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JACC Vol. 57, No.

9, 2011 March 1, 2011:1126–66

Douglas et al. Appropriate Use Criteria for Echocardiography

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7. Echocardiography Appropriate Use Criteria (by Indication)

Table 1. TTE for General Evaluation of Cardiac Structure and Function
Indication 1. 2.

Appropriate Use Score (1–9) Suspected Cardiac Etiology—General With TTE Symptoms or conditions potentially related to suspected cardiac etiology including but not limited to chest pain, shortness of breath, palpitations, TIA, stroke, or peripheral embolic event Prior testing that is concerning for heart disease or structural abnormality including but not limited to chest X-ray, baseline scout images for stress echocardiogram, ECG, or cardiac biomarkers Arrhythmias With TTE Infrequent APCs or infrequent VPCs without other evidence of heart disease Frequent VPCs or exercise-induced VPCs Sustained or nonsustained atrial fibrillation, SVT, or VT Asymptomatic isolated sinus bradycardia Lightheadedness/Presyncope/Syncope With TTE Clinical symptoms or signs consistent with a cardiac diagnosis known to cause lightheadedness/presyncope/ syncope (including but not limited to aortic stenosis, hypertrophic cardiomyopathy, or HF) Lightheadedness/presyncope when there are no other symptoms or signs of cardiovascular disease Syncope when there are no other symptoms or signs of cardiovascular disease Evaluation of Ventricular Function With TTE Initial evaluation of ventricular function (e.g., screening) with no symptoms or signs of cardiovascular disease Routine surveillance of ventricular function with known CAD and no change in clinical status or cardiac exam Evaluation of LV function with prior ventricular function evaluation showing normal function (e.g., prior echocardiogram, left ventriculogram, CT, SPECT MPI, CMR) in patients in whom there has been no change in clinical status or cardiac exam Perioperative Evaluation With TTE Routine perioperative evaluation of ventricular function with no symptoms or signs of cardiovascular disease Routine perioperative evaluation of cardiac structure and function prior to noncardiac solid organ transplantation Pulmonary Hypertension With TTE Evaluation of suspected pulmonary hypertension including evaluation of right ventricular function and estimated pulmonary artery pressure Routine surveillance ( 1 y) of known pulmonary hypertension without change in clinical status or cardiac exam Routine surveillance ( 1 y) of known pulmonary hypertension without change in clinical status or cardiac exam Re-evaluation of known pulmonary hypertension if change in clinical status or cardiac exam or to guide therapy A (9) A (9)

3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

● ● ● ●

I (2) A (8) A (9) I (2) A (9) I (3) A (7) I (2) I (3) I (1)

● ●

● ● ●

13. 14.

● ●

I (2) U (6)

15. 16. 17. 18.

A (9) I (3) A (7) A (9)

● ● ●

A indicates appropriate; I, inappropriate; and U, uncertain.

Table 2. TTE for Cardiovascular Evaluation in an Acute Setting
Indication Hypotension or Hemodynamic Instability With TTE 19. 20. 21. 22. 23.
● ●

Appropriate Use Score (1–9) Hypotension or hemodynamic instability of uncertain or suspected cardiac etiology Assessment of volume status in a critically ill patient Myocardial Ischemia/Infarction With TTE

A (9) U (5) A (9) A (8) A (9)

Acute chest pain with suspected MI and nondiagnostic ECG when a resting echocardiogram can be performed during pain Evaluation of a patient without chest pain but with other features of an ischemic equivalent or laboratory markers indicative of ongoing MI Suspected complication of myocardial ischemia/infarction, including but not limited to acute mitral regurgitation, ventricular septal defect, free-wall rupture/tamponade, shock, right ventricular involvement, HF, or thrombus

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Douglas et al. Appropriate Use Criteria for Echocardiography

JACC Vol. 57, No. 9, 2011 March 1, 2011:1126–66

Table 2. Continued
Indication Evaluation of Ventricular Function after ACS With TTE 24. 25. 26. 27. 28. 29. 30. 31.
● ●

Appropriate Use Score (1–9) Initial evaluation of ventricular function following ACS Re-evaluation of ventricular function following ACS during recovery phase when results will guide therapy Respiratory Failure With TTE
● ●

A (9) A (9) A (8) U (5) I (2) A (8) I (1) A (7)

Respiratory failure or hypoxemia of uncertain etiology Respiratory failure or hypoxemia when a noncardiac etiology of respiratory failure has been established Pulmonary Embolism With TTE Suspected pulmonary embolism in order to establish diagnosis Known acute pulmonary embolism to guide therapy (e.g., thrombectomy and thrombolytics) Routine surveillance of prior pulmonary embolism with normal right ventricular function and pulmonary artery systolic pressure Re-evaluation of known pulmonary embolism after thrombolysis or thrombectomy for assessment of change in right ventricular function and/or pulmonary artery pressure Cardiac Trauma With TTE Severe deceleration injury or chest trauma when valve injury, pericardial effusion, or cardiac injury are possible or suspected Routine evaluation in the setting of mild chest trauma with no electrocardiographic changes or biomarker elevation

● ● ●

32. 33.

