Table 2 Appropriateness, timing and triage of the most common inpatient TTE referrals
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 [12] 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 |