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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
VOL.
ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
PUBLISHED BY ELSEVIER INC.
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-, NO. -, 2014
ISSN 0735-1097/$36.00
http://dx.doi.org/10.1016/j.jacc.2014.08.003
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APPROPRIATE USE CRITERIA
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ACC/AAP/AHA/ASE/HRS/
SCAI/SCCT/SCMR/SOPE
2014 Appropriate Use Criteria for
Initial Transthoracic Echocardiography
in Outpatient Pediatric Cardiology
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A Report of the American College of Cardiology Appropriate Use Criteria Task Force,
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American Academy of Pediatrics, American Heart Association, American Society of
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Echocardiography, Heart Rhythm Society, Society for Cardiovascular Angiography and
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Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular
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Magnetic Resonance, and Society of Pediatric Echocardiography
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Q1
Writing Group for Robert M. Campbell, MD, FACC, FAHA, FAAP, FHRS,
Wyman W. Lai, MD, MPH, FACC, FASE
Echocardiography Chair
Leo Lopez, MD, FACC, FAAP, FASE
in Outpatient
Pediatric
Cardiology
Ritu Sachdeva, MD, FACC, FAAP, FASE
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Pamela S. Douglas, MD, MACC, FAHA, FASE
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Benjamin W. Eidem, MD, FACC, FASE
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Robert M. Campbell, MD, FACC, FAHA, FAAP, FHRS,
Richard Lockwood, MD**
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Chair*
G. Paul Matherne, MD, MBA, FACC, FAHAyy
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Pamela S. Douglas, MD, MACC, FAHA, FASE, Moderator*
David Nykanen, MD, FACCzz
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Rating Panel
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Catherine L. Webb, MD, FACC, FAHA, FASEyy
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Robert Wiskind, MD, FAAP*
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Louis I. Bezold, MD, FACC, FAAP, FASEy
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William B. Blanchard, MD, FACC, FAHA, FAAP*
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Jeffrey R. Boris, MD, FACC*
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Bryan Cannon, MDz
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Gregory J. Ensing, MD, FACC, FASEx
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Craig E. Fleishman, MD, FACC, FASEjj
Pediatric Echocardiography representative. {Society for Cardiovascular
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Mark A. Fogel, MD, FACC, FAHA, FAAP{
Magnetic Resonance representative. #Society of Cardiovascular Computed
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B. Kelly Han, MD, FACC#
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Shabnam Jain, MD, MPH, FAAP*
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Mark B. Lewin, MDjj
*American College of Cardiology representative. yAmerican Academy of
Pediatrics representative. zHeart Rhythm Society representative.
xAmerican Society of Echocardiography representative. jjSociety of
Tomography representative. **Health Plan representative. yyAmerican
Heart Association representative. zzSociety for Cardiovascular
Angiography and Interventions representative.
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This document was approved by the American College of Cardiology Board of Trustees in June 2014.
The American College of Cardiology requests that this document be cited as follows:
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Campbell RM, Douglas PS, Eidem BW, Lai WW, Lopez L, Sachdeva R. ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 appropriate use criteria
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for initial transthoracic echocardiography in outpatient pediatric cardiology: a report of the American College of Cardiology Appropriate Use Criteria
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Task Force, American Academy of Pediatrics, American Heart Association, American Society of Echocardiography, Heart Rhythm Society, Society for
Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and
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Society of Pediatric Echocardiography. J Am Coll Cardiol 2014;XX:xxx-xx.
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This document is copublished in the Journal of the American Society of Echocardiography.
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Copies: This document is available on the World Wide Web site of the American College of Cardiology (www.acc.org). For copies of this document,
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please contact Elsevier Inc. Reprint Department, fax (212) 633-3820, e-mail [email protected].
Permissions: Modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the
American College of Cardiology.
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Appropriate
Manesh R. Patel, MD, FACC, Chair
Pamela S. Douglas, MD, MACC, FAHA, FASE
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Use Criteria
Christopher M. Kramer, MD, FACC, FAHA, Co-Chair
Robert C. Hendel, MD, FACC, FAHA, FASNC
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Task Force
Bruce D. Lindsay, MD, FACC
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Steven R. Bailey, MD, FACC, FAHA, FSCAI
Leslee J. Shaw, PhD, FACC, FASNC, FAHA
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Alan S. Brown, MD, FACC
L. Samuel Wann, MD, MACC
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John U. Doherty, MD, FACC, FAHA
Joseph M. Allen, MA
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ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XX
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9. DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XX
1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XX
2. METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XX
Figure 1. AUC Development Process . . . . . . . . . . . . . . . xx
3. GENERAL ASSUMPTIONS . . . . . . . . . . . . . . . . . . . . . XX
Figure 2. Factors Influencing Outcomes
of an Imaging Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx
4. DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XX
5. ABBREVIATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . XX
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6. RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XX
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7. TRANSTHORACIC ECHOCARDIOGRAPHY IN
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OUTPATIENT PEDIATRIC CARDIOLOGY:
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APPROPRIATE USE CRITERIA (BY INDICATION) . . . . . XX
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Assumptions and Definitions . . . . . . . . . . . . . . . . . . . . xx
Indications and Ratings . . . . . . . . . . . . . . . . . . . . . . . . . xx
Comparison with the Adult Cardiology AUC . . . . . . . . xx
Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx
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Figure 5. Palpitaions and Arrhythmias . . . . . . . . . . . . . xx
Figure 6. Murmur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx
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PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XX
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TABLE OF CONTENTS
Table 1. Palpitations and Arrhythmias . . . . . . . . . . . . . xx
Use of AUC to Improve Care . . . . . . . . . . . . . . . . . . . . . xx
10. CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XX
APPENDIX A
Appropriate Use Criteria for Initial Transthoracic
Echocardiography in Outpatient Pediatric Cardiology:
Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx
APPENDIX B
Relationships With Industry (RWI) and
Other Entities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx
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ABSTRACT
Table 2. Syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx
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Table 3. Chest Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx
The American College of Cardiology (ACC) participated in
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a joint project with the American Society of Echocardi-
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Table 4. Murmur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx
ography, the Society of Pediatric Echocardiography, and
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Table 5. Other Symptoms and Signs . . . . . . . . . . . . . . . xx
several other subspecialty societies and organizations to
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Table 6. Prior Test Results . . . . . . . . . . . . . . . . . . . . . . . xx
Table 7. Systemic Disorders . . . . . . . . . . . . . . . . . . . . . . xx
Table 8. Family History of Cardiovascular Disease in
Patients Without Signs or Symptoms and Without
Confirmed Cardiac Diagnosis . . . . . . . . . . . . . . . . . . . . . xx
Table 9. Outpatient Neonates Without Post-Natal
Cardiology Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . xx
establish and evaluate Appropriate Use Criteria (AUC) for
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the initial use of outpatient pediatric echocardiography.
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Assumptions for the AUC were identified, including the
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fact that all indications assumed a first-time transthoracic
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echocardiographic study in an outpatient setting for pa-
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tients without previously known heart disease. The defi-
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nitions for frequently used terminology in outpatient
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pediatric cardiology were established using published
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guidelines and standards and expert opinion. These AUC
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serve as a guide to help clinicians in the care of children
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8. FLOW DIAGRAMS FOR COMMON
PATIENT SYMPTOMS . . . . . . . . . . . . . . . . . . . . . . . . . XX
Figure 3. Chest Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx
Figure 4. Syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx
with possible heart disease, specifically in terms of when
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a transthoracic echocardiogram is warranted as an initial
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diagnostic modality in the outpatient setting. They are
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also a useful tool for education and provide the
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infrastructure for future quality improvement initiatives
increase in the utilization of such technologies. As these
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as well as research in healthcare delivery, outcomes, and
imaging technologies and clinical applications continue to
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resource utilization.
advance, the healthcare community needs to understand
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To complete the AUC process, the writing group iden-
how best to incorporate these options into daily clinical
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tified 113 indications based on common clinical scenarios
care and how to choose between new and long-standing,
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and/or published clinical practice guidelines, and each
established imaging technologies. In an effort to res-
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indication was classified into 1 of 9 categories of common
pond to this need and to ensure the effective use of
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clinical presentations, including palpitations, syncope,
advanced diagnostic imaging tools and procedures, the
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chest pain, and murmur. A separate, independent rating
AUC project was initiated. The AUC in this document have
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panel evaluated each indication using a scoring scale of 1
been developed in order to promote effective patient
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to 9, thereby designating each indication as “Appropriate”
care, better clinical outcomes, and improved resource
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(median score 7 to 9), “May Be Appropriate” (median
utilization. This set of AUC should be useful not only for
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score 4 to 6), or “Rarely Appropriate” (median score 1 to
pediatric cardiologists, but also for general pediatricians
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3). Fifty-three indications were identified as Appropriate,
and family practitioners, who are frequently the first cli-
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28 as May Be Appropriate, and 32 as Rarely Appropriate.
nicians to consider the need for this modality.
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Although AUC have been established for echocardiog-
PREFACE
In an effort to respond to the need for the rational use of
services in the delivery of high quality care, the ACC has
undertaken a process to determine the appropriate use of
cardiovascular imaging and procedures for selected patient indications.
AUC publications reflect an ongoing effort by the ACC
to critically and systematically create, review, and categorize clinical situations where diagnostic tests and procedures are utilized by physicians caring for patients with
known or suspected cardiovascular diseases. The process
is based on current understanding of the technical capabilities of the imaging modalities and procedures examined. Although not intended to be entirely comprehensive
due to the wide diversity of clinical disease, the indications are meant to identify common scenarios
encountered by the majority of contemporary practices.
Given the breadth of information they convey, the indications do not directly correspond to the International
Classification of Diseases (ICD) system.
The ACC believes that careful blending of a broad range
of clinical experiences and available evidence-based information will help guide a more efficient and equitable allocation of health care resources in cardiovascular imaging.
The ultimate objective of AUC is to improve patient care
and health outcomes in a cost-effective manner, but they
are not intended to ignore ambiguity and nuance intrinsic
to clinical decision-making. Local parameters, such as the
availability or quality of equipment or personnel, may influence the selection of certain tests or procedures. AUC
thus should not be considered substitutes for sound clinical
judgment and practice experience.
1. INTRODUCTION
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raphy in adult patients (1–3), a similar document for pe-
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diatric patients has not yet been published. This is partly
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because the scope of such a document would require an
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impossibly extensive list, if criteria were developed for
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each congenital cardiac malformation and its variants
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before and after intervention. Guidelines and standards
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for performing a pediatric echocardiogram, as well as
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recommendations
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for
quantification
methods,
have
already been published (4,5). However, the questions
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often raised by AUC of “when to do” and “how often to
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do” a pediatric echocardiogram still remained.
To address these concerns, the American College of
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Cardiology initiated an AUC document on pediatric
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echocardiography in the outpatient setting, since outpa-
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tient care is an important component of clinical pediatric
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cardiology. Children with heart disease represent a widely
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varied group of patients, frequently characterized by
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complex
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anatomic
malformations
requiring
lifelong
follow-up. While echocardiography is the primary diag-
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nostic modality for children with established congenital
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and acquired heart disease, the scope of the current
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document has been limited to first-time outpatient
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transthoracic
patients
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without previously known cardiac abnormalities. This
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echocardiographic
studies
in
narrower set of clinical presentations has been chosen
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because of the high volume of such testing within pedi-
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atric cardiology. In addition, this initiative has established
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the infrastructure to develop additional AUC for pediatric
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and congenital echocardiography in other settings.
