Echocardiogram+ordering

Echocardiogram ordering
To maximize the efficient use of echocardiography in our system, here are some guidelines to assist you:


 * 1) Before ordering an echocardiogram, please review MediTech to check whether a prior echocardiogram was ordered (which may obviate the need to order an echocardiogram now). Before April 21, 2003, echocardiogram reports were filed under "CARDIOPULMONARY Reports". Since then, they are filed under "MED REC DICTATION reports".
 * 2) Please make sure that your echocardiogram order includes relevant clinical information. The requisition must be faxed from outlying clinics to 370-5379 at the time of scheduling the echo. In Martinez, the patient may be sent to the Cardiopulmonary department with the requisition.
 * 3) Use discretion when ordering an echocardiogram in the following situations:
 * **A repeat echocardiogram for CHF**:
 * ECHOs should not be ordered routinely for simple exacerbations of CHF, since that rarely will reveal significant change unless there has been a dramatic change in heart size, ECG, or heart exam (e.g. new loud murmur). Of course, it is appropriate that all patients with new CHF diagnosis get an ECHO to evaluate LV function and valve function.
 * Other tests (cardiac catheterizations, Persantine thallium tests) also measure LV function
 * Often patients who had a catheterization or ECHO elsewhere 6-12 months ago get an ECHO ordered here when there has been no change in ECG, CXR or exam.
 * A note in the chart referring to prior studies (here or elsewhere) is sufficient to meet JCAHO and HCFA guidelines, which state that patients with CHF need a study to document LV function
 * **Dyspnea**:
 * The ECHO is rarely helpful if the heart exam, ECG, and chest film are WNL.
 * Patients with dyspnea should generally get an ECG and CXR first, unless a new diagnosis of CHF is clear. Afterwards, a decision can be made if an ECHO will be helpful
 * 1) There is likely a higher-yield test (or perhaps no need for a test at all) in the following situations:
 * **Chest pain**
 * Generally, a resting ECHO will be relatively low yield in this setting, if there is no evidence of MI on EKG or the patient has no documented history of MI.
 * A more appropriate test to consider if suspicion of angina exists would be a [|treadmill, thallium or stress echo].
 * **Palpitations**
 * Holter monitor or Event monitor will be much higher yield in most cases of palpitations.
 * If the patient has no symptoms or signs of heart failure and no significant resting EKG abnormalities, ECHO is unlikely to help determine the etiology of the patient's palpitations
 * **2/6 systolic murmur:**
 * A grade 1 or 2 systolic murmur that is not associated with symptoms or signs of heart failure (i.e. no dyspnea, no displaced PMI or extra heart sounds, normal EKG) does not meet American College of Cardiology (ACC) criteria for echocardiographic evaluation (UpToDate has a [|table]on ACC guidelines for when to evaluate an asymptomatic murmur).
 * 1) Lastly, if the patient has had an ECHO within the last 6 months for whatever reason, and there has been no change in overall clinical status, generally a repeat echo will not change management (of course, there can be exceptions).

(Last reviewed by D. Mahar, May 2008)