A (9) I (2)

A indicates appropriate; I, inappropriate; and U, uncertain.

Table 3. TTE for Evaluation of Valvular Function
Indication Murmur or Click With TTE 34. 35. 36. 37.
● ● ●

Appropriate Use Score (1–9) Initial evaluation when there is a reasonable suspicion of valvular or structural heart disease Initial evaluation when there are no other symptoms or signs of valvular or structural heart disease Re-evaluation in a patient without valvular disease on prior echocardiogram and no change in clinical status or cardiac exam Re-evaluation of known valvular heart disease with a change in clinical status or cardiac exam or to guide therapy Native Valvular Stenosis With TTE Routine surveillance ( 3 y) of mild valvular stenosis without a change in clinical status or cardiac exam Routine surveillance ( 3 y) of mild valvular stenosis without a change in clinical status or cardiac exam Routine surveillance ( 1 y) of moderate or severe valvular stenosis without a change in clinical status or cardiac exam Routine surveillance ( 1 y) of moderate or severe valvular stenosis without a change in clinical status or cardiac exam Native Valvular Regurgitation With TTE Routine surveillance of trace valvular regurgitation Routine surveillance ( 3 y) of mild valvular regurgitation without a change in clinical status or cardiac exam Routine surveillance ( 3 y) of mild valvular regurgitation without a change in clinical status or cardiac exam Routine surveillance ( 1 y) of moderate or severe valvular regurgitation without a change in clinical status or cardiac exam Routine surveillance ( 1 y) of moderate or severe valvular regurgitation without change in clinical status or cardiac exam Prosthetic Valves With TTE Initial postoperative evaluation of prosthetic valve for establishment of baseline Routine surveillance ( 3 y after valve implantation) of prosthetic valve if no known or suspected valve dysfunction Routine surveillance ( 3 y after valve implantation) of prosthetic valve if no known or suspected valve dysfunction Evaluation of prosthetic valve with suspected dysfunction or a change in clinical status or cardiac exam Re-evaluation of known prosthetic valve dysfunction when it would change management or guide therapy A (9) I (2) I (1) A (9)

38. 39. 40. 41.

● ● ●

I (3) A (7) I (3) A (8)

42. 43. 44. 45. 46.

● ● ● ●

I (1) I (2) U (4) U (6) A (8)

47. 48. 49. 50. 51.

● ●

A (9) I (3) A (7) A (9) A (9)