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2. METHODS
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This document covers a wide array of potential signs
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and symptoms associated with cardiovascular disease in
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pediatric patients. A standardized approach was used to
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Improvements in cardiovascular imaging technologies
create different categories of indications with the goal of
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and their application, particularly with increasing thera-
capturing actual clinical scenarios, without making the list
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peutic options for cardiovascular disease, have led to an
of indications excessively long. Indications were created
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to represent most of the possible uses of echocardiography
should be categorized as Appropriate care, May Be
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in the outpatient pediatric setting rather than limiting the
Appropriate care, or Rarely Appropriate care, and was
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AUC to indications for which evidence was available.
provided the following definition of appropriate use:
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To identify and categorize the indications, a writing
An appropriate imaging study is one in which the ex-
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group of pediatric echocardiography experts was formed
pected incremental information, combined with clinical
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of representatives from a variety of organizations and
judgment, exceeds the expected negative consequences 1
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societies. Wherever possible during the writing process,
by a sufficiently wide margin for a specific indication
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the group members would map the indications to rele-
that the procedure is generally considered acceptable
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vant clinical guidelines and key publications or refer-
care and a reasonable approach for the indication.
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ences (See Online Appendix). Once the indications were
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formed, they were reviewed and critiqued by the parent
Median Score 7 to 9: Appropriate test for specific indi-
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AUC Task Force and numerous external reviewers repre-
cation (test is generally acceptable and is a reasonable
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senting all pediatric cardiovascular specialties and pri-
approach for the indication).
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mary care. After the writing group incorporated this
An appropriate option for management of patients in this
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initial feedback, the indications were sent to an inde-
population due to benefits generally outweighing risks;
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pendent rating panel comprised of additional experts in
effective option for individual care plans although not
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the pediatrics and pediatric cardiology realm, before be-
always necessary depending on physician judgment and
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ing sent back to the writing group for additional vetting.
patient specific preferences (i.e., procedure is generally
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Each indication was then rated and classified as either
acceptable and is generally reasonable for the indication).
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“Appropriate care”, “May Be Appropriate care”, or
Median Score 4 to 6: May Be Appropriate test for specific
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“Rarely Appropriate care” based on these multiple rounds
indication (test may be generally acceptable and may be a
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reasonable approach for the indication). May Be Appro-
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of review and revision (see Figure 1).
The rating panel scored each indication as follows:
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priate also implies that more research and/or patient in-
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selected clinical indications is found in a previous publi-
formation is needed to classify the indication definitively.
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cation, “ACCF Proposed Method for Evaluating the
At times an appropriate option for management of pa-
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tients in this population due to variable evidence or lack of
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A detailed description of the methods used for rating the
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Appropriateness of Cardiovascular Imaging,” (6) as well as
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the updated version, “Appropriate Use of Cardiovascular
agreement regarding the benefits risks ratio, potential
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Technology:
Criteria
benefit based on practice experience in the absence of evi-
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Methodology Update: A Report of the American College
dence, and/or variability in the population; effectiveness
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of Cardiology Foundation Appropriate Use Criteria Task
for individual care must be determined by a patient’s
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Force” (7). Briefly, this process combines evidence-based
physician in consultation with the patient based on addi-
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medicine and practice experience and engages a rating
tional clinical variables and judgment along with patient
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panel in a modified Delphi exercise. Other steps are
preferences (i.e., procedure may be acceptable and may be
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convening a formal writing group with diverse expertise
reasonable for the indication).
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in pediatric imaging and clinical care, circulating the
Median Score 1 to 3: Rarely Appropriate test for specific
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indications for external review prior to being sent to the
indication (test is not generally acceptable and is not a
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rating
reasonable approach for the indication).
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expertise and practice areas among the rating panelists,
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developing a standardized rating package that includes
patients in this population due to the lack of a clear benefit/
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relevant evidence, and establishing formal roles for
risk advantage; rarely an effective option for individual
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facilitating panel interaction at the face-to-face meeting.
panel,
2013
ACCF
ensuring
Appropriate
an
appropriate
Use
balance
of
Rarely an appropriate option for management of
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care plans; exceptions should have documentation of the
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The rating panel first evaluated the indications inde-
clinical reasons for proceeding with this care option
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pendently. Then, the panel was convened for a face-to-face
(i.e., procedure is not generally acceptable and is not
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meeting for discussion of each indication. At this meeting,
generally reasonable for the indication).
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panel members were given their scores and a blinded
The division of the numerical scores into 3 levels of
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summary of their peers’ scores. After the meeting, panel
appropriateness is somewhat arbitrary and the numeric
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members were then asked to independently provide their
designations should be viewed as existing on a contin-
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final scores for each indication (See Online Appendix).
uum. Further, there may be diversity in clinical opinion
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Although panel members were not provided explicit
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cost information to help determine their appropriate use
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ratings, they were asked to implicitly consider cost as an
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additional factor in their evaluation of appropriate use. In
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rating these criteria, the AUC Rating Panel was asked to
contrast exposure) and the downstream impact of poor test performance such as
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assess whether the use of the test for each indication
delay in diagnosis (false negatives) or inappropriate diagnosis (false positives).
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for particular clinical scenarios, such that scores in the
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1
Negative consequences include the risks of the procedure (i.e., radiation or
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IndicaƟon Development
Develop list of indicaƟons,
assumpƟons, and definiƟons
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Literature review and
Guideline Mapping
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Review Panel >30 members
provide feedback
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WriƟng Group revises indicaƟons
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RaƟng Panel rates the IndicaƟons
in two rounds
Appropriateness
DeterminaƟon
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1st round – No InteracƟon
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2nd Round – Panel InteracƟon
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Appropriate Use Score
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(7-9) Appropriate
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(4-6) May Be Appropriate
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(1-3) Rarely Appropriate
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ProspecƟve comparison
with clinical records
ValidaƟon
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ProspecƟve clinical
decision aids
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% Use that is Appropriate,
May Be Appropriate, or
Rarely Appropriate
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Increase Appropriate Use
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F I G U R E 1 AUC Development Process
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3. GENERAL ASSUMPTIONS
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intermediate level of appropriate use should be labeled
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“May Be Appropriate,” as critical patient or research data
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may be lacking or discordant. This designation should be
1. This document will address the initial use of outpa-
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a prompt to the field to carry out definitive research
tient transthoracic echocardiography (TTE) during
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investigation whenever possible. It is anticipated that the
pediatric (# 18 years of age) outpatient care. Although
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AUC reports will continue to be revised as further data are
TTE is also an essential tool in hospitalized patients,
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generated and information from criteria implementation
discussion of indications for this use is beyond the
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is accumulated.
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scope of this document.
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To prevent bias in the scoring process, the rating panel,
2. This AUC document will not address the use of TTE in
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by design, included a minority of specialists in pediatric
patients with previously known structural, functional,
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echocardiography. Specialists, while offering important
or primary electrical cardiac abnormalities.
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clinical and technical insights, might have a natural ten-
3. A comprehensive TTE examination may include 2-
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dency to rate the indications within their specialty as more
dimensional, M-mode, and 3-dimensional imaging as
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appropriate than non-specialists. In addition, care was
well as spectral and color Doppler evaluation, all of
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taken to provide objective, nonbiased information, in-
which are important elements (9–11) to evaluate rele-
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cluding guidelines and key references, to the rating panel.
vant
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The level of agreement among panelists was analyzed
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based on the RAND Corporation’s BIOMED Concerted
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Action on Appropriateness rule (8) for a panel of 14 to
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16 members. As such, agreement was defined as an
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indication where 4 or fewer panelists’ ratings fell outside
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the 3-point region containing the median score.
cardiac
structures
and
hemodynamics.
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A
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comprehensive TTE report includes interpretation of
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all aspects of the TTE.
4. The use of transesophageal or stress echocardiography will not be addressed in this document.
5. This document assumes that any other more defini-
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tive diagnostic test, including but not limited to
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Disagreement was defined as occurring when at least 5
electrocardiogram (ECG), chest X-ray, or genetic
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panelists’ ratings fell in both the Appropriate and the
testing, when appropriate will be considered prior to
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Rarely Appropriate categories. Any indication having
ordering a TTE.
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disagreement was categorized as May Be Appropriate
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regardless of the final median score.
6. All standard TTE techniques for image acquisition are
539
available for each indication and have a sensitivity
540
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541
595
542
596
543
597
544
598
545
Patient
546
Patient
Selection
Image
Acquisition
Image
Interpretation
Results
Communication
547
548
Improved
Patient Care
(Outcomes)
Imaging Process
549
550
Laboratory Structure
552
554
605
607
F I G U R E 2 Factors Influencing Outcomes of an Imaging Study (16)
608
609
556
610
557
and specificity similar to those found in the published
558
literature.
559
7. The test is performed and interpreted by qualified
560
individual(s) in a facility that is in compliance with
561
national standards for performing pediatric echocar-
563
603
606
555
562
601
602
604
551
553
599
600
12. If the reason for a test can be assigned to more than
611
one indication, it is classified under the most clinically
612
significant indication.
13. The term family history in this document refers to
first-degree relatives only.
14. Cost is considered implicitly in the appropriate use
diograms (4).
613
614
615
616
8. AUC is one aspect of quality for imaging procedures
determination. Clinical benefits should always be
617
564
occurring at the time of patient selection. Several
considered first, and costs should be considered in
618
565
additional factors should be addressed to support
relationship to these benefits in order to better convey
619
620
566
high-quality results (see Figure 2). These other factors
net value. For example, a procedure with moderate
567
are important but are not covered in this document.
clinical efficacy for a given AUC indication should not
621
622
568
9. The range of potential indications for echocardiogra-
be scored as more appropriate than a procedure with
569
phy is quite large, particularly in comparison with
high clinical efficacy solely due to its lower cost. When
623
570
other cardiovascular imaging tests. Thus, the in-
scientific evidence exists to support clinical benefit,
624
571
dications are, at times, purposefully broad to cover an
cost efficiency and cost effectiveness should be
625
572
array of cardiovascular signs and symptoms and to
considered for any indication.
626
573
account for the ordering physician’s best judgment as
15. For each indication, the rating reflects whether
627
574
to the presence of cardiovascular abnormalities.
the echocardiogram is reasonable for the patient ac-
628
575
Additionally, there are likely clinical scenarios that
cording to the appropriate use definition, not whether
629
576
are not covered in this document.
the test is preferred over another modality. It is not
630
577
10. A qualified clinician has obtained a complete clinical
assumed that the decision to perform a diagnostic test
631
578
history and performed the physical examination such
has already been made. The level of appropriateness
632
579
that the clinical status of the patient can be assumed
also does not consider issues of local availability or
633
580
to be valid as stated in the indication (e.g., an
skill for any modality.
634
581
asymptomatic patient is truly asymptomatic for the
16. The category of May Be Appropriate is used when
635
582
condition in question and sufficient questioning of
insufficient data are available for a definitive catego-
636
the patient has been undertaken).
583
rization or when there is substantial disagreement
637
584
11. Some indications address whether or not an ECG
regarding the appropriateness of that indication. The
638
585
has been obtained and whether or not it reveals
designation May Be Appropriate should not be used as
639
586
any abnormalities as influencing the appropriateness
grounds for denial of reimbursement.
640
587
of additional echocardiographic assessment. It is
17. This manuscript does not address whether a cardiol-
641
588
beyond the scope of this document to define every
ogy consultation is required prior to the echocardio-
642
589
possible clinical scenario involving specific ECG
gram unless specified in the indication.
590
abnormalities. Therefore, the term “abnormal ECG”
643
644
4. DEFINITIONS
591
refers to only clinically pertinent ECG findings.
