Download Current Guidelines and Recommendations for Echocardiography in

Current Guidelines and Recommendations for Echocardiography in Non-­
Cardiology Settings. Carlee A. Clark, MD Assistant Professor of Anesthesia and Perioperative Medicine Medical Director, Ashley River Tower Operating Room Medical University of South Carolina Echocardiography is a tool used to obtain ultrasound images of the heart and it’s immediately surrounding vascular structures. Whether the setting is one of cardiology, the emergency room, the Post Anesthesia Care Unit or the Intensive Care Unit, echocardiography is commonly used to answer very similar questions regarding evolving patient status. The use of echocardiography outside the realm of cardiology has increased in the last decade as many physicians have come to recognize its value in diagnosis and treatment for the acutely or critically ill patient. Many different medical societies have developed training curriculums and courses, in addition to releasing or updating consensus statements and guidelines in the last five years regarding the use of echocardiography in general or specifically in the critically ill patient. Taken together, these statements and guidelines discuss the available literature and expert opinions and suggest how to safely apply this technology across multiple medical specialties. In order to get a complete understanding of the differing guidelines, we will discuss recommendations from The American Society of Echocardiography, The American College of Chest Physicians and The American Society of Emergency Physicians. The American Society of Echocardiography 2011 Appropriate use of Echocardiography1,2 The American Society of Echocardiography, in accordance with many subspecialty societies, updated their guidelines for use of echocardiography in 2011. These guidelines discuss different uses for echocardiography, assumptions about patient care, physician qualifications and facility services in utilizing echocardiography and then recommendations based on recent guidelines and evidence. These guidelines are detailed and inclusive, and applicable to the evaluation and treatment of all critically ill patients. Only the sections or recommendations applying to the non-­‐
cardiology settings will be discussed here. General guidelines for use of echocardiography 1. Initial diagnosis 2. Guide therapy or management, regardless of symptom status 3. Evaluate a change in clinical status or cardiac exam 4. Early follow-­‐up without change in clinical status 5. Late follow-­‐up without change in clinical status Assumptions regarding the use of echocardiography 1. Test is performed and interpreted by qualified individuals in a facility that is proficient in echocardiography. 2. Range of indications is broad and based clinical signs and symptoms and clinician best judgment. 3. Complete history and physical has been completed by a qualified physician prior to the use of echocardiography. 4. Cost should be considered in the appropriate use determination. 5. TEE is used as an adjunct or subsequent test to TTE when indicated, such as suboptimal TTE images. Recommendations for TTE for general evaluation of cardiac structure and function 1.
Symptoms or conditions potentially related to suspected cardiac etiology including but not limited to chest pain, shortness of breath, palpitations, TIA, CVA or peripheral embolic event. 2.
Prior testing that is concerning for heart disease or structural abnormality including but not limited to chest xray, ECG or cardiac biomarkers 3.
Frequent VPCs or exercise-­‐induced VPCs 4.
Clinical symptoms or signs consistent with a cardiac diagnosis known to cause lightheadedness/presyncope/syncope (including but not limited to AS, IHHS or HF) 5.
Syncope when there are no other symptoms or signs of cv disease 6.
Evaluation of suspected pulmonary hypertension including evaluation of RV function and estimated PAP 7.
Routine surveillance of known Pulm HTN > 1 yr 8.
Re-­‐evaluation of known Pulm HTN if change in clinical status or cardiac exam or to guide therapy Recommendations for TTE in acute setting 1. Hypotension or hemodynamic instability of uncertain or suspected cardiac etiology 2. Acute chest pain with suspected MI and nondiagnostic ECG when a resting echocardiogram can be performed during pain 3. Evaluation of a patient without chest pain but with other features of an ischemic equivalent or biomarkers indicative of ongoing MI 4. Suspected complication of MI, including MR, VSD, Free wall rupture/Tamponade, shock, RV failure, HF or thrombus 5. Initial evaluation of ventricular function following ACS 6. Re-­‐evaluation of ventricular function following ACS during recovery 7. Respiratory failure or hypoxemia of uncertain etiology 8. Known acute PE to guide therapy 9. Re-­‐evaluation of known pulmonary embolism after thrombolysis or thrombectomy for assessment of change in RV function and PAP 10. Severe deceleration injury or chest trauma when valve injury, pericardial effusion or cardiac injury are possible or suspected Recommendations for TTE evaluation of Valvular function 1. Initial evaluation when there is a reasonable suspicion of Valvular or structural heart disease 2. Re-­‐evaluation of known Valvular heart disease with a change in clinical status or cardiac exam or to guide therapy 3. Routine surveillance > 3 yrs of mild Valvular stenosis without a change in in clinical status or cardiac exam 4. Routine surveillance >1yr of mod or severe stenosis without a change 5. Initial postoperative evaluation of prosthetic valve for establishment of baseline 6. Initial evaluation for endocarditis with positive blood cultures or a new murmur 7. Re-­‐evaluation of infective endocarditis at high risk for progression or complication or with a change in clinical status or cardiac exam Recommendations for TTE for evaluation of intracardiac and extracardiac structures and chambers 1. Suspected cardiac mass 2. Suspected cardiovascular source of embolus 3. Suspected pericardial conditions 4. Re-­‐evaluation of known pericardial effusion to guide management or therapy Recommendations for TTE for evaluation of aortic disease 1.
Evaluation of the ascending aorta in the setting of a known or suspected connective tissue 2.
