Pediatric Echocardiography Appropriate Use Criteria

Study Questions:

What is the appropriateness of transthoracic echocardiography (TTE) as currently performed in pediatric cardiology clinics, and what is the diagnostic yield of TTE for various appropriate use criteria (AUC) indications?


Prospective data collection from patients undergoing initial outpatient TTE was performed at six academic centers. TTE indications were categorized according to the appropriateness criteria as Appropriate [A], May Be Appropriate [M], or Rarely Appropriate [R], and by findings (normal, incidental finding, or abnormal).


Of the 2,655 studies reviewed, 71% were performed for “A” indications, 12% for “M” indications, and 12% for “R” indications; 5% were unclassifiable. Innocent murmur and syncope or palpitations with no other indications of cardiovascular disease, a benign family history, and normal electrocardiogram accounted for the vast majority (75%) of “R” indications. Pathologic murmur had the highest yield of abnormal findings at 40%. The yield for presumptively innocent murmur was 3% (5/172) and presumptively innocent murmur with signs, symptoms, or findings of cardiovascular disease was 8% (13/160). The yield for exertional syncope was 0% (0/51) and exertional chest pain was 1% (2/355). Abnormal findings were more common in patients <1 year of age versus those >10 years of age (odds ratio, 6.4; 95% confidence interval, 4.7-8.7). Age significantly predicted an abnormal finding after adjusting for indication and site (p < 0.001).


The authors concluded that most TTEs ordered in pediatric cardiology clinics were for indications rated “A.” The study identified differences in the yield of TEE based on patient age, and the most common indications rated “R.”


While developed to provide quality and efficient care, appropriateness criteria are increasingly used by payers to determine reimbursement. It is important for practitioners to be both aware of the content of the guidelines as well as their validity. This study assessed echocardiograms at six academic pediatric cardiology centers, in the context of the recent AUC for pediatric echocardiography. It is interesting to note the low yield of echocardiography for common appropriate lesions such as exertional chest pain and syncope (1% and 0%, respectively). The highest yield of echocardiography occurs with pathologic murmurs, although this is dependent upon the skill of the examiner to appropriately diagnose the murmur as categorized by the guidelines (pathologic, presumptively innocent, and presumptively innocent with signs, symptoms, or findings of cardiovascular disease).

Clinical Topics: Noninvasive Imaging, Echocardiography/Ultrasound

Keywords: Chest Pain, Diagnostic Imaging, Echocardiography, Electrocardiography, Heart Murmurs, Incidental Findings, Pediatrics, Quality of Health Care, Syncope

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