592
Criteria for “abnormal ECG” will be based upon stan-
593
dard published ECG normal values in pediatric pa-
Abnormal electrocardiogram (ECG): Electrocardiographic
647
594
tients (12–15).
findings regarded as probably or definitely abnormal
648
645
646
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AUC for Pediatric Echocardiography
649
according to age as well as clinically significant, and
murmur, pulmonary flow murmur, physiologic pe-
703
650
including but not limited to ventricular hypertrophy,
ripheral pulmonary stenosis, supraclavicular arterial
704
651
atrial enlargement, complete bundle branch block, atrio-
bruit, and venous hum; most innocent murmurs are
705
652
ventricular block, prolonged QTc, abnormal T waves or
soft (less than or equal to grade 2/6), heard in early
706
653
ST-T wave segments, Wolff-Parkinson-White syndrome,
systole, characterized as crescendo-decrescendo
707
654
premature atrial contractions (PACs), premature ventric-
type, and may vary with position
708
655
ular contractions (PVCs), supraventricular tachycardia,
Pathologic murmur: Murmur that is suggestive of the
709
656
ventricular tachycardia, and Brugada syndrome
presence of a cardiovascular abnormality (not clearly
710
657
Arrhythmia: Documented irregular and/or abnormal
innocent sounding), including but not limited to
711
658
heart rate or rhythm (Patients with palpitations do not
diastolic murmurs, holosystolic murmurs, late sys-
712
659
necessarily have an arrhythmia, and patients with an
tolic murmurs, grade 3/6 systolic murmur or louder,
713
660
arrhythmia do not necessarily experience palpitations)
continuous murmurs other than venous hums, harsh
714
661
Cardiomyopathy: Disease affecting the structure and/or
murmurs, and murmurs that are provoked or be-
715
662
function of the myocardium, including but not limited to
come louder with changes in position (from squat-
716
663
hypertrophic, dilated, or restrictive cardiomyopathy, left
ting to standing) or during the strain phase of a
717
664
ventricular non-compaction, or arrhythmogenic right
Valsalva maneuver
718
665
ventricular cardiomyopathy
719
666
Channelopathy: A clinical syndrome involving a genetic
667
mutation or acquired malfunction of the proteins forming
Neurocardiogenic syncope: A type of syncope typically
721
668
the myocardial ion channels (including but not limited to
occurring in the upright position, in which the triggering
722
669
Naþ, Kþ, and Ca2 þ) of the cardiovascular electrical sys-
of a neural reflex results in a usually self-limited episode
723
of systemic hypotension and/or bradycardia or asystole
724
670
tem, including but not limited to long QT syndrome, short
671
QT syndrome, catecholaminergic polymorphic ventricular
672
673
674
675
676
677
678
679
tachycardia, and Brugada syndrome
Chest pain: Physical discomfort in the anterior thoracic
region
dizziness, weakness, visual changes (such as spots, tunnel
buzzing, or muffled hearing), or feeling hot or cold
metabolic demands
without loss of consciousness
Cyanosis: Bluish discoloration of the skin and mucous
membranes
682
oximeter; for newborns $24 hours of age, an oxygen
683
saturation that is (a) <90% in the initial screen or in repeat
684
screens, (b) <95% in the right hand and foot on 3 mea-
685
sures, each separated by 1 hour, or (c) a >3% absolute
686
difference in oxygen saturation between the right hand
687
and foot on 3 measures, each separated by 1 hour (17)
688
Echogenic focus: Small bright spot(s) frequently seen on
689
a fetal echocardiogram, usually related to the ventricular
690
papillary muscles and chordae and generally considered a
691
benign finding
692
Hypertension: Average systolic and/or diastolic blood
693
pressure that is $95th percentile for gender, age, and
694
height on 3 or more occasions
695
Murmur: Additional heart or vascular sound due to
696
normal or abnormal turbulent blood flow heard during
697
auscultation
702
727
728
is unable to pump enough blood to meet the body’s
borns, an oxygen saturation <95% as measured by pulse
701
Pre-Syncope: A state of experiencing lightheadedness,
729
681
700
ular, and/or forceful beating of the heart
725
726
730
Desaturation: For pediatric patients other than new-
699
Palpitations: An unpleasant sensation of rapid, irreg-
720
vision, or loss of vision), auditory changes (ringing,
Congestive heart failure: A condition in which the heart
680
698
Neonate: A child that is less than or equal to 28 days old
Syncope: Sudden temporary loss of consciousness asso-
731
732
ciated with a loss of postural tone and with spontaneous
733
recovery that does not require electrical or chemical
734
cardioversion
735
736
5. ABBREVIATIONS
AUC ¼ Appropriate Use Criteria
ECG ¼ electrocardiogram
PAC ¼ premature atrial contraction
PVC ¼ premature ventricular contraction
TTE ¼ transthoracic echocardiogram
6. RESULTS
The final ratings for pediatric echocardiography are listed
by indication in Tables 1 to 9. The final score for each
indication reflects the median score of the 15 Rating
Panel members and has been labeled according to the
categories of Appropriate (median 7 to 9), May Be
Innocent murmur: Murmur that is consistent with
Appropriate (median 4 to 6), or Rarely Appropriate (me-
normal blood flow and is determined not to be
dian 1 to 3). In the tables, the final score for each indi-
related to any structural abnormalities of the heart or
cation is shown in parentheses with the ratings. Out of
great vessels, including but not limited to Still’s
113 total indications, 53 were considered Appropriate
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737
738
739
740
741
742
743
744
745
746
747
748
749
750
751
752
753
754
755
756
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AUC for Pediatric Echocardiography
757
(47%), 28 were considered May Be Appropriate (25%),
AUC score is attained. Likewise, Figure 7 (a-d) in the
811
758
and 32 were considered Rarely Appropriate (28%). To see
Online Appendix shows flow diagrams grouped by clin-
812
759
the indications listed by Appropriate Use rating, see the
ical presentation, such as family history and test
813
760
Online Appendix. The Discussion section highlights
findings.
814
761
further trends in scoring.
7. TRANSTHORACIC ECHOCARDIOGRAPHY IN
816
815
762
Figures 3, 4, 5, and 6 illustrate flow diagrams based on
763
common patient symptoms (chest pain, syncope, palpi-
OUTPATIENT PEDIATRIC CARDIOLOGY:
817
764
tations and arrhythmias, and murmur) that the clinician
APPROPRIATE USE CRITERIA (BY INDICATION)
818
765
can use to narrow down patient information until the
819
766
767
768
769
820
TABLE 1
821
Palpitations and Arrhythmias
822
Indication
Appropriate Use Rating
Palpitations
770
823
824
771
1.
Palpitations with no other symptoms or signs of cardiovascular disease, a benign family history, and no recent ECG
R (2)
825
772
2.
Palpitations with no other symptoms or signs of cardiovascular disease, a benign family history, and a normal ECG
R (1)
826
773
3.
Palpitations with abnormal ECG
M (6)
827
774
4.
Palpitations with family history of a channelopathy
R (3)
828
775
5.
Palpitations in a patient with known channelopathy
M (4)
829
776
6.
Palpitations with family history at a young age (before the age of 50 years) of sudden cardiac arrest or death
and/or pacemaker or implantable defibrillator placement
A (7)
830
778
7.
Palpitations with family history of cardiomyopathy
A (9)
832
779
8.
Palpitations in a patient with known cardiomyopathy
A (9)
777
780
781
10.
783
11.
785
786
787
788
789
833
834
ECG Findings
9.
782
784
831
R (3)
835
PACs after the neonatal period
R (3)
836
Supraventricular tachycardia
A (7)
PACs in the prenatal or neonatal period
12.
PVCs in the prenatal or neonatal period
M (6)
13.
PVCs after the neonatal period
M (6)
14.
Ventricular tachycardia
A (9)
15.
Sinus bradycardia
R (2)
16.
Sinus arrhythmia
R (1)
790
The number in parentheses next to the rating reflects the median score for that indication.
791
Abbreviations: A ¼ Appropriate; M ¼ May Be Appropriate; R ¼ Rarely Appropriate; ECG ¼ electrocardiogram; PACs ¼ premature atrial contractions; PVCs ¼ premature ventricular contractions.
837
838
839
840
841
842
843
844
792
845
846
793
847
794
848
795
796
TABLE 2
Syncope
Indication
Appropriate Use Rating
849
850
17.
Syncope with or without palpitations and with no recent ECG
R (3)
798
18.
Syncope with no other symptoms or signs of cardiovascular disease, a benign family history, and a normal ECG
R (2)
799
19.
Syncope with abnormal ECG
A (7)
853
800
20.
Syncope with family history of channelopathy
M (5)
854
801
21.
Syncope with family history at a young age (before the age of 50 years) of sudden cardiac arrest or death and/or
pacemaker or implantable defibrillator placement
A (9)
22.
Syncope with family history of cardiomyopathy
A (9)
804
23.
Probable neurocardiogenic (vasovagal) syncope
R (2)
805
24.
Unexplained pre-syncope
M (4)
859
806
25.
Exertional syncope
A (9)
860
807
26.
Unexplained post-exertional syncope
A (7)
861
808
27.
Syncope or pre-syncope with a known non-cardiovascular cause
R (2)
862
797
802
803
809
810
The number in parenthesis next to the rating reflects the median score for that indication.
Abbreviations: A ¼ Appropriate; M ¼ May Be Appropriate; R ¼ Rarely Appropriate; ECG ¼ Electrocardiogram.
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852
855
856
857
858
863
864
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TABLE 3
919
Chest Pain
866
867
868
9
AUC for Pediatric Echocardiography
920
Indication
28.
Appropriate Use Rating
Chest pain with no other symptoms or signs of cardiovascular disease, a benign family history, and a normal ECG
R (2)
921
922
869
29.
Chest pain with other symptoms or signs of cardiovascular disease, a benign family history, and a normal ECG
M (6)
923
870
30.
Exertional chest pain
A (8)
924
871
31.
Non-exertional chest pain with no recent ECG
R (3)
925
872
32.
Non-exertional chest pain with normal ECG
R (1)
926
873
33.
Non-exertional chest pain with abnormal ECG
A (7)
927
874
34.
Chest pain with family history of sudden unexplained death or cardiomyopathy
A (8)
928
875
35.
Chest pain with family history of premature coronary artery disease
M (4)
929
876
36.
Chest pain with recent onset of fever
M (6)
930
37.
Reproducible chest pain with palpation or deep inspiration
R (1)
877
878
879
880
881
38.
Chest pain with recent illicit drug use
M (6)
The number in parenthesis next to the rating reflects the median score for that indication.
931
932
933
934
Abbreviations: A ¼ Appropriate; M ¼ May Be Appropriate; R ¼ Rarely Appropriate; ECG ¼ Electrocardiogram.
935
882
936
883
937
884
938
885
939
886
940
887
941
888
942
889
943
890
TABLE 4
891
Indication
892
Murmur
944
Appropriate Use Rating
945
39.
Presumptively innocent murmur with no symptoms, signs, or findings of cardiovascular disease and a benign
family history
R (1)
946
894
40.
Presumptively innocent murmur with signs, symptoms, or findings of cardiovascular disease
A (7)
948
895
41.
Pathologic murmur
A (9)
949
893
896
897
947
950
The number in parenthesis next to the rating reflects the median score for that indication.
951
Abbreviations: A ¼ Appropriate; M ¼ May Be Appropriate; R ¼ Rarely Appropriate; ECG ¼ Electrocardiogram.
898
952
899
953
900
954
901
955
902
956
903
957
904
958
905
906
907
908
959
TABLE 5
Other Symptoms and Signs
Indication
960
Appropriate Use Rating
961
42.
Symptoms and/or signs suggestive of congestive heart failure, including but not limited to respiratory distress,
poor peripheral pulses, feeding difficulty, decreased urine output, edema, and/or hepatomegaly
A (9)
962
910
43.
Chest wall deformities and scoliosis pre-operatively
M (6)
964
911
44.
Fatigue with no other signs and symptoms of cardiovascular disease, a normal ECG, and a benign family history
R (3)
965
912
45.
Signs and symptoms of endocarditis in the absence of blood culture data or a negative blood culture
A (8)
966
913
46.
Unexplained fever without other evidence for cardiovascular or systemic involvement
M (5)
967
914
47.
Central cyanosis
A (8)
968
915
48.
Isolated acrocyanosis
R (1)
969
909
916
917
The number in parenthesis next to the rating reflects the median score for that indication.
Abbreviations: A ¼ Appropriate; M ¼ May Be Appropriate; R ¼ Rarely Appropriate; ECG ¼ Electrocardiogram.
918
963
970
971
972
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TABLE 6
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1027
Prior Test Results
974
1028
975
Indication
976
49.
