assume that from time to time, there are uses of the technology where it probably isn't needed, that is, care could continue without [the ultrasound], then we are helping to keep the cost of healthcare in check."

Additionally, according to the report, the results of such an ultrasound could lead to further downstream tests and "treatment such as unwarranted coronary revascularization or unnecessary repeat follow-up."

Overall, 14 scenarios cited in the criteria were found to be inappropriate reasons for the performance of the TTE/TEE study.

Echocardiography has long been recognized in the broader medical community as a valuable diagnostic test for the evaluation of cardiac structure and function, ASE said.

As both TTE and TEE are relatively easy on the patient, are low risk (meaning not requiring radiation) and provide comprehensive diagnostic information, the opportunity exists for inappropriate use in patients who may not benefit from having the exam.

The Appropriateness Criteria for TTE/TEE should help guide physicians in determining when and how often to use the tests, the organizations said. 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.

The groups developing the criteria said they are intended to increase physicians' confidence that they are ordering an echocardiogram more appropriately and they said they plan efforts to educate them about when a test may not be necessary.

Besides issues of cost and unneeded following testing, Inappropriate use of TTE and TEE can limit resources for those patients who do need testing, the ASE said.

"For the very first time, we are formally addressing the appropriate use of one of the earliest and most commonly used imaging technologies. Although the concept of proper use of technology is not new, providing physicians with the tools to assess our own practice patterns is a critically important and new undertaking. It gives real meaning to our efforts to promote quality in cardiovascular care," said Pamela Douglas, MD, chair of the TTE/TEE Appropriateness Criteria Writing Group and a past president of both the American College of Cardiology (Washington) and ASE.

The ACCF said that, to date, criteria exist for SPECT MPI, CCT and CMR, and now TEE and TTE.

The other groups that partnered with ASE and ACCF to developer the criteria were the American College of Emergency Physicians (Dallas), the American Society of Nuclear Cardiology (Bethesda), the Society for Cardiovascular Angiography and Interventions (Washington), the Society of Cardiovascular Computed Tomography (Washington), and the Society for Cardiovascular Magnetic Resonance (Royal, New Jersey).

The criteria are posted online at or and will be published in print in the July 2007 issue of The Journal of the American Society of Echocardiography and the July 10 issue of The Journal of the American College of Cardiology.

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