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Table 1 Appropriateness, timing and triage of the most common outpatient TTE referrals

From: Clinical indications and triaging for adult transthoracic echocardiography: a consensus statement by the British Society of Echocardiography in collaboration with British Heart Valve Society

1. Heart murmur [6]
Not indicated:
• Assessment of an innocent murmur*diagnosed by a physician
• Unchanged murmur in an asymptomatic individual with previous normal echocardiogram
Indicated:
• Murmur in the presence of cardiac or respiratory symptoms
• Murmur in an asymptomatic individual in whom clinical features or other investigation suggest structural heart disease
Urgent:
• Murmur in the presence of class 3 or 4 heart failure symptoms or syncope
*An innocent murmur has previously been defined as: A systolic murmur of short duration, grade 1 or 2 intensity at the left sternal border, a systolic ejection pattern, a normal S2, no other abnormal sounds or murmurs, no evidence of ventricular hypertrophy or dilation, no thrills, and the absence of an increase in intensity with the Valsalva manoeuvre. Such murmurs are especially common in high-output states such as pregnancy [7, 8]
2. Suspected heart failure
Not indicated:
• Radiographic cardiomegaly with no symptoms or signs of heart failure and in the absence of other clinical information
• Assessment of patients with peripheral oedema but normal jugular venous pressure and no evidence of cardiac disease (e.g., asymptomatic with a normal 12 lead ECG)
• Patients in AF with an uncontrolled ventricular rate (unless class 3 or 4 heart failure symptoms)
Indicated:
• Clinical signs of heart failure (e.g., peripheral oedema, bilateral pleural effusions)
• Unexplained shortness of breath in the absence of clinical signs of heart failure if ECG/CXR abnormal
• Persistent hypotension of unknown cause
• Suspected cardiomyopathy based on abnormal examination, ECG, or family history in first degree relative
• Assessment of neuromuscular diseases associated with cardiac manifestations, (e.g., muscular dystrophies, Friedreich's ataxia or mitochondrial myopathies)
Urgent:
• Class 3 or 4 heart failure symptoms
• Raised NT-pro BNP* or previous history of myocardial infarction
• Clinical suspicion of pericardial effusion
NT-proBNP > 2000 ng/litre requires TTE within 2 weeks. NTproBNP between 400 and 2000 ng/litre requires TTE within 6 week [9]
3. Hypertension and suspected left ventricular hypertrophy
Not indicated:
• Routine assessment of any patient with essential hypertension
• Routine assessment of asymptomatic patients with an established genetic or infiltrative cause of LVH where there is no change in clinical status and where an echo has been performed within the last 12 months
• Repeat assessment of LV function in asymptomatic patients
• Repeat assessment for left ventricular mass regression (if clinical concern is present regarding hypertrophic cardiomyopathy then repeat assessment with cMRI is preferable)
Indicated:
• Suspected LV dysfunction
• Evaluation of clinically suspected aortic co-arctation (e.g., hypertension in the young)
• Elevated blood pressure with concerns for end organ damage
• Patients with a suspected or established genetic or infiltrative cause of LVH (with support from appropriate specialist teams where relevant)
Urgent:
• Accelerated hypertension with breathlessness or other clinical concerns of acute LV dysfunction
4. Suspected cardiac mass/possible cardiac cause of systemic-circulation embolism
Not indicated:
• Patients with terminal illness whose management would not be affected by identification of any TTE abnormalities
• Patients in whom TTE will not affect the decision to commence anticoagulation (e.g., patients in AF with cerebrovascular event and no suspicion of structural heart disease)
Indicated:
• Embolic peripheral or neurological events suggesting intracardiac mass:
    ◦ Acute interruption of blood flow to major peripheral or visceral artery
    ◦ Unexplained stroke or TIA without evidence of prior cerebrovascular disease or without significant risk factors for other cause (consider saline-contrast echocardiography by TTE or TOE, this may only be appropriate in < 55 year old patients)
• Cross-sectional imaging or clinical findings suggesting intra-cardiac mass (if possible left atrial appendage thrombus then TOE preferable)
• Periodic repeat assessment following removal of cardiac mass/tumour (usually annual review will suffice after an initial post-op scan)
• Known primary malignancies where echocardiographic surveillance for cardiac involvement forms part of the normal staging process (e.g., renal cell carcinoma)
Urgent:
• Embolic event in the presence of clinical or ECG suspicion of significant left ventricular impairment (e.g., anterior Q waves on 12 lead ECG or clinical examination findings suggestive of LV dysfunction)
5. Pulmonary disease
Not indicated:
• Repeat assessment to evaluate the probability of PHT in the absence of a meaningful tricuspid regurgitation jet or other echo markers of PHT on echo within the last 12 months. If there is clinical concern regarding PHT then advice from a pulmonary hypertension specialist service is recommended
• Lung disease with no clinical suspicion of cardiac involvement or PHT
Indicated:
• Lung disease combined with a clinical suspicion of RV failure (e.g., peripheral oedema, raised jugular venous pressure)
• Following pulmonary embolism when clinical concern for right ventricular impairment and/or presence of developing PHT
• Evaluation for suspected or established PHT