977
50.
Genotype positive for cardiomyopathy
A (9)
1031
978
51.
Abnormal chest X-ray findings suggestive of cardiovascular disease
A (9)
1032
979
52.
Abnormal ECG without symptoms
A (7)
1033
980
53.
Desaturation based on pulse oximetry
A (9)
1034
981
54.
Previously normal echocardiogram with no change in cardiovascular status or family history
R (1)
1035
982
55.
Previously normal echocardiogram with a change in cardiovascular status and/or a new family history suggestive of
heritable heart disease
A (7)
1036
984
56.
Elevated anti-streptolysin O titers without suspicion for rheumatic fever
R (3)
1038
985
57.
Chromosomal abnormality known to be associated with cardiovascular disease
A (9)
1039
986
58.
Chromosomal abnormality with undefined risk for cardiovascular disease
M (5)
1040
987
59.
Positive blood cultures suggestive of infective endocarditis
A (9)
1041
988
60.
Abnormal cardiac biomarkers
A (9)
1042
989
61.
Abnormal barium swallow or bronchoscopy suggesting vascular ring
A (7)
983
Appropriate Use Rating
Known channelopathy
M (4)
1037
990
991
The number in parenthesis next to the rating reflects the median score for that indication.
1045
Abbreviations: A ¼ Appropriate; M ¼ May Be Appropriate; R ¼ Rarely Appropriate; ECG ¼ Electrocardiogram.
1046
993
1047
994
TABLE 7
995
Indication
Systemic Disorders
1048
Appropriate Use Rating
996
62.
Cancer without chemotherapy
M (5)
997
63.
Prior to or during chemotherapy in cancer
A (8)
999
1000
1043
1044
992
998
1029
1030
64.
Sickle cell disease and other hemoglobinopathies
A (8)
65.
Connective tissue disorder such as Marfan, Loeys Dietz, and other aortopathy syndromes
A (9)
1049
1050
1051
1052
1053
1054
66.
Suspected connective tissue disorder
A (7)
67.
Clinically suspected syndrome or extracardiac congenital anomaly known to be associated with congenital heart disease
A (9)
1003
68.
Human immunodeficiency virus infection
A (8)
1057
1004
69.
Suspected or confirmed Kawasaki disease
A (9)
1058
1005
70.
Suspected or confirmed Takayasu arteritis
A (9)
1059
1006
71.
Suspected or confirmed acute rheumatic fever
A (9)
1060
1007
72.
Systemic lupus erythematosis and autoimmune disorders
A (7)
1061
1008
73.
Muscular dystrophy
A (9)
1062
1009
74.
Systemic hypertension
A (9)
1063
1064
1001
1002
1055
1056
1010
75.
Renal failure
A (7)
1011
76.
Obesity without other cardiovascular risk factors
R (2)
1065
1066
1012
1013
1014
77.
Obesity with obstructive sleep apnea
M (6)
78.
Obesity with other cardiovascular risk factors
M (6)
1067
1068
79.
Diabetes mellitus
R (3)
80.
Lipid disorders
R (3)
81.
Stroke
A (8)
1018
82.
Seizures, other neurologic disorders, or psychiatric disorders
R (2)
1019
83.
Suspected pulmonary hypertension
A (9)
1073
1020
84.
Gastrointestinal disorders, not otherwise specified
R (2)
1074
1021
85.
Hepatic disorders
M (4)
1075
1022
86.
Failure to thrive
M (5)
1076
1023
87.
Storage diseases, mitochondrial and metabolic disorders
A (8)
1077
1024
88.
Abnormalities of visceral or cardiac situs
A (9)
1078
1015
1016
1017
1025
1026
The number in parenthesis next to the rating reflects the median score for that indication.
Abbreviations: A ¼ Appropriate; M ¼ May Be Appropriate; R ¼ Rarely Appropriate.
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1070
1071
1072
1079
1080
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1082
1083
1084
TABLE 8
11
AUC for Pediatric Echocardiography
Family History of Cardiovascular Disease in Patients Without Signs or Symptoms and Without Confirmed
Cardiac Diagnosis
Indication
Appropriate Use Rating
1135
1136
1137
1138
89.
Unexplained sudden death before the age of 50 years
M (6)
90.
Premature coronary artery disease before the age of 50 years
R (2)
1087
91.
Channelopathy
R (3)
1141
1088
92.
Hypertrophic cardiomyopathy
A (9)
1142
1089
93.
Non-ischemic dilated cardiomyopathy
A (9)
1143
1090
94.
Other cardiomyopathies
A (8)
1144
1091
95.
Unspecified cardiovascular disease
R (3)
1145
1092
96.
Disease at high risk for cardiovascular involvement, including but not limited to diabetes, systemic hypertension,
obesity, stroke, and peripheral vascular disease
R (2)
1146
97.
Genetic disorder at high risk for cardiovascular involvement
A (7)
1148
1085
1086
1093
1094
1139
1140
1147
1095
98.
Marfan or Loeys Dietz syndrome
A (7)
1149
1096
99.
Connective tissue disorder other than Marfan or Loeys Dietz syndrome
M (6)
1150
1097
100.
Congenital left-sided heart lesion, including but not limited to mitral stenosis, left ventricular outflow tract
obstruction, bicuspid aortic valve, aortic coarctation, and/or hypoplastic left heart syndrome
M (6)
1098
1151
1152
1099
101.
Congenital heart disease other than the congenital left-sided heart lesions
M (5)
1153
1100
102.
Idiopathic pulmonary arterial hypertension
M (5)
1154
1101
103.
Heritable pulmonary arterial hypertension
A (8)
1155
1102
104.
Pulmonary arterial hypertension other than idiopathic and heritable
R (3)
1156
1103
105.
Consanguinity
R (3)
1104
1105
1157
1158
The number in parenthesis next to the rating reflects the median score for that indication.
1159
Abbreviations: A ¼ Appropriate; M ¼ May Be Appropriate; R ¼ Rarely Appropriate.
1106
1160
1107
1161
1108
1162
1109
1163
1110
1164
1111
1112
TABLE 9
Outpatient Neonates Without Post-Natal Cardiology Evaluation
Indication
1165
Appropriate Use Rating
1166
1113
106.
Suspected cardiovascular abnormality on fetal echocardiogram
A (9)
1167
1114
107.
Isolated echogenic focus on fetal ultrasound
R (2)
1168
1115
108.
Maternal infection during pregnancy or delivery with potential fetal/neonatal cardiac sequelae
A (7)
1169
1116
109.
Maternal diabetes with no prior fetal echocardiogram
M (6)
1170
1117
110.
Maternal diabetes with a normal fetal echocardiogram
M (4)
1171
1172
1118
111.
Maternal phenylketonuria
A (7)
1119
112.
Maternal autoimmune disorder
M (5)
1173
M (6)
1174
1120
113.
Maternal teratogen exposure
1121
1122
1123
1175
The number in parenthesis next to the rating reflects the median score for that indication.
Abbreviations: A ¼ Appropriate; M ¼ May Be Appropriate; R ¼ Rarely Appropriate.
1124
1176
1177
1178
1125
1179
1126
1180
1127
1181
1128
1182
1129
1183
1130
1184
1131
1185
1132
1186
1133
1187
1134
1188
PGL 5.2.0 DTD JAC20491_proof 12 September 2014 3:25 pm ce
Campbell et al.
12
JACC VOL.
AUC for Pediatric Echocardiography
-, NO. -, 2014
-, 2014:-–-
1189
8. FLOW DIAGRAMS FOR COMMON
1243
1190
PATIENT SYMPTOMS
1244
1191
1245
1192
1246
1193
1247
1194
1248
1195
1249
1196
1250
1197
1251
1198
1252
1199
1253
1200
1254
1201
1255
1202
1256
1203
1257
1204
1258
1205
1259
1206
1260
1207
1261
1208
1262
1210
1211
1212
1263
p r i n t & w e b 4 C=F P O
1209
1213
1264
1265
1266
1267
F I G U R E 3 Chest Pain
1214
1268
1215
Each indication is preceded with a number sign. The rating of A, M, or R is then followed by the median score in parenthesis for that particular indication. *See
1269
1216
Discussion section. Abbreviations: A ¼ Appropriate; M ¼ May Be Appropriate; R ¼ Rarely Appropriate; ECG ¼ Electrocardiogram.
1270
1217
1271
1218
1272
1219
1273
1220
1274
1221
1275
1222
1276
1223
1277
1224
1278
1225
1279
1226
1280
1227
1281
1228
1282
1229
1283
1230
1284
1231
1285
1232
1286
1287
1234
1288
1235
1236
1237
1238
1239
p r i n t & w e b 4 C=F P O
1233
1289
1290
1291
1292
F I G U R E 4 Syncope
1293
1240
Each indication is preceded with a number sign. The rating of A, M, or R is then followed by the median score in parenthesis for that particular indication.
1241
Abbreviations: A ¼ Appropriate; M ¼ May Be Appropriate; R ¼ Rarely Appropriate; ECG ¼ Electrocardiogram; ICD ¼ Implantable Cardioverter Defibrillator.
1242
1294
1295
1296
PGL 5.2.0 DTD JAC20491_proof 12 September 2014 3:25 pm ce
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Campbell et al.
-, 2014:-–-
13
AUC for Pediatric Echocardiography
1297
1351
1298
1352
1299
1353
1300
1354
1301
1355
1302
1356
1303
1357
1304
1358
1305
1359
1306
1360
1307
1361
1308
1362
1309
1363
1310
1364
1311
1365
1312
1366
1313
1367
1314
1368
1315
1369
1316
1370
1317
1371
1318
1372
1320
1321
1322
1373
p r i n t & w e b 4 C=F P O
1319
1323
1374
1375
1376
F I G U R E 5 Palpitations and Arrhythmias
1324
1377
1378
1325
Each indication is preceded with a number sign. The rating of A, M, or R is then followed by the median score in parenthesis for that particular indication. *See
1379
1326
Discussion section. Abbreviations: A ¼ Appropriate; M ¼ May Be Appropriate; R ¼ Rarely Appropriate; ECG ¼ Electrocardiogram; ICD ¼ Implantable Car-
1380
dioverter Defibrillator; PACs ¼ Premature Atrial Contractions; PVCs ¼ Premature Ventricular Contractions.
1327
1328
1381
1382
1329
1383
1330
1384
1331
1385
1332
1386
1333
1387
1334
1388
1335
1389
1336
1390
1337
1391
1338
1392
1339
1393
1340
1394
1395
1342
1396
1343
1344
1345
1346
1347
p r i n t & w e b 4 C=F P O
1341
1397
1398
1399
1400
F I G U R E 6 Murmur
1401
1348
Each indication is preceded with a number sign. The rating of A, M, or R is then followed by the median score in parenthesis for that particular indication.
1349
Abbreviations: A ¼ Appropriate; M ¼ May Be Appropriate; R ¼ Rarely Appropriate.
1350
1402
1403
1404
PGL 5.2.0 DTD JAC20491_proof 12 September 2014 3:25 pm ce
14
Campbell et al.
JACC VOL.
1405
-, NO. -, 2014
-, 2014:-–-
AUC for Pediatric Echocardiography
9. DISCUSSION
1406
test for an individual patient should not be undermined
1459
because there may be reasons other than those listed in
1460
1407
This is the first report by the American College of Cardi-
this document that preclude application of the AUC. The
1461
1408
ology addressing appropriate use in the field of pediatric
AUC may also not be applicable if another diagnostic
1462
1409
cardiology. Although the use of AUC for various areas of
modality has already proven the diagnosis for which an
1463
1410
cardiovascular imaging in adult cardiology has been
echocardiogram was intended. For example, if a vascular
1464
1411
established since 2005, there has not been a tool to
ring is confirmed by cardiac magnetic resonance imaging
1465
1412
guide practice in pediatric cardiology (1,18). Given the
(MRI), then an echocardiogram will not provide any
1466
1413
high level of utilization of echocardiography in the
additional critical information. Even though this indica-
1467
1414
outpatient setting, this topic was chosen as the subject
tion is rated as Appropriate in this document, clinical
1468
1415
for the first pediatric AUC, and was intentionally
judgment in such scenarios will definitely supersede the
1469
1416
restricted to initial, outpatient, and transthoracic echo-
AUC rating.
