Appropriateness Criteria for Performance of Cardiac Ultrasound

Contact: Amy Murphy,, 202-375-6476

SEATTLE, WA – JUNE 15, 2007- In an effort to ensure quality cardiac ultrasound imaging for all patients and to avoid unnecessary use of the technology, the American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE) in partnership with the American College of Emergency Physicians, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and the Society for Cardiovascular Magnetic Resonance today released Appropriateness Criteria for two of the most commonly used cardiac ultrasound techniques – transthoracic (TTE) and transesophageal (TEE) echocardiography – just in time for the 18th Annual Scientific Sessions of ASE in Seattle, Washington.

The TTE/TEE Appropriateness Criteria review common scenarios found in clinical practice and address the appropriateness of ordering echocardiograms for each situation. The Criteria address a broad range of clinical situations in which TTE/TEE might be used, such as for patients presenting with signs and symptoms that could represent heart disease, like murmurs and palpitations, and conditions such as hypertension, stroke, heart valve disease, and suspected or known congenital heart disease.

Echocardiography has long been recognized in the broader medical community as a valuable diagnostic test for the evaluation of cardiac structure and function. As both TTE and TEE are relatively easy on the patient, low risk (no radiation is involved), and provide comprehensive diagnostic information, the opportunity exists for inappropriate use in patients who may not benefit from having the exam. Fourteen scenarios addressed in the Criteria were found to be inappropriate reasons for the performance of the TTE/TEE study.

The Appropriateness Criteria for TTE/TEE should help guide physicians in determining when and how often to use the tests. In general, use of TTE/TEE for the initial evaluation of structure and function was viewed favorably, while routine repeat testing and general screening uses in certain clinical scenarios were viewed less favorably.

The new criteria will increase physicians’ confidence that they are ordering an echocardiogram for the appropriate reasons, and help to educate them about when the test may not be necessary.

Inappropriate use of TTE and TEE can be costly, leading to a decline in the overall quality of care by subjecting patients to unnecessary initial and follow-up testing, and can limit resources for those patients who do need testing.

“For the very first time, we are formally addressing the appropriate use of one of the earliest and most commonly used imaging technologies. Although the concept of proper use of technology is not new, providing physicians with the tools to assess our own practice patterns is a critically important and new undertaking. It gives real meaning to our efforts to promote quality in cardiovascular care,” said Pamela S. Douglas, M.D., M.A.C.C., F.A.S.E., who is the chair of the TTE/TEE Appropriateness Criteria Writing Group and a past president of both the ACC and ASE.

“I am very excited by the introduction of these appropriateness criteria. This is an excellent supporting document as we continue the ASE’s goal to ensure that every echocardiogram performed is a quality echocardiogram and one that is necessary for the clinical care of the patient. The scenarios discussed in the document are commonly encountered and will serve as an excellent reference for physicians when they are deciding whether or not to order an echo,” said Michael Picard, M.D., F.A.C.C., F.A.S.E., president of the American Society of Echocardiography.

Appropriateness criteria standards reflect an ongoing effort by the American College of Cardiology to critically and systematically create, review and categorize clinical situations where diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on current understanding of the technical capabilities of the imaging modalities examined and their clinical impact. Although not intended to be fully comprehensive, the indications are meant to identify common scenarios encompassing the majority of contemporary practice. To date, criteria exist for SPECT MPI, CCT and CMR, and now TEE and TTE. For more information, visit

As data have shown that the majority of echocardiograms are ordered by non-cardiologists, ASE is developing initiatives to widely disseminate the Criteria beyond its membership to all medical professionals who are responsible for ordering echocardiograms. The medical community and patients are encouraged to review the criteria and discuss the incremental value each test will contribute to their care. By taking shared responsibility, the medical profession and patients can direct the resources spent on health care toward the most effective, patient-centered, and high value services and avoid forcing other stakeholders to make arbitrary decisions in an effort to control costs.

The TTE/TEE Appropriateness Criteria can be found online at or and will be published in print in the July 2007 issue of The Journal of the American Society of Echocardiography and the July 10, 2007 issue of The Journal of the American College of Cardiology.


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The American College of Cardiology is leading the way to optimal cardiovascular care and disease prevention. The College is a 34,000-member nonprofit medical society and bestows the credential Fellow of the American College of Cardiology upon physicians who meet its stringent qualifications. The College is a leader in the formulation of health policy, standards and guidelines, and is a staunch supporter of cardiovascular research. The ACC provides professional education and operates national registries for the measurement and improvement of quality care. The American Society of Echocardiography is a nonprofit organization made up of over 11,000 professionals committed to excellence in Cardiovascular Ultrasound. ASE acknowledges and promotes the importance of maintaining the highest standards in all activities related to the performance of cardiovascular ultrasound and the provision of patient care. ASE has demonstrated this commitment through the implementation of quality initiatives including funding the development of the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL) and the National Board of Echocardiography (NBE). In addition, ASE regularly publishes and distributes Guidelines and Standards regarding the performance and interpretation of Cardiovascular Ultrasound. These guidelines can be found online at ASE’s patient information site is

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