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Title of Guideline (must include the word “Guideline” (not protocol, policy, procedure etc) Author: Contact Name and Job Title Directorate & Speciality Date of submission Guidelines for requesting echocardiographic studies in adults. Dr Mike Sosin Consultant Cardiologist DIRC Cardiology 1.2.2014 Explicit definition of patient group to which it applies (e.g. inclusion Requests for echocardiography in and exclusion criteria, diagnosis) Adults Version 1 If this version supersedes another clinical guideline please be n/a explicit about which guideline it replaces including version number. Statement of the evidence base of the guideline – has the guideline 1 - NICE guidance and ESC guidance been peer reviewed by colleagues? Evidence base: (1-6) 1 NICE Guidance, Royal College Guideline, SIGN (please state which source). 2a meta analysis of randomised controlled trials 2b at least one randomised controlled trial 3a at least one well-designed controlled study without randomisation 3b at least one other type of well-designed quasi-experimental study 4 well –designed non-experimental descriptive studies (ie comparative / correlation and case studies) 5 expert committee reports or opinions and / or clinical experiences of respected authorities 6 recommended best practise based on the clinical experience of the guideline developer Consultation Process Reviewed by echocardiographers and consultants in cardiology, microbiology, anaesthetics. Junior cardiology doctors also gave input. Ratified by: Cardiology governance meeting September 2014 Date: Target audience Junior and senior doctors and specialist nurses who order echocardiograms. Review Date: (to be applied by the Integrated Governance Team) A review date of 5 years will be applied by the Trust. Directorates can choose to apply a shorter review date, however this must be managed through Directorate Governance processes. This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. Page 1 Contents 1.1 Introduction ....................................................................................................................3 2. Transthoracic Echocardiography .....................................................................................3 2.1 Inpatients ....................................................................................................................3 2.2 Portable scan requests...............................................................................................4 2.3 Urgent scan requests .................................................................................................4 2.4 Out of Hours requests ................................................................................................4 2.5 SPECIFIC INDICATIONS ..............................................................................................5 2.5.1 Requests for assessment of ‘new murmur’ .............................................................5 2.5.2 Requests for ‘query endocarditis’ ............................................................................5 2.5.3 Pre-op assessment .................................................................................................6 2.5.4 Where echo is not helpful ........................................................................................6 2.6 Outpatients .................................................................................................................7 2.7 Valve surveillance echos ............................................................................................7 3. Transoesophageal echocardiography (TOE) ...................................................................9 3.1. Introduction ...............................................................................................................9 3.2. Indications: ................................................................................................................9 3.3 Contraindications:.......................................................................................................9 3.4 Patient preparation: ..................................................................................................10 3.5 Post procedure: ........................................................................................................10 3.6 Requesting TOE .......................................................................................................10 4 Contrast Echo .................................................................................................................11 4.1 Introduction ..............................................................................................................11 4.2 Agitated Saline Bubble Contrast Echo .....................................................................11 4.3 Sonovue/Optison Contrast Echo ..............................................................................11 5 Stress echocardiography ................................................................................................13 5.1. Introduction .............................................................................................................13 5.2 Indications: ...............................................................................................................13 5.3 Requesting Stress echocardiography.......................................................................13 6 References: ....................................................................................................................15 Page 2 Guidelines for requesting echocardiographic studies in Adults 1.1Introduction Echocardiography is a non invasive study that can provide useful information in many clinical scenarios with minimal risk of harm to the patient. Echocardiography can be performed portably and is therefore possible in very unstable patients. Additional information can be gained from specialist echocardiographic studies such as contrast echo, stress echo, and transoesophageal echo. Over 16000 echocardiographic studies are performed across NUH per year. However, it has been shown that echocardiographic studies frequently do not lead to a change in management.