Evaluation of Appropriate Use of Transthoracic Echocardiography in 1,820 Consecutive Patients Using the 2011 Revised Appropriate Use Criteria for Echocardiography

Study Questions:

What are the rates of appropriate and inappropriate utilization of transthoracic echocardiography (TTE) in a series of consecutive patients, and what is the ability of the 2011 revised Appropriate Use Criteria (AUC) to fully classify a broad range of clinical presentations?


Indications for performing TTE were analyzed in 1,825 consecutive patients over an approximate 6-week period at a single center. Indications were then assigned to 1 of 98 indications outlined in the 2011 AUC for TTE. Both inpatient and outpatient TTEs were analyzed, and all patients were ≥18 years of age.


Insufficient documentation for determining an indication was noted in five subjects, leaving 1,820 subjects in the study group, 850 of whom were inpatients and 970 outpatients. For the total group, inpatient and outpatient groups, appropriate studies were noted in 82%, 88.7%, and 76.2%, respectively (p > 0.0001). Inappropriate studies were noted in 12.3%, 9.5%, and 14.6%, respectively (p > 0.0009), and an uncertain indication in 5.3%, 1.5%, and 8.6%, respectively (p > 0.0001). Only eight patients (0.4%) were unclassifiable by the 2011 AUC. AUC indication #1: "symptoms or conditions potentially related to suspected cardiac etiology…," was the single most common appropriate indication, occurring in 500 (27.5%) of requested studies. Other commonly listed indications included #5: “sustained or nonsustained atrial fibrillation, SVT, or VT,” representing 7.6% of the study population; #2: “prior testing that is concerning for heart disease or structural abnormality,” representing 6.3; and #58: “suspected cardiovascular source of embolus,” representing 6.25% of studies. The most common inappropriate indication was #74: “routine surveillance (<1 year) of heart failure with no change in clinical status or cardiac examination,” which occurred in 46 subjects (2.5%).


The 2011 AUC document adequately describes the vast majority of indications for TTE, and (in this single-center study), the majority of TTEs are ordered for appropriate indications.


This is one of the first studies outlining a comparison of the newly published 2011 AUC to actual clinical practice in a large volume of patients. Within the context of the methodology, it appears that at this single center, the overwhelming majority of echocardiograms are ordered for an appropriate indication. The fact that the single most commonly utilized indication is a fairly broad description of suspicion of cardiovascular disease is a bit concerning in that it may represent alteration of ordering patterns away from known inappropriate or questionable indications into a fairly ill-defined category of ‘symptoms or conditions potentially related to suspected cardiac etiology, including but not limited to chest pain, shortness of breath, palpitations, TIA, stroke, or peripheral embolic event.’

Previous studies have demonstrated that one of the more common inappropriate indications encountered is surveillance for chronic conditions, congestive heart failure, or valvular disease <1 year out from a previous study in the absence of change in clinical symptoms or physical exam findings. This study demonstrated that that indication represents the largest, although a small absolute number, of inappropriately ordered studies. There have been multiple previous evaluations of how the previous AUC match up with actual ordering patterns in single centers. These studies illustrated a significant flaw in the earlier AUC in that the number of unclassifiable examinations ranged from 7% to 35%. The newest iteration of the AUC was specifically designed to eliminate many of the unclassifiable indications, and based on this study from a large center with a broad range of clinical indications and pathology investigated, suggests that the majority of unclassifiable indications have been addressed, as only 0.4% of studies were for unclassifiable indications.

It should be emphasized that comparison of indications to AUC criteria will vary tremendously from institution to institution based on a variety of factors including the sophistication of the medical records, allowing for a precise indication to be actually identified on a requisition, as well as the sophistication of the requesting physicians. In an era of concern regarding cost containment, studies such as this provide a valuable window into actual practice patterns, and again within the limitations of a single-center study, provide what may be valuable targets for compliance with AUC.

Clinical Topics: Heart Failure and Cardiomyopathies, Noninvasive Imaging, Acute Heart Failure, Echocardiography/Ultrasound

Keywords: Heart Diseases, Stroke, Chest Pain, Heart Failure, Cost Control, Embolism, Dyspnea, Patient Compliance, Echocardiography, Transesophageal

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