1470
1417
cardiographic evaluation. Of the various diagnostic mo-
The definitions provided in this document were final-
1471
1418
dalities, echocardiography remains the most readily
ized by the writing group after it had given due consid-
1472
1419
available, non-invasive and highly diagnostic tool for
eration to the current literature and views provided by the
1473
1420
assessing cardiac structure, function and hemodynamics
external reviewers and the rating panel. The users of this
1474
1421
in those with suspected cardiac disease. This report will
document should be well versed in these assumptions
1475
1422
help
and definitions prior to implementing the AUC.
1476
1423
expanding AUC for echocardiography in pediatric pa-
1424
tients as well as AUC for other diagnostic modalities and
Indications and Ratings
1478
1425
procedures used in this field.
The indications presented in this report were finalized
1479
1480
us
establish
the
infrastructure
precedent
for
1477
1426
It is important to note the differences between clinical
after incorporating the suggestions by the external re-
1427
practice guidelines and AUC (19). The American College of
viewers, and the members of the rating panel rated the
1481
1482
1428
Cardiology guidelines have been developed by leaders in
indications independently. The median score for each
1429
the field of cardiovascular medicine using evidence-
indication became the final rating. In general, the in-
1483
1484
1430
based documents and expert opinion and are in general
dications rated as Appropriate included evaluation of
1431
quite broad. Even though AUC are evidence based,
new cardiac symptoms or clinical scenarios known to be
1485
1486
1432
they are created around possible clinical scenarios
associated with congenital or acquired heart disease in
1433
that are encountered in everyday practice rather than
the pediatric population. The indications ranked as
1487
1434
starting
evidence.
Rarely Appropriate clustered around broad systemic
1488
1435
Echocardiography is the most common imaging modality
diseases and family history of conditions that are
1489
1436
used in cardiology, but there is evidence that it may not
generally not known to be associated with structural or
1490
1437
be a cost-effective or high-yield diagnostic test for some
functional abnormalities detectable by echocardiogra-
1491
1438
indications included in this document (20–29). The AUC
phy. Scenarios that were rated as May Be Appropriate, in
1492
1439
address a reasonable role of echocardiography. Each
general, involved uncertainty or required additional
1493
1440
individual patient is unique and the possible use of
clinical information to better define the appropriateness
1494
1441
echocardiography deserves to be considered in full
of the test.
1442
clinical context. It is noteworthy that there are no recent
In the pediatric population, chest pain, syncope and
1443
practice guidelines for indications of echocardiography
murmur are 3 common reasons for referral of an echo-
1497
1444
in pediatric patients and this report may become a
cardiogram in the outpatient setting. For this reason,
1498
1445
clinically useful guide for practitioners (30).
tables dedicated to each of these conditions with various
1499
clinical scenarios were included in the current report.
1500
with
options
based
on
current
1446
1495
1496
1447
Assumptions and Definitions
Although a murmur is one of the most common indica-
1501
1448
Some of the assumptions used while writing this report
tions for obtaining an echocardiogram in the pediatric
1502
1449
are important to emphasize. It is assumed that a thor-
population, it is well known that a large number of pa-
1503
1450
ough history and physical examination has been per-
tients are referred with an innocent murmur that does
1504
1451
formed by a qualified clinician and that use of other
not require evaluation with an echocardiogram. The
1505
1452
more diagnostic tests has been considered prior to
current document presumes that the clinician has made
1506
1453
ordering an echocardiogram. It is also assumed that the
every effort to determine whether the murmur is inno-
1507
1454
echocardiogram is performed and interpreted by quali-
cent or not prior to considering the use of an echocar-
1508
1455
fied individuals. Although the AUC ratings listed in this
diogram
for
1509
1456
report provide general guidance for when transthoracic
presumably or clearly innocent murmur has been rated as
1510
1457
echocardiography may be useful in a specific patient
Rarely Appropriate in this document. This rating is sup-
1511
1458
population, the role of clinical judgment in ordering the
ported by prior publications reporting that examination
1512
(21,31).
Echocardiographic
PGL 5.2.0 DTD JAC20491_proof 12 September 2014 3:25 pm ce
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Campbell et al.
-, 2014:-–-
15
AUC for Pediatric Echocardiography
1513
by a pediatric cardiologist is quite accurate in dis-
more than one indication listed in this document could
1567
1514
tinguishing between innocent and pathologic murmurs
be applied, clinicians need to use their judgment in
1568
1515
(21,32,33). Pathologic murmurs (including those that are
picking the scenario that most closely fits the individual
1569
1516
not clearly innocent after evaluation), along with pre-
patient.
1570
1517
sumably innocent murmurs with other signs, symptoms
1518
or findings of cardiovascular disease, were found to be
Comparison With the Adult Cardiology AUC
1572
1519
Appropriate for an echocardiogram, since these situa-
The current adult cardiology AUC for echocardiography
1573
1520
tions suggest the possibility of a cardiovascular abnor-
includes initial and follow-up evaluation in the inpatient
1574
1521
mality as their underlying cause. Of course, the ability to
and
trans-
1575
1522
make a final diagnosis of innocent murmur after an
esophageal, and stress echocardiography (3). In contrast,
1576
1523
echocardiogram for patients meeting either of these
this current document is limited to initial outpatient
1577
1524
appropriate indications does not imply that the rationale
transthoracic echocardiography. The initial adult car-
1578
1525
for using an echocardiogram to rule out a cardiovascular
diology
transesophageal
1579
1526
abnormality was not appropriate.
echocardiography were published in 2007 (1). After
1580
1571
outpatient
AUC
for
setting
using
transthoracic
transthoracic,
and
1527
Chest pain and syncope are 2 other common pre-
practical application of these AUC, a revised version was
1581
1528
sentations in the pediatric age group. The etiology for
published in 2011. This revised version which is currently
1582
1529
these is generally benign and echocardiography has
in use included many more indications and now provides
1583
1530
been shown to be low-yield, unlike in adult patients
a more complete range of clinical scenarios (3). Studies
1584
1531
(25–29). For this reason, the indications and their ratings
comparing the application of these two AUC in adult
1585
1532
related to chest pain in this document are very different
cardiology clinical practice have demonstrated significant
1586
1533
from those in the adult AUC. Syncope with no other
improvement in the ability to classify the various clinical
1587
1588
1534
symptoms or signs of cardiac disease has been rated as
scenarios using the revised version (34,35). This current
1535
Appropriate in the adult AUC (3), but rated as Rarely
report for pediatric patients has certainly benefited from
1589
1590
1536
Appropriate
#18),
the maturational process and experience gained by the
1537
albeit with additional qualifiers of a benign family
AUC in adults (36). Implementation studies in the
1591
1592
for
pediatric
patients
(Indication
1538
history and a normal ECG. The reasonableness of using
pediatric population will help us to identify any missing
1539
an echocardiogram as a primary screen versus using an
or ambiguous indications that could be addressed in
1593
future revisions.
1594
1540
echocardiographic assessment only after a pediatric
1541
cardiology consultation for evaluation of a murmur, chest
In comparing the ratings of various indications in
1595
1542
pain, syncope, or any other indication, depends on many
the current document with those in the adult AUC, there
1596
1543
factors and needs to be given due consideration on a
were many indications that were rated similarly (3).
1597
1544
case-by-case basis.
For example, isolated PACs and sinus bradycardia
1598
1545
Given the complexity of clinical presentations, it is
were rated as Rarely Appropriate indications in both
1599
1546
likely that there will be some overlap between the in-
documents, while SVT, VT, pathologic murmurs, initial
1600
1547
dications in this document. Several indications share
evaluation of suspected pulmonary hypertension, sys-
1601
1548
identical accompanying findings, signs or symptoms, but
temic hypertension, and suspected endocarditis were
1602
1549
differ as to the primary patient complaint. As such, the
rated as Appropriate in both. However, there were some
1603
1550
ratings were driven in these scenarios by the prevalence
striking differences in the ratings of some indications
1604
1551
of the primary presentation and the likelihood of it being
such as syncope and chest pain due to variations in the
1605
1552
cardiac-related. For example, non-exertional chest pain
most common underlying causes in pediatric versus adult
1606
1553
with abnormal ECG (A [7] #33) and palpitations with
patients.
1554
abnormal ECG (M [6] #3) have been rated slightly
There are also differences in format. In this report,
1608
1555
differently by the panel even though they both relate to
prior test results for which a subsequent echocardiogram
1609
1556
an abnormal ECG. Given the broad definition of an
may be ordered are listed separately in Table 7 with
1610
1557
abnormal ECG described in this paper, it is not unex-
individual ratings; but in the adult AUC report they are
1611
1558
pected that the ratings for palpitations that may
lumped together under one indication (‘Prior testing
1612
1559
accompany more benign ECG findings were a bit lower.
that is concerning for heart disease or structural
1613
1560
Similarly, ratings for indications related to symptoms
abnormality including but not limited to chest X-ray,
1614
1561
or signs of cardiovascular disease changed slightly
baseline scout images for stress echocardiogram, ECG, or
1615
1562
depending on other presenting factors described in the
cardiac biomarkers’ (3)), and are rated as Appropriate.
1616
1563
scenarios (#29 – chest pain and signs and symptoms – M
The current report also includes a broad list of systemic
1617
1564
[6], #40 – presumptively innocent murmur with signs
disorders (Table 7) and scenarios related to family
1618
1565
and symptoms – A [7], and #42 – congestive heart failure
history (Table 8) that are not covered in the adult AUC
1619
1566
with signs and symptoms – A [9]). In applying the AUC, if
report.
1620
PGL 5.2.0 DTD JAC20491_proof 12 September 2014 3:25 pm ce
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AUC for Pediatric Echocardiography
1621
Limitations
of this category lies more in recognition of a pattern of
1675
1622
The current AUC report is not fully inclusive of all
ordering where a significantly higher number of echo-
1676
1623
possible clinical scenarios and does not include in-
cardiograms are requested for the Rarely Appropriate in-
1677
1624
dications for follow-up or inpatient echocardiography. In
dications by an individual provider compared with their
1678
1625
addition, it is restricted to the first use of transthoracic
peers. Indications rated as May Be Appropriate could be
1679
1626
echocardiography and does not include indications for
considered reasonable for obtaining an echocardiogram,
1680
1627
fetal or transesophageal echocardiography. Some of the
particularly if the physician taking care of the patient
1681
1628
indications have been purposefully kept broad either
determines that it would provide helpful information.
1682
1629
because it was beyond the scope of this report to list each
These two categories should not be considered as the
1683
1630
and every possible scenario, or because they were
basis for denying insurance coverage or reimbursement
1684
1631
considered fairly uncommon in routine practice. Exam-
for the procedure, as individual decision making is
1685
1632
ples of these broad indications include use of illicit drugs,
required to determine what is best for each patient.
1686
1633
chest wall deformities, chromosomal abnormalities with
Nevertheless, it is important for the clinicians taking care
1687
1634
undefined risk of cardiovascular disease, suspected con-
of pediatric patients to recognize that healthcare facil-
1688
1635
nective tissue disorders, neurologic or psychiatric disor-
ities, accreditation bodies, or payers for these tests may
1689
1636
ders, gastrointestinal and hepatic disorders and several
use this document to ensure quality care and appropriate
1690
1637
indications related to family history.
use of financial resources.