Re-­‐evaluation of known ascending aortic dilation or history of aortic dissection to establish a baseline rate of expansion 3.
Re-­‐evaluation of known ascending aortic dilation or history of aortic dissect ion with a change in clinical status or cardiac exam or when findings may alter management or therapy. Recommendations for TTE for evaluation of HTN/HF or cardiomyopathy 1. Initial evaluation of known or suspected HF based on symptoms, signs or abnormal test results 2. Re-­‐evaluation of known HR with a change in clinical status or cardiac exam without a clear precipitating change in medication or diet 3. Re-­‐evaluation of known HF to guide therapy 4. To determine candidacy for VAD 5. Optimization of VAD settings 6. Re-­‐evaluation for signs/symptoms suggestive of VAD related complications 7. Monitoring for rejection in a cardiac transplant recipient 8. Cardiac structure and function evaluation in a potential heart donor 9. Initial evaluation of known or suspected cardiomyopathy 10. Re-­‐evaluation of known cardiomyopathy with a change in clinical status or cardiac exam or to guide therapy Recommendations for TTE for adult congenital heart disease 1. Known adult congenital heart disease with a change in clinical status 2. Initial evaluation of known or suspected adult congenital heart disease 3. Re-­‐evaluation to guide therapy in known adult congenital heart disease ASE/ACEP consensus statement on Focused Cardiac ultrasound in the emergency setting3 This joint statement describes how the Focused Cardiac Ultrasound (FOCUS) is essential to patient care in the emergency room and complimentary to an extensive echocardiographic exam. The presentation of patients to the emergency and to the intensive care unit is often similar. Patients arrive hypotensive or in respiratory failure and in a short amount of time, diagnosis needs to be made to guide therapy. The FOCUS exam, therefore, is applicable to patients in all critical care settings, and not just the emergency department, and this exam is commonly performed by Trauma Surgeons, Emergency Physicians and Intensivists. Goals of the FOCUS exam 1. Assessment for the presence of pericardial effusion 2. Assessment of global cardiac systolic function 3. Identification of marked right ventricular and left ventricular enlargement 4. Intravascular volume assessment 5. Guidance of pericardiocentesis 6. Confirmation of Transvenous pacing wire placement Detailed Valvular abnormalities, specific regional wall motion abnormalities, aortic dissections, diastolic dysfunction and identification of endocarditis requires additional training and should prompt a consult for comprehensive echocardiography. Clinical Situations applicable for the FOCUS exam 1. Cardiac Trauma 2. Hypotension/Shock 3. Suspected Pulmonary Embolus 4. Cardiac Arrest 5. Dyspnea/Respiratory Failure 6. Chest Pain Critical Care Echocardiography4,5 Critical care echocardiography is performed and interpreted by the intensivists to allow for real time diagnosis and guiding of therapy in patients with or at risk for cardiopulmonary compromise. Competency is divided into basic and advance levels, and the basic level utilizes TTE to obtain basic images and answer straightforward clinical questions. Most intensivists are able to obtain basic skills through multiple educational venues, including their training programs and various courses held by specialty societies. Competence in Basic CCE: Required Cognitive Skills in Image Interpretation 1. Echocardiographic patterns 2. Global LV size and systolic function 3. Homogenous/heterogeneous LV contraction pattern 4. Global RV size and systolic function 5. Assessment for pericardial fluid/Tamponade 6. IVC size and respiratory variation 7. Basic color Doppler assessment for severe valvular regurgitation Competence in Basic CCE: Required Cognitive Skills in Recognition of Clinical Syndromes 1. Severe hypovolemia -­‐ Left Ventricle and IVC assessment 2. LV function – Global systolic function, myocardial suggestions of MI 3. RV function – Acute RV failure, Septal motion analysis, RV dilation, IVC assessment 4. Tamponade – Pericardial effusion, RA/RV collapse, IVC assessment 5. Acute massive Left-­‐sided Valvular regurgitation – LV function and cavity size, Doppler assessment 6. Circulatory arrest – Tamponade, RV failure, LV function, Contractility pattern after resuscitation References 1. Douglas PS, Garcia MJ, Haines DE, Lai WW, Manning WJ, Patel AR, Picard MH, Polk DM, Ragosta M, Parker Ward R, Weiner RB. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance American College of Chest Physicians. J Am Soc Echocardiogr 2011;24:229-­‐
67. 2. Douglas PS, Garcia MJ, Haines DE, Lai WW, Manning WJ, Patel AR, Picard MH, Polk DM, Ragosta M, Ward RP, Weiner RB. 3. 4. 5. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance Endorsed by the American College of Chest Physicians. J Am Coll Cardiol 2011;57:1126-­‐66. Labovitz AJ, Noble VE, Bierig M, Goldstein SA, Jones R, Kort S, Porter TR, Spencer KT, Tayal VS, Wei K. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr 2010;23:1225-­‐30. Mayo PH. Training in critical care echocardiography. Ann Intensive Care 2011;1:36. Mayo PH, Beaulieu Y, Doelken P, Feller-­‐Kopman D, Harrod C, Kaplan A, Oropello J, Vieillard-­‐Baron A, Axler O, Lichtenstein D, Maury E, Slama M, Vignon P. American College of Chest Physicians/La Societe de Reanimation de Langue Francaise statement on competence in critical care ultrasonography. Chest 2009;135:1050-­‐60.