[1] The fact that echo is non invasive, presents little or no risk to the patient, and is relatively widely available may lead to requests for echo where there is little chance that useful information will be obtained. This is particularly true of repeat echo studies. These guidelines are intended to assist in targeting adult echocardiographic studies to patients most likely to benefit, as well as detailing the process for requesting such studies. This guideline is not intended as an exhaustive list of indications for echocardiography. 2.TransthoracicEchocardiography 2.1Inpatients Inpatient scans should be requested via NOTIS, using code ‘ECHO’. Please use the ‘preferred date’ option within the NOTIS request to indicate if a study is not urgent, for example if it can wait more than 24 hours - doing so provides the echo department with flexibility. Critically urgent scans (see below) still need a NOTIS request but should also be discussed direct with the cardiology department. Phoned requests will not be accepted without a NOTIS request. Inpatient requests are not automatically accepted - they are vetted by experienced cardiac physiologists for appropriateness. After requesting an echo, please check NOTIS regularly in case your request has been rejected. The reason for rejection is specified under ‘responses’ on NOTIS. Requests are most often rejected because insufficient information has been included. If a request is rejected please do not telephone the department, please review the guidance notes below and consider whether your request is in fact appropriate. Consider taking advice from your seniors and/or discussing with the cardiology registrar on call. If you still feel an echo is Page 3 indicated then re-request with additional information covering the points set out below under specific indications. If a patient has had an echocardiogram within the last 12 months, a repeat study is rarely indicated. All echo reports performed since January 2013 are available on NOTIS - please check before requesting. For example, if a patient is already known to have impaired left ventricular function, and has presented with heart failure symptoms, a repeat echo is very unlikely to be useful. 2.2Portablescanrequests Wherever possible, echocardiography should be performed within the cardiology department. Portable scans are usually of lower quality, and due to poor patient/echocardiographer positioning can result in injuries to echocardiographers. Portable scans should therefore only be requested where the patient physically cannot come to the department (e.g. a ventilated patient), where it is medically unsafe for the patient to leave their ward, or where there is a critical indication for echo (see below). Please specify this information when requesting a portable scan. 2.3Urgentscanrequests The echocardiography department aims to perform all inpatient scans within 24 hours. It is therefore only necessary to request an urgent scan where there is a critical indication: 1. suspected pericardial tamponade 2. suspected acute pulmonary embolism with haemodynamic instability 3. acute heart failure with suspicion of acute mitral regurgitation 4. Suspected acute ischaemia/infarction where the diagnosis is not clear from history and ECG. 5. Suspected aortic dissection – although please note that while echocardiography can be helpful it should not delay definitive investigations such as CT scanning. If any of these diagnoses are suspected to the point where such an echo is requested, then it is also expected that the on call cardiology team will be contacted and involved in the decision to request echo. 2.4OutofHoursrequests All out of hours requests should be approved by the on call cardiologist or cardiology registrar before you contact the on call echocardiographer. Bear in mind that the echocardiographers do a 24 hour on call. Please consider whether it is really essential that the scan is performed out of hours and be Page 4 prepared to justify this when you call, specifically stating how the scan will change your management now. 2.5SPECIFICINDICATIONS 2.5.1Requestsforassessmentof‘newmurmur’ If a patient has in fact had an echo within the last 12 months which appears to explain the described murmur, the echo department will simply provide the previous report rather than performing a new scan. If a new scan is still clinically indicated, you will need to re-request explaining how a new scan will change management. 