1691
1638
Though we have attempted to cover a broad range of
Ideally, this document will also serve as an educational
1639
clinical scenarios in this document, we realize that by no
and quality improvement tool for addressing the high
1693
1640
means is this list exhaustive. Given the experience with
number of Rarely Appropriate referrals for echocardio-
1694
1641
the adult cardiology AUC, it would not be surprising for us
grams by individual providers. Experience with the adult
1695
1696
1692
1642
to have missed some common indications. We also
echocardiography
1643
recognize that this document does not address the
engagement in quality improvement programs, and
1697
1698
AUC
has
shown
that
physician
1644
appropriateness, or lack thereof, of not performing echo-
tracking and benchmarking of test ordering behavior, has
1645
cardiograms. This underutilization of echocardiography
reduced the percentage of inappropriate testing (37).
1699
1700
1646
could result from a lack of availability (equipment, so-
Further, lab accreditation organizations such as the
1647
nographer or interpreting cardiologist), denial by payers
Intersocietal Accreditation Commission (IAC) require
1701
1702
1648
or lack of insurance, alteration of the management plan
attention to AUC as part of their quality improvement
1649
following expert consultation, or lack of sound clinical
process (38). Finally, the AUC may provide the basis for
1703
judgment.
evaluation of the impact of using AUC, especially as
1704
1650
1651
accessed by online tools, instead of more onerous and
1705
1652
less physician-driven administrative controls on imaging
1706
1653
1654
1655
1656
1657
1658
1659
1660
1661
1662
1663
1664
1665
1666
1667
1668
1669
1670
1671
1672
1673
1674
Use of AUC to Improve Care
We foresee several important applications of these AUC in
use.
the pediatric population. The most obvious use of this
document will be to support the clinical decision making
1707
1708
10. CONCLUSIONS
of a provider as to the appropriateness of care that they
deliver to an individual pediatric patient. It is important
This AUC report provides a helpful guide to clinicians in
to keep in mind that an Appropriate rating in this docu-
determining the reasonable role of initial transthoracic
ment should not be misinterpreted as a recommendation
echocardiography in the evaluation of pediatric patients
to perform an echocardiogram in every patient that meets
in an outpatient setting. It also lays the foundation for
the indications described herein. Rather, it should be
developing AUC in other areas of pediatric cardiology.
interpreted as something that would be reasonable to do
Furthermore, it can form the basis of designing educa-
if the information obtained will help in caring for the
tional and quality improvement projects to improve
patient. On the other hand, a Rarely Appropriate rating
quality of care. Future studies to evaluate implementa-
should not be misinterpreted as one in which an echo-
tion of these AUC in clinical care will be helpful not only
cardiogram should absolutely not be performed. This
in identifying any deficiencies in the current document,
category was termed as “Inappropriate” in the initial AUC
but also in defining ordering patterns for individual
documents, but due to significant misperceptions, the
practitioners and understanding variations in delivery of
AUC Task Force changed the terminology from Inappro-
care. We expect that there will be a continued need for
priate to Rarely Appropriate to emphasize that individual
refinement of these AUC based on any gaps identified
patient circumstances do exist where an echocardiogram
through this initial effort, changes in evidence-based
would be reasonable to perform. Instead of precluding an
medicine, and availability of technical and financial
echocardiogram in an individual patient, the importance
resources.
PGL 5.2.0 DTD JAC20491_proof 12 September 2014 3:25 pm ce
1709
1710
1711
1712
1713
1714
1715
1716
1717
1718
1719
1720
1721
1722
1723
1724
1725
1726
1727
1728
JACC VOL.
-, NO. -, 2014
Campbell et al.
-, 2014:-–-
1729
ACC PRESIDENT AND STAFF
Z. Jenissa Haidari, MPH, CPHQ, Senior Research Specialist,
1730
Appropriate Use Criteria
1731
Patrick T. O’Gara, MD, FACC, President
1732
Shalom Jacobovitz, Chief Executive Officer
1733
William J. Oetgen, MD, FACC, Executive Vice President,
1734
1735
1736
17
AUC for Pediatric Echocardiography
Lara M. Gold, MA, Senior Research Specialist, Appropriate
Science, Education, and Quality
1783
1784
1785
1786
Use Criteria
Amelia Scholtz, PhD, Publications Manager, Clinical
Policy and Pathways
Joseph M. Allen, MA, Senior Director, Clinical Policy and
1787
1788
1789
Pathways
1790
1737
1791
1738
1792
1739
1740
1741
1742
1743
1744
1745
1746
1747
1748
1749
1750
1751
1752
1753
1754
1755
1756
1757
1758
1759
1760
1761
1762
1763
1764
1765
1766
1767
1768
1769
1770
1771
1772
1773
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1776
1777
1778
1779
1780
1781
REFERENCES
1793
1. Douglas PS, Khandheria B, Stainback RF, et al. ACCF/
ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 appropriateness criteria for transthoracic and transesophageal
echocardiography: a report of the American College of
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Committee Appropriateness Criteria Working Group,
American Society of Echocardiography, American College of Emergency Physicians, American Society of
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2. Douglas PS, Khandheria B, Stainback RF, et al. ACCF/
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5. Lopez L, Colan SD, Frommelt PC, et al. Recommendations for quantification methods during the
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American Society of Echocardiography Pediatric and
Congenital Heart Disease Council. J Am Soc Echocardiogr 2010;23:465–95.
6. Patel MR, Spertus JA, Brindis RG, et al. ACCF proposed method for evaluating the appropriateness of
cardiovascular imaging. J Am Coll Cardiol 2005;46:
1606–13.
7. Hendel RC, Patel MR, Allen JM, et al. Appropriate
use of cardiovascular technology: 2013 ACCF appropriate use criteria methodology update: a report of the
American College of Cardiology Foundation appropriate use criteria task force. J Am Coll Cardiol 2013;61:
1305–17.
8. Fitch K, Bernstein S, Aguilar M, et al. The RAND/
UCLA Appropriateness Method User’s Manual. Arlington, VA: RAND Corporation, 2001.
9. Quinones MA, Otto CM, Stoddard M, et al. Recommendations for quantification of Doppler echocardiography: a report from the Doppler Quantification Task
Force of the Nomenclature and Standards Committee
of the American Society of Echocardiography. J Am Soc
Echocardiogr 2002;15:167–84.
10. Thomas JD, Adams DB, Devries S, et al. Guidelines
and recommendations for digital echocardiography.
J Am Soc Echocardiogr 2005;18:287–97.
11. Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from
the American Society of Echocardiography’s Guidelines
and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with
the European Association of Echocardiography, a
branch of the European Society of Cardiology. J Am
Soc Echocardiogr 2005;18:1440–63.
12. Hancock EW, Deal BJ, Mirvis DM, et al. AHA/
ACCF/HRS recommendations for the standardization
and interpretation of the electrocardiogram: part V:
electrocardiogram changes associated with cardiac
chamber hypertrophy: a scientific statement from
the American Heart Association Electrocardiography
and Arrhythmias Committee, Council on Clinical
Cardiology; the American College of Cardiology
Foundation; and the Heart Rhythm Society.
Endorsed by the International Society for Computerized Electrocardiology. J Am Coll Cardiol 2009;53:
992–1002.
13. Rautaharju PM, Surawicz B, Gettes LS, et al. AHA/
14. Surawicz B, Childers R, Deal BJ, et al. AHA/ACCF/
HRS recommendations for the standardization and
interpretation of the electrocardiogram: part III: intraventricular conduction disturbances: a scientific
statement from the American Heart Association
1794
Electrocardiography and Arrhythmias Committee,
Council on Clinical Cardiology; the American College
of Cardiology Foundation; and the Heart Rhythm
Society. Endorsed by the International Society for
Computerized Electrocardiology. J Am Coll Cardiol
2009;53:976–81.
1798
15. Wagner GS, Macfarlane P, Wellens H, et al. AHA/
ACCF/HRS recommendations for the standardization
and interpretation of the electrocardiogram: part VI:
acute ischemia/infarction: a scientific statement from
the American Heart Association Electrocardiography
and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. Endorsed by the
International Society for Computerized Electrocardiology. J Am Coll Cardiol 2009;53:1003–11.
16. Douglas P, Iskandrian AE, Krumholz HM, et al.
Achieving quality in cardiovascular imaging: proceedings from the American College of CardiologyDuke University Medical Center Think Tank on Quality
in Cardiovascular Imaging. J Am Coll Cardiol 2006;48:
2141–51.
17. Kemper AR, Mahle WT, Martin GR, et al. Strategies
for implementing screening for critical congenital heart
disease. Pediatrics 2011;128:e1259–67.
18. Brindis RG, Douglas PS, Hendel RC, et al. ACCF/
ASNC appropriateness criteria for single-photon
emission computed tomography myocardial perfusion
imaging (SPECT MPI): a report of the American College
of Cardiology Foundation Quality Strategic Directions
Committee Appropriateness Criteria Working Group
and the American Society of Nuclear Cardiology
endorsed by the American Heart Association. J Am Coll
Cardiol 2005;46:1587–605.
19. Antman EM, Peterson ED. Tools for guiding clinical
practice from the american heart association and the
american college of cardiology: what are they and
how should clinicians use them? Circulation 2009;119:
1180–5.
1795
1796
1797
1799
1800
1801
1802
1803
1804
1805
1806
1807
1808
1809
1810
1811
1812
1813
1814
1815
1816
1817
1818
1819
1820
1821
1822
1823
1824
1825
1826
1827
1828
ACCF/HRS recommendations for the standardization
and interpretation of the electrocardiogram: part IV:
the ST segment, T and U waves, and the QT interval: a
scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee,
Council on Clinical Cardiology; the American College of
Cardiology Foundation; and the Heart Rhythm Society.
20. Sable CA, Rome JJ, Martin GR, et al. Indications for
echocardiography in the diagnosis of infective endocarditis in children. Am J Cardiol 1995;75:801–4.
of the evaluation of heart murmurs in children.
Pediatrics 1993;91:365–8.
1832
Endorsed by the International Society for Computerized Electrocardiology. J Am Coll Cardiol 2009;53:
982–91.
22. Yi MS, Kimball TR, Tsevat J, et al. Evaluation of
heart murmurs in children: cost-effectiveness and
practical implications. J Pediatr 2002;141:504–11.
1834
21. Danford DA, Nasir A, Gumbiner C. Cost assessment
1782
1829
1830
1831
1833
1835
1836
PGL 5.2.0 DTD JAC20491_proof 12 September 2014 3:25 pm ce
18
Campbell et al.
JACC VOL.
1837
1838
1839
1840
1841
23. Friedman KG, Kane DA, Rathod RH, et al.
Management of pediatric chest pain using a standardized assessment and management plan. Pediatrics
2011;128:239–45.
24. McCrindle BW, Shaffer KM, Kan JS, et al. Cardinal
clinical signs in the differentiation of heart murmurs in
1842
children. Arch Pediatr Adolesc Med 1996;150:169–74.
1843
25. Drossner DM, Hirsh DA, Sturm JJ, et al. Cardiac
disease in pediatric patients presenting to a pediatric
ED with chest pain. Am J Emerg Med 2011;29:632–8.
1844
1845
1846
1847
1848
1849
1850
1851
1852
1853
-, NO. -, 2014
-, 2014:-–-
AUC for Pediatric Echocardiography
26. Massin MM, Bourguignont A, Coremans C, et al.
Chest pain in pediatric patients presenting to an
emergency department or to a cardiac clinic. Clin
Pediatr (Phila) 2004;43:231–8.
27. Ritter S, Tani LY, Etheridge SP, et al. What is the
yield of screening echocardiography in pediatric syncope? Pediatrics 2000;105:E58.
28. Steinberg LA, Knilans TK. Syncope in children:
diagnostic tests have a high cost and low yield.
J Pediatr 2005;146:355–8.
29. Verghese GR, Friedman KG, Rathod RH, et al.
Resource Utilization Reduction for Evaluation of Chest
Pain in Pediatrics Using a Novel Standardized Clinical
Assessment and Management Plan (SCAMP). Journal
of the American Heart Assocation 2012;1.
