The ACC, in collaboration with eight partnering societies, released new appropriate use criteria (AUC)  aimed at helping clinicians determine the reasonable role of initial transthoracic echocardiography in the evaluation of pediatric patients in an outpatient setting. The AUC, published Sept. 29 in the Journal of the American College of Cardiology, are the first of their kind focusing on pediatric patients. Previous AUC were published in 2005 for echocardiography in adults.   

The new criteria govern 113 indications for outpatient pediatric echocardiography based on common clinical scenarios and/or clinical practice guidelines. Specifically, scenarios that were rated “Appropriate” included evaluation of new cardiac symptoms or clinical scenarios known to be associated with congenital or acquired heart disease in the pediatric population. Meanwhile, indications ranked as “Rarely Appropriate” clustered around broad systemic diseases and family history of conditions that are generally not known to be associated with structural or functional abnormalities detectable by echocardiography. In general, scenarios rated as “May Be Appropriate” involved uncertainty or required additional clinical information to better define the appropriateness of the test.

The new AUC also highlight three of the most common reasons for outpatient echocardiogram referrals in the pediatric population – chest pain, syncope and murmur – and included dedicated tables for each of these conditions with various clinical scenarios. Although a murmur is one of the most common indications for obtaining an echocardiogram in the pediatric population, it is well established that a large number of patients are referred with an innocent murmur that does not require evaluation with an echocardiogram. As such an echocardiographic screening for a presumably or clearly innocent murmur has been rated as “Rarely Appropriate.” Though rated “Appropriate” in the adult AUC, chest pain and syncope are also rated as “Rarely Appropriate” for pediatric patients, as the etiology for these are generally benign and echocardiography has been shown to have low-yield, unlike in adult patients.

“The purpose of the new criteria is to improve patient care and outcomes in a cost-effective manner,” said Robert Campbell, MD, FACC, chief of the Children’s Healthcare of Atlanta Sibley Heart Center, professor of pediatrics at Emory University School of Medicine, and chair of the writing committee. “This document will also help to improve quality within practices.” He adds that ultimately the document should help to reduce the rate of “Rarely Appropriate” echocardiograms in the pediatric patient population.

Keywords: Cooperative Behavior, Patient Care, Chest Pain, Pediatrics, Referral and Consultation, Heart Murmurs, Syncope, Echocardiography