Download Page 1 Title of Guideline (must include the word “Guideline” (not

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.
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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
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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
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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
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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
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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.
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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.
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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.
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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).
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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.
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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.
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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.
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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
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