2.5.2Requestsfor‘queryendocarditis’ Endocarditis is suspected very frequently, but the yield from echocardiography in such patients is very low. Requests should meet at least 3 of the criteria below. It is not necessary to wait for the results of echocardiography before referring such a patient to the cardiology department if the clinical suspicion of endocarditis is high. All patients with suspected endocarditis in the context of prosthetic heart valves or implantable devices such as pacemakers should be referred to cardiology. Positive blood culture with an organism consistent with endocarditis (see list below) Raised CRP Pyrexia No other source of infection identified New murmur If the criteria are not met, the request will be rejected unless the request includes the name of a consultant cardiologist, consultant in infectious diseases, or consultant microbiologist who has authorised the request. Note: During or following an episode of endocarditis, vegetations do not necessarily resolve, irrespective of whether treatment has been successful or not. Repeat echocardiography simply to ‘follow up vegetations‘ are NOT indicated. Organisms consistent with Endocarditis [2] Staph aureus — 31% - note that while Staph Aureus is a cause of endocarditis, the majority of Staph Aureus bacteraemias are not caused by endocarditis, and so a lower index of suspicion is appropriate compared to other organisms such as Viridans strep Page 5 particularly where there is an alternative source of sepsis such as a line infection or a diabetic foot ulcer. *Viridans group streptococci — 17% (includes P. mutans, S. mitis, S. sanguinus, P. anginosus, S. oralis and S. salivarius) *Enterococci — 11% (in absence of other focus) Coagulase-negative staphylococci — 11% *Streptococcus bovis — 7% *Other streptococci — 5% Non-HACEK gram-negative bacteria — 2% Fungi — 2% *Coxiella Burnetti *HACEK — 2%; organisms in this category include a number of gram-negative bacilli: Haemophilus aphrophilus (subsequently called Aggregatibacter aphrophilus and Aggregatibacter paraphrophilus); Actinobacillus actinomycetemcomitans (subsequently called Aggregatibacter actinomycetemcomitans); Cardiobacterium hominis; Eikenella corrodens; and Kingella kingae Note that the spectrum of organisms that cause endocarditis on prosthetic valves early after surgery (up to 1 year) is different, including a high proportion of staph epidermidis, staph aureus, and fungi. Causes of late prosthetic endocarditis (>1 year after surgery) are similar to those that cause endocarditis on native valves. 2.5.3Pre‐opassessment Echocardiography is indicated for 1. New murmur, not previously assessed by cardiology and no prior echo 2. Clinical signs of heart failure, not previously assessed by cardiology and no prior echo 3. Previous diagnosis of heart failure, but not well controlled and no echo in last 12 months 4. Previous diagnosis of aortic stenosis with change in symptoms since last echo or no echo in the last 12 months Echocardiography is NOT indicated for pre-op patients in the following situations: 1. Routine assessment of risk of cardiac events in the perioperative period Echo is a very poor test for this indication. Some patients at high risk of perioperative events will have a normal echocardiogram and thus be falsely reassured. Stress echocardiography may be useful if the surgery can safely be delayed and the results would change management. [3] 2. Reassessment in patients with a previous echo where there has been no change in clinical status 2.5.4 Whereechoisnothelpful An Echo is NOT indicated in the following circumstances 1. Repeat assessment of asymptomatic mild valvular regurgitation Page 6 2. Pyrexia of unknown origin with no other features of endocarditis 3. Non cardiac chest pain 4. Cardiomegaly on chest Xray with no clinical signs of heart failure 5. Clinically stable heart failure patients where no change in management is contemplated 6. Repeat assessment of a small pericardial effusion where there is no clinical change. 7. Patients with terminal illness whose management would not be affected by echocardiographic abnormalities 8. Palpitations without documented arrhythmia or suspicion of structural heart disease 9. Routine assessment of risk of cardiac events in pre-op patients 10. Reassessment in pre-op patients with a previous echo where there has been no change in clinical status 2.6Outpatients Requesting transthoracic echo Currently, inpatient echos are requested through NOTIS, using code ‘ECHO’. Please check NOTIS regularly in case your request is rejected. To minimise the risk of an appropriate echo request being rejected, please make sure you include as much detail as possible in your request. Outpatient studies can be requested through NOTIS (recommended), using code ‘ECHOOP’. Alternatively an echo request card can be completed and sent to cardiology south (at the QMC), or Linby ward (at the City hospital). 2.7Valvesurveillanceechos 2.7.1 Valve clinic Since September 2013 an echocardiographer led valve surveillance clinic has been in operation at QMC. This may be extended to City hospital in due course. This clinic is for patients who need echocardiographic surveillance with cardiologist support, and accepts patients with: Asymptomatic moderate-severe or severe aortic stenosis or regurgitation Asymptomatic moderate-severe or severe mitral stenosis or regurgitation Bicuspid aortic valves (with or without valve dysfunction) Tissue prosthetic valves >5 years old (or earlier if evidence of valve dysfunction) Patients post mitral valve repair surgery Page 7 Referrals to this clinic are only accepted from a general cardiology clinic, to ensure suitability. Patients from other specialities who are found to have valve disease should be referred to cardiology in the usual way and can then be directed to the valve clinic if appropriate. Patients with significant comorbidity such as arrhythmia or coronary disease are not appropriate for the