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Quinones
ET AL., ACC/AHA CLINICAL COMPETENCE STATEMENT ON ECHOCARDIOGRAPHY
J Am Coll Cardiol 2003;41:687-708
ACC/AHA
Clinical Competence Statement on Echocardiography
A
Report of the American College of Cardiology/American Heart
Association/American College of Physicians–American Society
of Internal Medicine Task Force on Clinical Competence
Developed
in Collaboration with the American Society of Echocardiography,
the Society of Cardiovascular Anesthesiologists, and the Society
of Pediatric Echocardiography
II. General Principles
Regardless of the echocardiographic modality utilized, there
is a body of knowledge required by any physician involved
in performance and/or interpretation of echocardiograms that
includes: ultrasound physics and use of instrumentation, anatomy,
physiology, and pathology of the heart and great vessels (Table
2).
Basic
Knowledge of Ultrasound Physics. Echocardiographic imaging
and Doppler systems generate ultrasound signals that follow
the laws of physics. Appropriate utilization of these instruments
and interpretation of the data generated require an understanding
of the fundamental principles of ultrasound physics and how
they relate to the images produced and the spectral and color
Doppler information. This understanding is considered to be
an important requirement for clinical competence in all modalities
of echocardiography.
Technical
Aspects of the Examination. An essential component of
the diagnostic accuracy of echocardiography is the skill and
experience of the individual responsible for image and data
acquisition. Technical skills related to echocardiographic
data acquisition may be divided into two important skill sets:
transducer manipulation and ultrasound system adjustments.
Perhaps the most difficult and underestimated skill set to
master is transducer manipulation, which is critical to obtaining
optimal image quality in standard tomographic imaging planes,
and optimal Doppler flow velocity signals. This is true regardless
of the type of transducer utilized (i.e., transthoracic, transesophageal,
or intravascular). The second set of technical skills includes
appropriate knowledge of ultrasound instrument settings such
as transducer frequency, use of harmonics, mechanical index,
depth, gain, time-gain-compensation, dynamic range, filtering,
velocity scale manipulations, and display of received signals.
Anatomy
and Physiology. Echocardiography is a powerful diagnostic
tool that provides immediate access for the evaluation of
cardiac and vascular structures and assessment of heart function.
Intrinsic to a competent echocardiographic examination is
a thorough understanding of the anatomy and physiology of
the heart and great vessels. Two-dimensional imaging can accurately
quantify cardiac chamber sizes, wall thickness, ventricular
function, valvular anatomy, and great vessel size. Pulsed,
continuous-wave, and color-flow Doppler echocardiography,
especially when combined with two-dimensional imaging, can
be used to quantify blood flow velocities and calculate blood
flow; assess intracardiac pressures and hemodynamics; and
detect and quantify stenosis, regurgitation, and other abnormal
flow states. Documentation of normal and abnormal cardiac
anatomy and physiology must be accomplished by the individual
performing the examination.
Recognition
of Simple and Complex Pathology. The ability to recognize
both simple and complex pathology of the heart and great vessels
is required for competence in echocardiography. A fundamental
knowledge of cardiac pathology is required during data acquisition
to tailor the examination appropriately and maximize demonstration
of the abnormalities present. This includes the ability to
modify standard imaging planes and optimize the Doppler beam
angle of incidence to achieve this goal. In addition, an extensive
knowledge of pathology and pathophysiology is required to
interpret recorded echocardiographic data.
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