With the rapid advance-ment of cardiovascular imaging technologies, it is important for physicians to understand how best to incorporate these options into clinical care and how to choose between imaging modalities. Recently, the American College of Cardiology, the Society for Cardiovascular Angiography and Interventions, and other expert societies released the first appropriate use criteria (AUC) for suspected heart disease in pediatric patients. The AUC document specifically addressed the use of initial transthoracic echocardiography in outpatient pediatric cardiology.

“The purpose of the new criteria is to improve patient care and outcomes in a cost-effective manner as well as enhance quality within practices,” explains David G. Nykanen, MD, FACC, FRCPC, FSCAI, who was a member of the AUC technical panel that developed the document. “We wanted to give clinicians a roadmap to follow when determining whether or not it was appropriate to use echocardiograms in this complex patient population.”

Echocardiography: Judicious Use

For the AUC document, experts identified 113 indications for outpatient pediatric echocardiography based on common clinical scenarios and/or clinical practice guidelines. Each indication was then rated for echocardiographic assessment as “appropriate,” “may be appropriate,” or “rarely appropriate.” Dr. Nykanen says the AUC document can familiarize pediatricians and pediatric cardiologists on when echocardiography may help elucidate a diagnosis and when other diagnostic pathways may be more useful. “Echocardiograms are expensive diagnostic tests,” he says. “We need to be judicious with how and why we order these tests.”


The writing committee offered assistance for determining the reasonable role of initial transthoracic echocardiography when evaluating pediatric patients in outpatient settings, and tackled various aspects for consideration. “For example,” says Dr. Nykanen, “we spent time determining the importance of recognizing when an echocardiogram may or may not be needed for a heart murmur. For innocent-sounding murmurs, clinicians shouldn’t automatically order an echocardiogram. However, transthoracic echocardiography should be considered if patients have a family history of hypertrophic cardiomyopathy, sudden cardiac death, or other important risk factors.”

More to Come on Appropriate Use Critiera

According to the writing group, the AUC criteria lay the foundation for developing AUC in other areas of pediatric cardiology. However, more research is needed to see how well these AUC are implemented in clinical care and to determine if there are any deficiencies. “The document provides a basis for designing educational and quality improvement projects so that individual providers can reduce the number of times they make rarely appropriate referrals for echocardiograms,” Dr. Nykanen says. “We hope that future studies will better define ordering patterns for individual practitioners and increase our understanding of variations in the delivery of care. As more information is gathered, there will likely be continued refinements of the AUC document.”