valve clinic (as it is physiologist led) and should remain in the general cardiology clinic. Referrals to the valve clinic should be addressed to Dr Sosin, Consultant Cardiologist and valve clinic lead. 2.7.2 Valve register Asymptomatic outpatients with less severe valve disease (mild, mildmoderate, or moderate) are automatically added to a valve register by the physiologists performing their scan, and will be called back for echos at a suitable interval (depending upon their valve pathology and severity). The reports for these patients are returned to the GP and they are considered to remain under GP care, and the GP is responsible for carrying out clinical review and referring to cardiology if necessary. Patients can be added to the register on request to Martin Giles, technical head of echocardiography. Page 8 3.Transoesophagealechocardiography(TOE) 3.1.Introduction TOE is an advanced echo technique where the echo transducer is located on an endoscope. The endoscope allows the transducer to be positioned in the oesophagus or the stomach, much closer to the heart than can be achieved with a transthoracic probe. This means that higher ultrasound frequencies can be used, resulting in better image quality. It is important to note however, that TOE is not always superior to a good quality TTE - in particular TTE tends to result in better imaging of the right sided heart chambers and valves than TOE. TOE is usually performed under conscious sedation. Very occasionally TOE is performed under general anaesthesia - generally only if a previous attempt at TOE under sedation was not successful. 3.2.Indications: 1. Assessment of mitral stenosis or regurgitation 2. Assessment of the inter atrial septum for atrial septal defect or patent foramen ovale 3. Assessment of suspected infective endocarditis (where TTE is non diagnostic) 4. Assessment of confirmed infective endocarditis where there are complications (such as heart failure, or ongoing signs of sepsis despite appropriate antibiotics). 5. Routine part of diagnostic work up in patients being considered for TAVI (transcatheter aortic valve implantation). Patients should be accepted in principle by a cardiologist who performs TAVI procedures (Dr Henderson or Dr Baig) before a TOE is requested for TAVI workup 6. In patients planned for inpatient DC cardioversion for atrial arrhythmia, where the arrhythmia has been present for more than 24-48 hours and the patient has not been taking oral anticoagulants, in order to exclude the presence of left atrial thrombus (TOE guided cardioversion). 3.3Contraindications: For obvious reasons TOE is not appropriate in patients with a pharyngeal pouch, oesophageal malignancy, in the early period after oesophageal surgery, or in patients with recent upper GI bleeding (especially variceal bleeding). A degree of patient cooperation is essential - if the patient cannot cooperate TOE will only be possible with general anaesthesia. Page 9 3.4Patientpreparation: Patients must be nil by mouth for 4 hours prior to the test. When planning to fast the patient please consider their medication - they may be able to take some medication earlier than usual in order to avoid missed doses. Warfarin and other anticoagulants do not generally need to be stopped prior to TOE patients on warfarin should have their INR checked on the day of the test but the test will only be cancelled if the INR is very high (above 4.5 in most cases). Unless specifically requested otherwise, TOEs are performed in the cardiology department. 3.5Postprocedure: Inpatients will be returned to their base ward shortly after the test, accompanied by a trained nurse. Patients should be observed closely until their sedation has worn off. It is usually recommended that the patient remain nil by mouth for one hour after the test, then they can try sips of water. After 2 hours they should be able to eat and drink normally. 3.6RequestingTOE For outpatients, TOE is requested via NOTIS using code TOE. All requests from outside cardiology are vetted by an imaging consultant cardiologist. For inpatients, please discuss with the on call cardiology registrar. Please be aware that it is not infrequent that TOE requests are declined and be prepared to answer detailed questions about the indication for the study. Please do not try to request a TOE for a patient that you have not seen personally. It is very important to include in your request any mobility or infection control issues as this will affect staffing and timing for the test. TOE studies are performed at both QMC and City hospitals. Several slots are made available every week for inpatients, but the slots are not every day. There is significant variation in the number of requests, resulting in variation in the time your patient will have to wait before a slot is available. Page 10 4ContrastEcho 4.1Introduction Bubbles suspended in fluid can be used to enhance ultrasound images. There are two types of contrast agents used in echocardiography - the indications and contraindications for each are different. Please note that contrast studies are not performed as part of routine inpatient or outpatient echo lists, as they require special arrangements which may include cardiologist or cardiology registrar supervision. 4.2AgitatedSalineBubbleContrastEcho Agitating saline with a small volume of air creates macrobubbles, which are too large to pass through the pulmonary circulation. Intravenous injection of agitated saline therefore only opacifies the right atrium and right ventricle, unless there is some sort of right to left shunt allowing bubbles to pass into the left heart. Agitated Saline contrast echo is therefore used as a method of detecting such shunts. Indications: 1. Suspected patent foramen ovale - for example in embolic stroke in young patients without significant risk factors for stroke. 