• Evaluation of response to treatment of PHT and PE
• To distinguish cardiac from non-cardiac causes of dyspnoea when the results of clinical and other diagnostic testing are ambiguous
• Patients with unexplained persistent or positional oxygen desaturation (consider bubble-contrast echocardiography to evaluate for a right to left shunt)
Urgent:
• Not applicable
6. Prior to cardioversion in patients with atrial fibrillation
Not indicated:
• Patients requiring emergency cardioversion
• Patients on long-term anti-coagulation at a therapeutic level with no clinical suspicion of structural heart disease
• Patients on long-term anti-coagulation at a therapeutic level with structural heart disease but no recent clinical change
Indicated:
• To guide decision-making regarding DC cardioversion in a patient with no recent echo study (i.e. within the last 12 months) or in a patient with a recent echo study and a change in clinical cardiovascular status since it was performed
• Patients requiring cardioversion with AF of greater than 48 h duration and not adequately anticoagulated (TOE required)
• Repeat assessment of documented left atrial appendage thrombus (TOE required)
Repeat assessment following an embolic event at previous cardioversion (TOE required)
• Patients with AF of less than 48 h duration together with a clinical suspicion of structural heart disease and not adequately anticoagulated (TOE required)
Urgent:
• Not applicable
7. Palpitations and pre-syncope/syncope
Not indicated:
• Palpitations without ECG proof of arrhythmia or clinical suspicion of structural heart disease on examination
• Low-burden (< 5%) or isolated ventricular ectopy in absence of a clinical suspicion of structural heart disease
• Classic neuro-cardiogenic syncope
Indicated:
• Clinical suspicion of structural heart disease in proven arrhythmia (e.g., AF or ventricular ectopy at greater than 10% frequency or ventricular ectopy occurring on exertion)
• Routine assessment of ventricular function to assist with the calculation of risk of sudden cardiac death post-myocardial infarction or following documented ventricular tachycardia
• Evaluation of cardiac structure and function to assist with future management (e.g., commencement of anti-arrhythmic medications)
• Syncope in a patient with high-risk occupation (e.g., pilot, bus driver)
• Assessment of patients without clinical suspicion of structural heart disease who have an arrhythmia commonly associated with structural heart disease (e.g., ventricular tachycardia)
Urgent:
• Syncope in a patient with clinically suspected structural of functional heart disease
• Exertional syncope
8. Suspected pericardial disease
Not indicated:
• Repeat assessment of small pericardial effusion (< 1 cm) with no hemodynamic compromise and without a change in clinical status
• Follow-up studies in patients with terminal illness whose management would not be affected by echocardiographic abnormalities
Indicated:
• Clinically suspected pericarditis, pericardial effusion, or pericardial constriction
• Periodic repeat assessment of moderate or large pericardial effusion
• Repeat assessment of small pericardial effusion with change in clinical status
Urgent:
• Clinical suspicion of cardiac tamponade (especially if predisposing factors are present, e.g., known malignancy, suspected myo-pericarditis and recent cardiac surgery)
9. Established cardiomyopathy
Not indicated:
• Patients with terminal illness whose management would not be affected by identification of any change in TTE appearance
• Routine repeat assessment in clinically stable patients in whom no change in management is contemplated
Indicated:
• Repeat assessment in documented cardiomyopathy where the result may change management or following procedures that may improve ventricular function (e.g., cardioversion or coronary revascularisation)
• Repeat assessment in documented cardiomyopathy where there has been a change in clinical status
Urgent:
• New onset class 3 or 4 heart failure symptoms
10. Aortopathy
Not indicated:
• Patients with terminal illness whose management would not be affected by identification of any change in TTE appearance
Indicated:
• Assessment of suspected or proven genetic disorders in which aortic pathology may be a feature, (e.g., Marfan Syndrome)
• Diagnosis and periodic assessment of aortic aneurysm, dilatation of the aorta and previous surgical repair of the aorta (an annual default interval between scans, but this timeline may be superseded following multi-disciplinary team review). Due to the limited ability of TTE to visualise the thoracic aorta the appropriate concomitant use of cross-sectional imaging is recommended
Urgent:
• Clinical suspicion of an acute aortic event (should not replace or delay cross-sectional imaging if more clinically appropriate)
11. Elective non-cardiac surgery
Not indicated:
• Routine pre-operative assessment
• Repeat assessment of previous echocardiogram in last 12 months with no intervening change in clinical status
Indicated:
• Murmur in an asymptomatic individual in whom clinical features suggest severe structural heart disease
• Documented ischemic heart disease with reduced functional capacity (< 4 METs)
• Murmur in the presence of cardiac or respiratory symptoms
Urgent:
• Not applicable
  1. AF (Atrial fibrillation), ECG (electro-cardiogram), NT-pro BNP (N-terminal pro hormone brain natriuretic peptide), CXR (chest x-ray), LV (left ventricular) TOE (trans-oesophageal echocardiogram), TTE (trans-thoracic echocardiogram), PHT (pulmonary hypertension), DC (direct current)