● ●

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Table 4. septal ablation. Appropriate Use Score (1–9) A (9) A (9) A (9) I (2) A (8) A (9) ● ● ● ● ● ● Suspected cardiac mass Suspected cardiovascular source of embolus Suspected pericardial conditions Routine surveillance of known small pericardial effusion with no change in clinical status Re-evaluation of known pericardial effusion to guide management or therapy Guidance of percutaneous noncoronary cardiac procedures including but not limited to pericardiocentesis. or Cardiomyopathy Indication Hypertension With TTE 67. 62. inappropriate. inappropriate.. TTE for Evaluation of Aortic Disease Indication 63. 59. 58. Appropriate Use Criteria for Echocardiography 1135 Table 3. 53. I. 61.org by on April 19. No. 9. Marfan syndrome) Re-evaluation of known ascending aortic dilation or history of aortic dissection to establish a baseline rate of expansion or when the rate of expansion is excessive Re-evaluation of known ascending aortic dilation or history of aortic dissection with a change in clinical status or cardiac exam or when findings may alter management or therapy Routine re-evaluation for surveillance of known ascending aortic dilation or history of aortic dissection without a change in clinical status or cardiac exam when findings would not change management or therapy ● ● ● A indicates appropriate.onlinejacc. 64. Appropriate Use Score (1–9) A (9) A (9) A (9) I (3) ● Evaluation of the ascending aorta in the setting of a known or suspected connective tissue disease or genetic condition that predisposes to aortic aneurysm or dissection (e.g. 69. 56. HF. 68. 60. Continued Indication Infective Endocarditis (Native or Prosthetic Valves) With TTE 52. ● ● ● Appropriate Use Score (1–9) Initial evaluation of suspected infective endocarditis with positive blood cultures or a new murmur Transient fever without evidence of bacteremia or a new murmur Transient bacteremia with a pathogen not typically associated with infective endocarditis and/or a documented nonendovascular source of infection Re-evaluation of infective endocarditis at high risk for progression or complication or with a change in clinical status or cardiac exam Routine surveillance of uncomplicated infective endocarditis when no change in management is contemplated A (9) I (2) I (3) A (9) I (2) ● ● A indicates appropriate. 65. and I. Table 5. 2011 . TTE for Evaluation of Hypertension.JACC Vol. 2011 March 1. TTE for Evaluation of Intracardiac and Extracardiac Structures and Chambers Indication 57. uncertain. ● ● ● Appropriate Use Score (1–9) Initial evaluation of suspected hypertensive heart disease Routine evaluation of systemic hypertension without symptoms or signs of hypertensive heart disease Re-evaluation of known hypertensive heart disease without a change in clinical status or cardiac exam A (8) I (3) U (4) Downloaded from content. and U. inappropriate. 57. or right ventricular biopsy A indicates appropriate. 54. 55. 66. Table 6. 2011:1126–66 Douglas et al. and I.

onlinejacc. 94. and U. 75. hypertrophic. Downloaded from content. ● Routine surveillance ( 2 y) of adult congenital heart disease following complete repair without residual structural or hemodynamic abnormality X without a change in clinical status or cardiac exam X U (6) 97. 78. I. uncertain. ● Routine surveillance ( 1 y) of adult congenital heart disease following incomplete or palliative repair with residual structural or hemodynamic abnormality X without a change in clinical status or cardiac exam X A (8) A indicates appropriate. inappropriate. I. uncertain. 2011:1126–66 Table 6. infiltrative. 90. or genetic cardiomyopathy) Re-evaluation of known cardiomyopathy with a change in clinical status or cardiac exam or to guide therapy Routine surveillance ( 1 y) of known cardiomyopathy without a change in clinical status or cardiac exam Routine surveillance ( 1 y) of known cardiomyopathy without a change in clinical status or cardiac exam Screening evaluation for structure and function in first-degree relatives of a patient with an inherited cardiomyopathy Baseline and serial re-evaluations in a patient undergoing therapy with cardiotoxic agents ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● A indicates appropriate. ● ● Appropriate Use Score (1–9) Initial evaluation of known or suspected HF (systolic or diastolic) based on symptoms. 9. Appropriate Use Score (1–9) A (9) A (9) A (9) I (3) ● ● ● ● Initial evaluation of known or suspected adult congenital heart disease Known adult congenital heart disease with a change in clinical status or cardiac exam Re-evaluation to guide therapy in known adult congenital heart disease Routine surveillance ( 2 y) of adult congenital heart disease following complete repair without a residual structural or hemodynamic abnormality X without a change in clinical status or cardiac exam X 96. 88. dilated. 71. ● Routine surveillance ( 1 y) of adult congenital heart disease following incomplete or palliative repair with residual structural or hemodynamic abnormality X without a change in clinical status or cardiac exam X U (5) 98. 72. or abnormal test results Re-evaluation of known HF (systolic or diastolic) with a change in clinical status or cardiac exam without a clear precipitating change in medication or diet Re-evaluation of known HF (systolic or diastolic) with a change in clinical status or cardiac exam with a clear precipitating change in medication or diet Re-evaluation of known HF (systolic or diastolic) to guide therapy Routine surveillance ( 1 y) of HF (systolic or diastolic) when there is no change in clinical status or cardiac exam Routine surveillance ( 1 y) of HF (systolic or diastolic) when there is no change in clinical status or cardiac exam Device Evaluation (Including Pacemaker. 87. 74. 83. 77. or CRT) With TTE ● A (9) A (8) U (4) A (9) I (2) U (6) A (9) U (6) A (8) I (1) I (3) A (9) A (7) A (9) A (7) A (9) A (9) A (9) I (2) U (5) A (9) A (9) ● ● ● ● Initial evaluation or re-evaluation after revascularization and/or optimal medical therapy to determine candidacy for device therapy and/or to determine optimal choice of device Initial evaluation for CRT device optimization after implantation Known implanted pacing device with symptoms possibly due to device complication or suboptimal pacing device settings Routine surveillance ( 1 y) of implanted device without a change in clinical status or cardiac exam Routine surveillance ( 1 y) of implanted device without a change in clinical status or cardiac exam Ventricular Assist Devices and Cardiac Transplantation With TTE To determine candidacy for ventricular assist device Optimization of ventricular assist device settings Re-evaluation for signs/symptoms suggestive of ventricular assist device-related complications Monitoring for rejection in a cardiac transplant recipient Cardiac structure and function evaluation in a potential heart donor Cardiomyopathies With TTE Initial evaluation of known or suspected cardiomyopathy (e. Appropriate Use Criteria for Echocardiography JACC Vol. Table 7. 80. restrictive. 91. 86. and U. 76.org by on April 19. 93. 82. 84. ICD. 2011 March 1. 2011 . 89. TTE for Adult Congenital Heart Disease Indication 92. 95. 85.1136 Douglas et al. inappropriate. 57. Continued Indication HF With TTE 70. 81. 73. 79. signs.g. No..