2. Suspected hepatopulmonary syndrome 3. Suspected pulmonary arteriovenous malformation - for example in patients with hereditary haemorrhagic telangectasia (Osler-Weber-Rendu syndrome). 4. Detection of persistent left sided SVC. Requesting saline contrast echo If the test is to be performed on an outpatient basis, this can be requested through NOTIS using code CONTRAST. Requests from outside cardiology will be vetted by an imaging consultant cardiologist. For inpatients, please discuss with the on call cardiology registrar. Please note inpatient saline contrast echos are performed very rarely - an inpatient study should only be requested if it will change management during that admission - for PFO this is very rarely the case. 4.3Sonovue/OptisonContrastEcho Sonovue and Optison are proprietary contrast agents given intravenously. Unlike saline bubble contrast, sonovue/optison bubbles are small enough to pass through the pulmonary circulation and therefore do opacify the left heart, improving image quality and outlining left ventricular thrombus if it is present. The test is associated with a very small risk of anaphylaxis (<1:10000). Page 11 Indications: 1. Used routinely during stress echocardiography to enhance definition of the LV myocardium. 2. To assess LV function in patients with poor echocardiographic windows. 3. To assess patients with suspected LV thrombus. Sonovue/optison contrast should only be considered where standard transthoracic echocardiography is non diagnostic. Requesting sonovue/optison contrast echo If the test is to be performed on an outpatient basis, this can be requested through NOTIS using code CONTRAST. Requests from outside cardiology will be vetted by an imaging consultant cardiologist. For inpatients, please discuss with the on call cardiology registrar. Page 12 5Stressechocardiography 5.1.Introduction Stress echo is only performed on the city hospital campus. Approximately 700 scans are performed per year. The purpose of stress echocardiography is to attempt to assess cardiac function during exercise. Stress can be achieved pharmacologically (with infusion of dobutamine or occasionally adenosine), or with exercise (using a special couch incorporating bicycle pedals). The way the study is performed differs depending upon the indication - so it is vital to give as much information as possible in the test request. 5.2Indications: 1. Diagnosis in patients with chest pain and intermediate probability of ischaemic heart disease (as per NICE guidelines for the assessment of chest pain of recent onset) [4] 2. Assessment of inducible ischaemia in patients with coronary artery disease of uncertain significance 3. Assessment of risk of peri-operative cardiovascular events in asymptomatic patients with risk factors in patients undergoing major non cardiac surgery (such as renal transplantation). 4. Assessment of myocardial viability in patients with left ventricular dysfunction due to coronary artery disease (low dose dobutamine stress) 5. Assessment of low flow low gradient aortic stenosis (low dose dobutamine stress) 6. Assessment of exercise induced mitral regurgitation (exercise stress) 7. Assessment of hypertrophic cardiomyopathy with no/minor resting LVOT obstruction (exercise stress) The majority of stress echos are performed for detection of ischaemia using dobutamine. For these studies, rate limiting medication such as beta blockers are routinely discontinued for 48 hours prior to the test. It is important to note that patients in atrial fibrillation or those with pacemakers are much less likely to get a conclusive result from stress echocardiography - requests for stress echo in such patients should always be discussed with an imaging consultant cardiologist. 5.3RequestingStressechocardiography Outpatient studies are requested through NOTIS using code DSE. All requests from outside cardiology are vetted by an imaging cardiologist. Page 13 Stress echos are only very rarely performed for inpatients (there are no dedicated inpatient slots on the DSE lists) and only then when authorised by an imaging consultant cardiologist. Requests for inpatient studies should be directed to the on call cardiology registrar in the first instance, with details of how the test will change management during that admission. Page 14 6References: 1. Matulevicius SA, Rohatgi A, Das SR, et al. Appropriate use and clinical impact of transthoracic echocardiography. JAMA Intern Med 2013;173:1600-7 2. Murdoch DR, Corey GR, Hoen B, MiróJM, Fowler VG Jr, Bayer AS, Karchmer AW, Olaison L, Pappas PA, Moreillon P, Chambers ST, Chu VH, FalcóV, Holland DJ, Jones P, Klein JL, Raymond NJ, Read KM, Tripodi MF, Utili R, Wang A, Woods CW, Cabell CH, International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS) Investigators. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study. Arch Intern Med. 2009;169(5):463. 3. The Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA). Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. European Heart Journal 2009;30:2769–2812 http://www.escardio.org/guidelines-surveys/escguidelines/guidelinesdocuments/guidelines-perioperative-cardiac-careft.pdf 4. NICE 2010 guideline for the assessment of chest pain of recent onset. http://www.nice.org.uk/guidance/cg95 Page 15