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Table 2 Appropriateness, timing and triage of the most common inpatient 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. Chest pain
Not indicated: Indicated: Urgent: Emergency:
• Evaluation of cardiac chest pain with a normal ECG, no murmur and negative cardiac biomarkers • Following confirmed acute myocardial infarction to assess for infarct size and complications • Murmur following a recent acute myocardial infarction • Chest pain with haemodynamic instability
• Assessment of suspected type I aortic dissection often in conjunction with cross-sectional imaging
2. Suspected heart failure
Not indicated: Indicated: Urgent: Emergency:
• Not applicable • Not applicable • Patients admitted for suspected heart failure commenced on inpatient treatment • Cardiogenic shock as judged by an appropriately senior clinician
• Return of circulation following cardiac arrest
3. Syncope
Not indicated: Indicated: Urgent: Emergency:
• No murmur detected or documented malignant arrhythmias. Vaso-vagal or situational syncope • Not applicable • Murmur detected clinically
• Arrhythmia-associated syncope
• Significantly abnormal ECG e.g., LBBB, RBB or LVH
• Not applicable
4. Arrhythmias
Not indicated: Indicated: Urgent: Emergency:
• Fast AF without hypotension or suspicion of structural heart disease
• Symptomatic ectopics (defer to outpatient following Holter monitoring)
• Not applicable • Arrythmia and hypotension
• Ventricular tachycardia or ventricular fibrillation
• Clinical suspicion of infective endocarditis with evidence of acute cardiac failure, valve decompensation, or abscess
• Not applicable
5. Suspected or established pulmonary embolism [11]
Not indicated: Indicated: Urgent: Emergency:
• Asymptomatic patient post therapy for a CTPA confirmed PE and/or right heart strain (defer to 3 month OP TTE)
• Pre-discharge to evaluate for features of persisting right heart strain in clinically stable patients (defer to 3 month OP echo)
• Re-evaluation for further therapy where CV compromise does not resolve with treatment • To establish right heart function in clinically unstable patients to facilitate decision making regarding thrombolysis or alternative therapies • Not applicable
6. Emergency non-cardiac surgery
Not indicated: Indicated: Urgent: Emergency:
• Known ventricular or valvular dysfunction established on TTE within 12 months without a change in symptoms
• AF without signs of congestive cardiac failure or murmur
• Referral based on age or frailty only
• Not applicable • Clinical suspicion of significant valvular or ventricular pathology which will alter the anaesthetic approach (e.g., LBBB, RBBB or significant LVH) • Not applicable
7. Infective endocarditis
Not indicated: Indicated: Urgent: Emergency:
• Fever with no other positive Duke criteria
• Repeat assessment in a clinically stable patient with known vegetations
• To characterise valve lesions and haemodynamic consequences where Duke’s criteria are positive
• One week following a negative TTE study in cases of high clinical suspicion where a TOE is not possible
• Detection of high-risk complications when suspected (e.g., fistula, abscess, mass lesions)
• Persistent bacteraemia of unknown source, particularly in staphylococcal aureus infection
• Baseline re-assessment prior to discharge following completion of treatment for endocarditis
• Not applicable • Not applicable
8. Post cardiac operation or procedure
Not indicated: Indicated: Urgent: Emergency:
• Following routine elective coronary revascularisation in stable patients
• Routine pre-discharge echo following valve replacement in asymptomatic patients. Obtain baseline haemodynamic data at 4–6 weeks post operation
• Routinely following AF ablation
• Routinely following structural heart disease intervention e.g., PFO closure
• Concern regarding cardiac tamponade following any cardiac or thoracic cavity procedure
• Concern regarding cardiac tamponade following structural heart disease procedure, coronary intervention or permanent/temporary pace-maker insertion or lead extraction
• Not applicable
9. Acute stroke
Not indicated: Indicated: Urgent: Emergency:
• Patient not in AF with no murmurs or suspicion of regional wall motion abnormality • Patient in AF
• Audible murmur
• Suspected regional wall motion abnormality from clinical assessment or ECG
• Not applicable • Not applicable
10. Specific indications for TTE [14]
Shock: TTE is recommended as the primary assessment tool for the shock state following senior clinical assessment
Not indicated: Indicated: Urgent: Emergency:
• Prior to clinical assessment and initial management • Not applicable • Where initial clinical assessment and management has failed to provide reasonable clinical improvement • Not applicable
11. Assessment of right heart function (see prior section for pulmonary embolism)
Not Indicated: Indicated: Urgent: Emergency:
• Not applicable • Not applicable • Where acute right heart dysfunction is clinically suspected (e.g., due to the use of high positive end expiratory pressure ventilation strategy or where ECG changes suggest right ventricular infarction) • Not applicable
12. Assessment of left ventricular function
Not indicated: Indicated: Urgent: Emergency:
• Where clinical information is otherwise adequate to answer the clinical question • Not applicable • Following cardiac arrest and return of circulation
• In cases of severe malnutrition
• Where underlying cardiomyopathy is suspected
• Where there is difficulty in maintaining end organ perfusion despite senior
assessment and therapy
• Where a direct effect of pathology on ventricular function is suspected e.g., septic cardiomyopathy
13. Assessment of complex fluid balance
Not indicated: Indicated: Urgent: Emergency:
• Prior to clinical assessment and initial management • Not applicable • To determine filling status in anuric state
• To guide renal replacement therapy and fluid therapy planning
• Where despite evidence to the contrary hypovolaemia may be the cause of hypotension/perfusion e.g., following large volume resuscitation or where peripheral oedema is present
14. Differentiation between acute respiratory distress syndrome and pulmonary oedema
Not indicated: Indicated: Urgent: Emergency:
• Where the cause of interstitial fluid appearance on chest radiology is known for example in acute pneumonitis diagnosed on cCT imaging • Not applicable • Not applicable • Where there is reasonable clinical suspicion that the cause of interstitial fluid seen on chest radiography or lung ultrasound is due to raised left ventricular end diastolic pressure
15. Suspicion of acute mechanical valvular pathology
Not indicated: Indicated: Urgent: Emergency:
• Where history examination and current illness are not supportive of a diagnosis of valve dysfunction as a cause for haemodynamic compromise • Not applicable • Where the history and examination findings suggest that the clinical picture and/or organ failure may be due to critical or acute valve dysfunction, e.g., flail mitral valve • Not applicable
16. Assessment of the pericardial space
Not indicated: Indicated: Urgent: Emergency:
• Small volume pericardial effusion is noted on cCT in the context of critical illness without haemodynamic effects • Not applicable • Where there is clinical suspicion of pyopericardium from clinical, microbiological and radiological information • Where clinical findings suggest that known or suspected pericardial fluid is either contributing to haemodynamic compromise or causing acute cardiac tamponade
17. Special circumstances
Not indicated: Indicated: Urgent: Emergency:
• Not applicable • Assessment of cardiac function to facilitate organ donation
• Guidance for positioning of extracorporeal support cannulae
• Search for penetrating objects or assessment of cardiac structure following trauma to the thorax
• Not applicable • Not applicable
  1. AF (atrial fibrillation), cCT (computed tomography), CTPA (computed tomography pulmonary artery), CXR (chest x-ray), DC (direct current), ECG (electro-cardiogram), LBBB (left bundle branch block), LVH (left ventricular hypertrophy), OP (out-patient), PFO (patent foramen ovale), PE (pulmonary embolus), PHT (pulmonary hypertension), RBBB (right bundle branch block), RV (right ventricle), TOE (trans-oesophageal echocardiogram), TTE (trans-thoracic echocardiogram)