Booking an Echo – A Physician’s Quick Reference Guide

Appropriate Use Criteria – Summarized

Abbreviations:             A = Appropriate       M = May Be Appropriate          R = Rarely Appropriate

If you are a physician booking an echocardiogram for the following ASE and Choosing Wisely Canada guidelines apply

• PALPITATIONS AND ARRYTHMIAS 1 – 8

• ECG FINDINGS 9 – 27

• CHEST PAIN 28 – 38

• MURMUR 39 – 41

• OTHER SIGNS AND SYMPTOMS 42 – 48

• PRIOR TEST RESULTS 49 – 61

• SYSTEMIC DISORDERS 62 -87

• FAMILY HISTORY OF CARDIOVASCULAR DISEASE 88 -104

• OUTPATIENT NEONATES WITHOUT POST-NATAL CARDIOLOGY EVALUATION 105 -112

PALPITATIONS AND ARRYTHMIAS the following ASE and Choosing Wisely Canada guidelines apply:

1. Palpitations with family history of cardiomyopathy A
2. 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
3. Palpitations in a patient with known cardiomyopathy A
4. Palpitations with abnormal ECG M
5. Palpitations in a patient with known channelopathy M
6. Palpitations with no other symptoms or signs of cardiovascular disease, a benign family history, and no recent ECG R
7. Palpitations with no other symptoms or signs of cardiovascular disease, a benign family history, and a normal ECG R

ECG FINDINGS; the following ASE and Choosing Wisely Canada guidelines apply:

Abbreviations:             A = Appropriate       M = May Be Appropriate          R = Rarely Appropriate

9. Supraventricular tachycardia A
10. Ventricular tachycardia A
11. Syncope with abnormal ECG A

12. 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
13. Syncope with family history of cardiomyopathy A
14. Unexplained post-exertional syncope A
15. Exertional syncope A
16. PVCs after the neonatal period M
17. PVCs in the prenatal or neonatal period M
18. Syncope with family history of channelopathy M
19. Unexplained pre-syncope M
20. PACs in the prenatal or neonatal period R
21. PACs after the neonatal period R
22. Sinus bradycardia R
23. Sinus arrhythmia R
24. Syncope with or without palpitations and with no recent ECG R
25. Syncope with no other symptoms or signs of cardiovascular disease, a benign family history, and a normal ECG R
26. Probable neurocardiogenic (vasovagal) syncope R
27. Syncope or pre-syncope with a known non-cardiovascular cause R

CHEST PAIN; the following ASE and Choosing Wisely Canada guidelines apply:

28. Exertional chest pain A
29. Non-exertional chest pain with abnormal ECG A
30. Chest pain with family history of sudden unexplained death or cardiomyopathy A
31. Chest pain with other symptoms or signs of cardiovascular disease, a benign family history, and a normal ECG M

32. Chest pain with family history of premature coronary artery disease M
33. Chest pain with recent onset of fever M
34. Chest pain with recent illicit drug use M
35. Chest pain with no other symptoms or signs of cardiovascular disease, a benign family history, and a normal ECG R
36. Non-exertional chest pain with no recent ECG R
37. Non-exertional chest pain with normal ECG R
38. Reproducible chest pain with palpation or deep inspiration R

Abbreviations:             A = Appropriate       M = May Be Appropriate          R = Rarely Appropriate

MURMUR the following ASE and Choosing Wisely Canada guidelines apply:

39. Pathologic murmur A
40. Presumptively innocent murmur with signs, symptoms, or findings of cardiovascular disease A
41. Presumptively innocent murmur with no symptoms, signs, or findings of cardiovascular disease and a benign family history R

OTHER SIGNS AND SYMPTOMS; the following ASE and Choosing Wisely Canada guidelines apply:

42. Central cyanosis A
43. Signs and symptoms of endocarditis in the absence of blood culture data or a negative blood culture A
44. 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
45. Chest wall deformities and scoliosis pre-operatively M
46. Unexplained fever without other evidence for cardiovascular or systemic involvement M
47. Fatigue with no other signs and symptoms of cardiovascular disease, a normal ECG, and a benign family history R
48. Isolated acrocyanosis R

PRIOR TEST RESULTS; the following ASE and Choosing Wisely Canada guidelines apply:

49. Abnormal chest X-ray findings suggestive of cardiovascular disease A
50. Genotype positive for cardiomyopathy A
51. Desaturation based on pulse oximetry A
52. Abnormal ECG without symptoms A
53. Previously normal echocardiogram with a change in cardiovascular status and/or a new family history suggestive of heritable heart disease A
54. Chromosomal abnormality known to be associated with cardiovascular disease A
55. Positive blood cultures suggestive of infective endocarditis A
56. Abnormal barium swallow or bronchoscopy suggesting vascular ring A
57. Abnormal cardiac biomarkers A
58. Chromosomal abnormality with undefined risk for cardiovascular disease M
59. Known channelopathy M
60. Previously normal echocardiogram with no change in cardiovascular status or family history R
61. Elevated anti-streptolysin O titers without suspicion for rheumatic fever R

Abbreviations:             A = Appropriate       M = May Be Appropriate          R = Rarely Appropriate

SYSTEMIC DISORDERS; the following ASE and Choosing Wisely Canada guidelines apply:

62. Prior to or during chemotherapy in cancer A
63. Sickle cell disease and other hemoglobinopathies A
64. Connective tissue disorder such as Marfan, Loeys Dietz, and other aortopathy syndromes A
65. Suspected connective tissue disorder A
66. Clinically suspected syndrome or extracardiac congenital anomaly known to be associated with congenital heart disease A
67. Human immunodeficiency virus infection A 67
68. Suspected or confirmed acute rheumatic fever A
69. Stroke A
70. Systemic lupus erythematosis and autoimmune disorders A
71. Muscular dystrophy A
72. Suspected pulmonary hypertension A
73. Storage diseases, mitochondrial and metabolic disorders A
74. Abnormalities of visceral or cardiac situs A
75. Systemic hypertension A
76. Renal failure A
77. Cancer without chemotherapy M
78. Obesity with obstructive sleep apnea M
79. Obesity with other cardiovascular risk factors M
80. Hepatic disorders M
81. Failure to thrive M
82. Unexplained sudden death before the age of 50 years M
83. Obesity without other cardiovascular risk factors R
84. Diabetes mellitus R
85. Lipid disorders R
86. Seizures, other neurologic disorders, or psychiatric disorders R
87. Gastrointestinal disorders, not otherwise specified R

Abbreviations:             A = Appropriate       M = May Be Appropriate          R = Rarely Appropriate 

FAMILY HISTORY OF CARDIOVASCULAR DISEASE IN PATIENTS WITHOUT SIGNS OR SYMPTOMS AND WITHOUT CONRIMED CARDIAC DIAGNOSIS; the following ASE and Choosing Wisely Canada guidelines apply:

88. Hypertrophic cardiomyopathy A
89. Non-ischemic dilated cardiomyopathy A
90. Other cardiomyopathies A
91. Genetic disorder at high risk for cardiovascular involvement A
92. Marfan or Loeys Dietz syndrome A
93. Heritable pulmonary arterial hypertension A
94. Connective tissue disorder other than Marfan or Loeys Dietz syndrome M
95. 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
96. Congenital heart disease other than the congenital left-sided heart lesions M
97. Idiopathic pulmonary arterial hypertension M
98. Unexplained sudden death before the age of 50 years M
99. Premature coronary artery disease before the age of 50 years R
100. Channelopathy R
101. Unspecified cardiovascular disease R
102. Disease at high risk for cardiovascular involvement, including but not limited to diabetes, systemic hypertension, obesity, stroke, and peripheral vascular disease R
103. Pulmonary arterial hypertension other than idiopathic and heritable R
104. Consanguinity R

OUTPATIENT NEONATES WITHOUT POST-NATAL CARDIOLOGY EVALUATION; the following ASE and Choosing Wisely Canada guidelines apply:

105. Maternal phenylketonuria A
106. Maternal infection during pregnancy or delivery with potential fetal/neonatal cardiac sequelae A
107. Suspected cardiovascular abnormality on fetal echocardiogram A
108. Maternal diabetes with no prior fetal echocardiogram M
109. Maternal autoimmune disorder M
110. Maternal diabetes with a normal fetal echocardiogram M
111. Maternal teratogen exposure M
112. Isolated echogenic focus on fetal ultrasound R