30. Cheitlin MD, Alpert JS, Armstrong WF, et al. ACC/
AHA Guidelines for the Clinical Application of Echocardiography. A report of the American College of
Cardiology/American Heart Association Task Force on
Practice Guidelines (Committee on Clinical Application
of Echocardiography). Developed in collaboration with
the American Society of Echocardiography. Circulation
1997;95:1686–744.
31. Rosenthal A. How to distinguish between innocent
and pathologic murmurs in childhood. Pediatr Clin
North Am 1984;31:1229–40.
32. Newburger JW, Rosenthal A, Williams RG, et al.
Noninvasive tests in the initial evaluation of
heart murmurs in children. N Engl J Med 1983;308:
61–4.
33. Geva T, Hegesh J, Frand M. Reappraisal of the
approach to the child with heart murmurs: is echocardiography mandatory? Int J Cardiol 1988;19:107–13.
34. Bhatia RS, Carne DM, Picard MH, et al. Comparison
of the 2007 and 2011 appropriate use criteria for
transthoracic echocardiography in various clinical settings. J Am Soc Echocardiogr 2012;25:1162–9.
35. Mansour IN, Razi RR, Bhave NM, et al. Comparison
of the updated 2011 appropriate use criteria for echocardiography to the original criteria for transthoracic,
transesophageal, and stress echocardiography. J Am
Soc Echocardiogr 2012;25:1153–61.
36. Douglas PS. Appropriate use criteria: past, present,
future. J Am Soc Echocardiogr 2012;25:1176–8.
1856
1857
1858
1859
1860
1861
1893
1894
1895
1896
1897
1898
1899
1900
1901
1902
37. Imaging in “FOCUS”. Available at: http://www.
1903
cardiosource.org/focus. Accessed January 24, 2014.
1904
38. Echocardiography/ ICAEL: Accreditation Evolved.
Available at: http://www.intersocietal.org/echo/.
Accessed January 24, 2014.
1905
1906
1907
1854
1855
1891
1892
1908
APPENDIX A. APPROPRIATE USE CRITERIA FOR
Montefiore; and Associate Professor of Clinical Pediatrics,
INITIAL TRANSTHORACIC ECHOCARDIOGRAPHY
Albert Einstein College of Medicine, New York, NY
IN OUTPATIENT PEDIATRIC CARDIOLOGY:
Ritu Sachdeva, MD, FACC, FAAP, FASE—Associate
PARTICIPANTS
Professor, Emory University; and Director, Cardiovascular
Imaging Research Core, Children’s Healthcare of Atlanta,
Sibley Heart Center, Atlanta, GA
Writing Group
1909
1910
1911
1912
1913
1914
1915
1862
Robert M. Campbell, MD, FACC, FAHA, FAAP, FHRS—
1863
Chief, Children’s Healthcare of Atlanta Sibley Heart
Rating Panel
1864
Center, Professor and Division Director of Cardiology,
Robert M. Campbell, MD, FACC, FAHA, FAAP, FHRS,
1865
Department of Pediatrics, Emory University School of
Writing Committee Liaison—Chief, Children’s Healthcare
1919
1866
Medicine, Atlanta, GA
of Atlanta Sibley Heart Center; Professor and Division
1920
1916
1917
1918
Director of Cardiology, Department of Pediatrics, Emory
1921
University School of Medicine, Atlanta, GA
1922
1867
Pamela S. Douglas, MD, MACC, FAHA, FASE—Past
1868
President, American College of Cardiology; Past Presi-
1869
dent, American Society of Echocardiography, and Ursula
Pamela S. Douglas, MD, MACC, FAHA, FASE, Moder-
1923
1870
Geller Professor of Research in Cardiovascular Diseases,
ator—Past President, American College of Cardiology;
1924
1871
Duke University Medical Center, Durham, NC
Past President, American Society of Echocardiography;
1925
and Ursula Geller Professor of Research in Cardio-
1926
1872
Benjamin W. Eidem, MD, FACC, FASE—Past President,
of
Pediatric
Echocardiography;
Past
Chair,
vascular Diseases, Duke University Medical Center,
1927
Durham, NC
1928
1873
Society
1874
Pediatric & Congenital Heart Disease Council; Past mem-
1875
ber, Board of Directors, American Society of Echocardiog-
Louis I. Bezold, MD, FACC, FAAP, FASE—UK Health
1929
1876
raphy; and Professor of Medicine and Pediatrics, Division
Care Enterprise Quality Director, Jennifer Gill Roberts
1930
1877
of Pediatric Cardiology, Department of Pediatric and
Professor in Pediatric Cardiology, and Vice Chair of Pedi-
1931
1878
Adolescent Medicine, Mayo Graduate School of Medicine,
atrics, University of Kentucky, Lexington, KY
1932
1879
Mayo Clinic College of Medicine, Rochester, MN
William B. Blanchard, MD, FACC, FAAP, FAHA—Past
1933
1880
Wyman W. Lai, MD, MPH, FACC, FASE—Chair, Pediatric
Medical Director of Nemours Children’s Clinic in Pensa-
1934
1881
and Congenital Council Board, American Society of
cola, FL; Past President, American Heart Association
1935
1882
Echocardiography;
Florida/Puerto Rico Affiliate; Statewide Associate Pediat-
1936
1883
Imaging, Pediatric Echocardiography Laboratory, and
ric Cardiology Consultant for Children’s Medical Services,
1937
1884
Congenital Cardiac MRI Program, Division of Pediatric
FL; and Medical Director, Florida Association of Chil-
1938
1885
Cardiology, Department of Pediatrics, New York Presby-
dren’s Hospitals, FL
1886
terian Morgan Stanley Children’s Hospital, New York, NY
1887
Leo Lopez, MD, FACC, FAAP, FASE—Chair, Pedia-
Professor of Pediatrics; Director, Postural Orthostatic
1941
1888
tric and Congenital Heart Disease Council, American
Tachycardia Syndrome Program; and Pediatric Cardiolo-
1942
1889
Society of Echocardiography; Director, Pediatric Cardiac
gist, Division of Cardiology, Children’s Hospital of Phila-
1943
1890
Non-invasive Imaging at the Children’s Hospital at
delphia, Philadelphia, PA
1944
Director
of
Non-invasive
Cardiac
Jeffrey R. Boris, MD, FACC, FAAP—Clinical Associate
PGL 5.2.0 DTD JAC20491_proof 12 September 2014 3:25 pm ce
1939
1940
JACC VOL.
-, NO. -, 2014
Campbell et al.
-, 2014:-–-
19
AUC for Pediatric Echocardiography
1945
Bryan Cannon, MD—Associate Professor of Pediatrics,
1946
and Director, Pediatric Arrhythmia and Pacing Service,
1947
Mayo Clinic, Rochester, MN
1948
Gregory J. Ensing, MD, FACC, FASE—Member of the
1949
ASE Pediatric Council Board, and Professor of Pediatrics
1950
and Pediatric Cardiology, University of Michigan CS Mott
1951
Hospital for Children, Ann Arbor, MI
Michigan Congenital Heart Center, University of Michigan
1999
Medical School, Ann Arbor, MI
2000
Robert Wiskind, MD, FAAP—President, Georgia Chapter
2001
of the American Academy of Pediatrics; Managing Part-
2002
ner, Peachtree Park Pediatrics, Atlanta, GA
2003
2004
Reviewers
2005
Meryl S. Cohen, MD—Medical Director, Non-Invasive
2006
1952
Craig E. Fleishman, MD, FACC, FASE—President, Soci-
1953
ety of Pediatric Echocardiography; Medical Director, Non-
Cardiovascular Laboratory, The Children’s Hospital of
2007
1954
Invasive Cardiac Imaging, The Heart Center at Arnold
Philadelphia, Philadelphia, PA
2008
1955
Palmer Hospital for Children; and Associate Professor of
Mario J. Garcia, MD, FACC—Chief, Division of Cardiol-
2009
1956
Pediatrics, University of Central Florida College of Medi-
ogy, Professor of Medicine and Radiology, and Co-Director,
2010
1957
cine, Orlando, FL
Montefiore-Einstein Center for Heart and Vascular Care,
2011
Montefiore Medical Center, The University Hospital for
2012
1958
Mark A. Fogel, MD, FACC, FAHA, FAAP—Professor of
1959
Cardiology and Radiology, University of Pennsylvania
1960
School of Medicine; Past member, Board of Trustees,
Michael Gewitz, MD, FACC, FAAP, FAHA—Professor
1961
Society for Cardiovascular Magnetic Resonance; Past
and Physician-in-Chief, Pediatric Cardiology, Maria Fareri
2015
1962
member, American College of Cardiology Imaging Coun-
Children’s Hospital at Westchester Medical Center; and
2016
1963
cil; Member, Board of Scientific Counselors, National
Professor and Vice Chairman, Department of Pediatrics,
2017
1964
Heart Lung and Blood Institute of the National Institute of
New York Medical College, Valhalla, NY
2018
1965
Health; and Director of Cardiac Magnetic Resonance, The
1966
1967
the Albert Einstein College of Medicine, Bronx, NY
2013
2014
Willem A. Helbing, MD—Professor of Pediatric Cardiol-
2019
Children’s Hospital of Philadelphia, Division of Cardiol-
ogy, Erasmus University Medical Center, Sophia Chil-
2020
ogy, Philadelphia, PA
dren’s Hospital, Rotterdam, The Netherlands
2021
1968
B. Kelly Han, MD, FACC—Director of Congenital Cardiac
Alexander J. Javois, MD, FACC, FAAP, FSCAI—Assistant
1969
Imaging, Minneapolis Heart Institute and the Children’s
Clinical Professor of Pediatrics, University of Illinois
2023
2024
1970
Heart Clinic at the Children’s Hospitals and Clinics of
Medical Center, Advocate Children’s Hospital, Oak Lawn,
1971
Minnesota, Minneapolis, MN
IL
2022
2025
1972
Shabnam Jain, MD, MPH, FAAP—Associate Professor of
Walter H. Johnson, Jr, MD—Professor of Pediatrics, Di-
1973
Pediatrics and Emergency Medicine; Director for Quality,
vision of Pediatric Cardiology, Alabama Congenital Heart
2027
1974
Pediatric Emergency Medicine, Emory University; Medi-
Disease Center, University of Alabama at Birmingham &
2028
1975
cal Director for Clinical Effectiveness, Children’s Health-
Children’s of Alabama, Birmingham, AL
1976
care of Atlanta, Atlanta, GA
Ann Kavanaugh-McHugh, MD—Associate Professor of
2026
2029
2030
1977
Mark B. Lewin, MD—Professor and Chief, Division of
Pediatrics, and Director of Pediatric Cardiology Imaging
2031
1978
Pediatric Cardiology, University of Washington School of
Laboratory, Division of Pediatric Cardiology, Vanderbilt
2032
1979
Medicine; and Co-Director, Heart Center, Seattle Chil-
University Medical Center
1980
dren’s Hospital, Seattle, WA
1981
1982
H. Helen Ko, BS, RDMS, RDCS, FASE—Technical
Richard H. Lockwood, MD—Associate Medical Director,
Excellus Blue Cross Blue Shield, Syracuse, NY
2033
2034
Director/Operations Manager, Pediatric Echocardiogra-
2035
phy, Mount Sinai Medical Center, New York, NY
2036
1983
G. Paul Matherne, MD, MBA, FACC, FAHA—Dammann
Seema Mital, MD, FACC, FAHA, FRCPC—Professor of
2037
1984
Professor of Pediatrics, Vice Chair for Clinical Affairs, and
Pediatrics, Hospital for Sick Children, University of Tor-
2038
1985
Associate Chief Medical Officer, University of Virginia
onto, Toronto, Ontario, Canada
1986
Children’s Hospital, Charlottesville, VA
Andrew J. Powell, MD—Associate Professor of Pediat-
2039
2040
1987
David Nykanen, MD, FACC, FRCPC, FSCAI—Member,
rics, Harvard Medical School; Senior Associate in Cardi-
2041
1988
Executive Committee, Congenital Heart Disease Council,
ology, Department of Cardiology, Boston Children’s
2042
1989
Society
Hospital, Boston, MA
1990
ventions; Co-Director, The Heart Center; and Chief, Car-
J. Carter Ralphe, MD—Assistant Professor of Pediatrics,
1991
diology and Cardiac Catheterization, Arnold Palmer
and Chief, Pediatric Cardiology, University of Wisconsin
2045
1992
Hospital for Children, Orlando, FL
School of Medicine & Public Health, Madison, WI
2046
for
Cardiovascular
Angiography
and
Inter-
2043
2044
1993
Catherine L. Webb, MD, FACC, FAHA, FASE—Past Chair,
Arno AW Roest, MD, PhD—Pediatric Cardiologist, Division
2047
1994
Council on Cardiovascular Disease in the Young, Amer-
of Pediatric Cardiology, Department of Pediatrics, Leiden
2048
1995
ican Heart Association; Past Co-Chair, Congenital Heart
University Medical Center, Leiden, The Netherlands
2049
1996
Public Health Consortium; Past Board Member, Sub-board
Jennifer N. A. Silva, MD—Pediatric Electrophysiology,
1997
of Pediatric Cardiology, American Board of Pediatrics; and
Washington University School of Medicine, St. Louis
2051
1998
Professor of Pediatrics and Communicable Diseases,
Children’s Hospital, St. Louis, MO
2052
PGL 5.2.0 DTD JAC20491_proof 12 September 2014 3:25 pm ce
2050
20
Campbell et al.
JACC VOL.
-, NO. -, 2014
-, 2014:-–-
AUC for Pediatric Echocardiography
2053
Julia Steinberger, MD, MS—Professor of Pediatrics, and
2054
Dwan Chair of Pediatric Cardiology, University of Min-
2055
nesota Amplatz Children’s Hospital, Minneapolis, MN
2056
Associate Professor of Medicine, Baylor College of Medi-
2107
cine, Houston, TX
2108
L. Samuel Wann, MD – Columbia St. Mary’s Healthcare,
Milwaukee, WI
2109
2110
2057
ACC Appropriate Use Criteria Task Force
2058
Steven R. Bailey, MD, FACC, FSCAI, FAHA—Chair, Divi-
2059
sion of Cardiology, Professor of Medicine and Radiology,
2113
2060
Janey Briscoe Distinguished Chair, University of Texas
2114
2061
Health Sciences Center, San Antonio, TX
Joseph M. Allen, MA—Senior Director, American Col-
2062
Alan S. Brown, MD, FACC—Medical Director, Midwest
2063
Heart Disease Prevention Center, Midwest Heart Special-
2064
ists, Edward Heart Hospital, Naperville, IL
lege of Cardiology, Washington, DC
2111
2112
APPENDIX B. RELATIONSHIPS WITH INDUSTRY
2115
(RWI) AND OTHER ENTITIES
2116
The College and its partnering organizations rigorously
2118
2117
2065
John U. Doherty, MD, FACC, FAHA—Professor of Med-
avoid any actual, perceived, or potential conflicts of in-
2119
2066
icine, Jefferson Medical College of Thomas Jefferson
terest that might arise as a result of an outside relation-
2120
2067
University, Philadelphia, PA
ship or personal interest of a member of the rating panel.
2121
2068
Pamela S. Douglas, MD, MACC, FAHA, FASE—Past
Specifically, all panelists are asked to provide disclosure
2122
2069
President, American College of Cardiology; Past Presi-
statements of all relationships that might be perceived
2123
2070
dent, American Society of Echocardiography; and Ursula
as real or potential conflicts of interest. These statements
2124
2071
Geller Professor of Research in Cardiovascular Diseases,
were reviewed by the Appropriate Use Criteria Task
2125
2072
Duke University Medical Center, Durham, NC
Force, discussed with all members of the rating panel at
2126
2073
the face-to-face meeting, and updated and reviewed as
2127
Imaging
necessary. A table of relevant disclosures by the rating
2128
Writing Group; Director of Cardiac Imaging and Outpa-
panel and oversight working group members can be found
2129
2130
Robert C. Hendel, MD, FACC, FAHA, FASNC—Chair,
2074
Appropriate
2075
Use
Criteria
for
Radionuclide
2076
tient Services, Division of Cardiology, Miami University
below. In addition, to ensure complete transparency,
2077
School of Medicine, Miami, FL
a full list of disclosure information—including relation-
2131
ships not pertinent to this document—is available in the
2132
2078
Christopher M. Kramer, MD, FACC, FAHA—Co-Chair,
2079
AUC Task Force, Ruth C. Heede Professor of Cardiology and
2080
Radiology, and Director, Cardiovascular Imaging Center,
2081
University of Virginia Health System, Charlottesville, VA
Online Appendix.
2133
2134
2135
Appropriate Use Criteria for Initial Transthoracic
2082
Bruce D. Lindsay, MD, FACC—Professor of Cardiology,
2083
Cleveland Clinic Foundation of Cardiovascular Medicine,
Echocardiography in Outpatient Pediatric Cardiology: Members
2137
2084
Cleveland, OH
of the Writing Group, Rating Panel, Indication Reviewers, and
2138
2136
2085
Manesh R. Patel, MD, FACC— Chair, AUC Task Force,
AUC Task Force—Relationships with Industry and Other Entities
2139
2086
Assistant Professor of Medicine, Division of Cardiology,
(Relevant)
2140
2087
Duke University Medical Center, Durham, NC
Note: A standard exemption to the ACC RWI policy is
2141
extended to Appropriate Use Criteria writing groups,
2142
2088
2089
Leslee Shaw, PhD, FACC, FASNC— Professor of Medi-
since they do not make recommendations but rather
2143
2090
Raymond F. Stainback, MD, FACC, FASE—Medical Di-
prepare background materials and typical clinical sce-
2144
2091
rector of Non-invasive Cardiac Imaging, Texas Heart
narios/indications that are rated independently by a
2145
2092
Institute
separate panel of experts.
2146
cine, Emory University School of Medicine, Atlanta, GA
at
St. Luke’s Episcopal
Hospital;
Clinical
2093
2147
2094
2148
2095
2149
2096
2150
2097
2151
2098
2152
2099
2153
2100
2154
2101
2155
2102
2156
2103
2157
2104
2158
2105
2159
2106
2160
PGL 5.2.0 DTD JAC20491_proof 12 September 2014 3:25 pm ce
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Campbell et al.
-, 2014:-–-
2161
APPENDIX B. CONTINUED
2215
2162
2216
2163
2164
2165
21
AUC for Pediatric Echocardiography
Participant
Consultant
Speakers
Bureau
Ownership/
Partnership/
Principal
Personal Research
Institutional,
Organizational,
or Other Financial
Benefit
2217
Expert
Witness
Writing Group
2166
2218
2219
2220
2167
Robert M. Campbell
None
None
None
None
None
None
2221
2168
Pamela S. Douglas
None
None
None
None
None
None
2222
2169
Benjamin W. Eidem
None
None
None
None
None
None
2223
2170
Wyman W. Lai
None
None
None
None
None
None
2224
2171
Leo Lopez
None
None
None
None
None
None
2225
2172
Ritu Sachdeva
None
None
None
None
None
None
2226
2173
2174
2175
2176
2227
Rating Panel
Louis I. Bezold
None
None
None
None
None
None
William B. Blanchard
None
None
None
None
None
None
2228
2229
2230
Jeffrey R. Boris
None
None
None
None
None
None
Bryan Cannon
None
None
None
None
None
None
2179
Gregory J. Ensing
None
None
None
None
None
None
2233
2180
Craig E. Fleishman
None
None
None
None
None
2234
2177
2178
2181
2182
2183
Gore Medical
Supplies
Mark A. Fogel
None
None
None
Siemens Medical
Systems
None
None
B. Kelly Han
None
None
None
Siemens Medical
Systems
None
None
2184
2231
2232
2235
2236
2237
2238
2185
Shabnam Jain
None
None
None
None
None
None
2239
2186
Mark B. Lewin
None
None
None
None
None
None
2240
2187
Richard H. Lockwood
None
None
None
None
2188
G. Paul Matherne
None
None
None
None
2189
David Nykanen
None
None
None
None
2190
2191
2241
None
None
2242
None
None
2243
2244
Catherine L. Webb
None
None
None
None
None
None
Robert Wiskind
None
None
None
None
None
None
2192
2193
None
Excellus BCBS*
2245
2246
Reviewers
2247
Meryl S. Cohen
None
None
None
None
None
None
Mario J. Garcia
None
None
None
None
None
None
Michael Gewitz
None
None
None
None
None
None
2197
Willem A. Helbing
None
None
None
None
None
None
2251
2198
Alexander J. Javois
None
None
None
None
None
None
2252
2199
Walter H. Johnson
None
None
None
None
None
None
2253
2200
Ann Kavanaugh-McHugh
None
None
None
None
None
None
2254
2201
Hyun-Sook Helen Ko
None
None
None
None
None
None
2255
2202
Seema Mital
None
None
None
None
None
None
2256
2203
Andrew J. Powell
None
None
None
None
None
None
2257
2258
2194
2195
2196
2204
J. Carter Ralphe
None
None
None
None
None
None
2205
Arno AW Roest
None
None
None
None
None
None
2206
2207
Jennifer Silva
None
None
None
None
None
None
Julia Steinberger
None
None
None
None
None
None
2208
(continued on the next page)
2209
2210
2248
2249
2250
2259
2260
2261
2262
2263
2264
2211
2265
2212
2266
2213
2267
2214
2268
PGL 5.2.0 DTD JAC20491_proof 12 September 2014 3:25 pm ce
22
Campbell et al.
JACC VOL.
-, NO. -, 2014
-, 2014:-–-
AUC for Pediatric Echocardiography
2269
APPENDIX B. CONTINUED
2323
2270
2271
2272
2273
Participant
Consultant
Speakers
Bureau
Ownership/
Partnership/
Principal
Personal Research
Institutional,
Organizational,
or Other Financial
Benefit
2324
2325
Expert
Witness
Appropriate Use Criteria Task Force
2274
2326
2327
2328
Steven R. Bailey
None
None
None
None
None
None
2276
Alan S. Brown
None
None
None
None
None
None
2277
John U. Doherty
None
None
None
None
None
None
2331
2278
Pamela S. Douglas
None
None
None
None
None
None
2332
2279
Robert C. Hendel
None
None
None
None
None
None
2333
2280
Christopher M. Kramer
None
None
None
None
None
2334
2282
Bruce D. Lindsay
None
None
None
None
None
None
2336
2283
Manesh R. Patel
None
None
None
None
None
None
2337
2284
Leslee J. Shaw
None
None
None
None
None
None
2338
2285
Raymond Stainback
None
None
None
None
None
None
2339
2286
L. Samuel Wann
None
None
None
None
None
None
2340
2287
Joseph M. Allen
None
None
None
None
None
None
2275
2281
2288
2289
2290
2291
2292
Siemens Medical
Solutions
2329
2330
2335
This table represents the relevant relationships with industry and other entities that were disclosed by participants at the time of participation. It does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% or more of the voting stock
or share of the business entity, or ownership of $10,000 or more of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5%
of the person’s gross income for the previous year. A relationship is considered to be modest if it is less than significant under the preceding definition. Relationships in this table are
modest unless otherwise noted. Names are listed in alphabetical order within each category of review. Participation does not imply endorsement of this document.
*Significant (greater than $10,000) relationship.
2341
2342
2343
2344
2345
2346
2293
2347
2294
2348
2295
2349
2296
2350
2297
2351
2298
2352
2299
2353
2300
2354
2301
2355
2302
2356
2303
2357
2304
2358
2305
2359
2306
2360
2307
2361
2308
2362
2309
2363
2310
2364
2311
2365
2312
2366
2313
2367
2314
2368
2315
2369
2316
2370
2317
2371
2318
2372
2319
2373
2320
2374
2321
2375
2322
2376
PGL 5.2.0 DTD JAC20491_proof 12 September 2014 3:25 pm ce