JACC Vol. 2011:1126–66 Douglas et al. ● ● ● A (7) U (5) I (1) 112. transient fever. 102. resolution of vegetation after antibiotic therapy) when a change in therapy is anticipated Surveillance of prior TEE finding for interval change (e. 117. Table 9. 2011 March 1. and percutaneous valve procedures Suspected acute aortic pathology including but not limited to dissection/transsection Routine assessment of pulmonary veins in an asymptomatic patient status post pulmonary vein isolation TEE as Initial or Supplemental Test—Valvular Disease ● ● A (8) I (1) A (8) I (2) A (9) A (9) I (3) A (9) I (3) A (9) ● ● ● ● ● ● Evaluation of valvular structure and function to assess suitability for.. Appropriate Use Criteria for Echocardiography 1137 Table 8.g. I. TEE Indication TEE as Initial or Supplemental Test—General Uses 99. 104. 100. 111. resolution of thrombus after anticoagulation. 108. 116. 118. inappropriate. No. staph bacteremia. Stress Echocardiography for Detection of CAD/Risk Assessment: Symptomatic or Ischemic Equivalent Indication Evaluation of Ischemic Equivalent (Nonacute) With Stress Echocardiography 114. or negative blood cultures/atypical pathogen for endocarditis) To diagnose infective endocarditis with a moderate or high pretest probability (e.onlinejacc. and U. ● A (9) I (2) ● A indicates appropriate.. 101. 103.g. 110. fungemia... 2011 . known alternative source of infection. ● ● ● ● ● ● ● ● ● ● Appropriate Use Score (1–9) Low pretest probability of CAD ECG interpretable and able to exercise Low pretest probability of CAD ECG uninterpretable or unable to exercise Intermediate pretest probability of CAD ECG interpretable and able to exercise Intermediate pretest probability of CAD ECG uninterpretable or unable to exercise High pretest probability of CAD Regardless of ECG interpretability and ability to exercise I (3) A (7) A (7) A (9) A (7) Downloaded from content. 107. 115.g. radiofrequency ablation. prosthetic heart valve. 113. cardioversion. and/or radiofrequency ablation Evaluation when a decision has been made to anticoagulate and not to perform cardioversion ● 109. an intervention To diagnose infective endocarditis with a low pretest probability (e. uncertain. 9.g. 105.org by on April 19. ● Appropriate Use Score (1–9) Use of TEE when there is a high likelihood of a nondiagnostic TTE due to patient characteristics or inadequate visualization of relevant structures Routine use of TEE when a diagnostic TTE is reasonably anticipated to resolve all diagnostic and management concerns Re-evaluation of prior TEE finding for interval change (e. 106. resolution of thrombus after anticoagulation. 57. or intracardiac device) TEE as Initial or Supplemental Test—Embolic Event Evaluation for cardiovascular source of embolus with no identified noncardiac source Evaluation for cardiovascular source of embolus with a previously identified noncardiac source Evaluation for cardiovascular source of embolus with a known cardiac source in which a TEE would not change management TEE as Initial Test—Atrial Fibrillation/Flutter Evaluation to facilitate clinical decision making with regard to anticoagulation. and assist in planning of. resolution of vegetation after antibiotic therapy) when no change in therapy is anticipated Guidance during percutaneous noncoronary cardiac interventions including but not limited to closure device placement.

inappropriate. ● ● ● ● Appropriate Use Score (1–9) Possible ACS ECG: no ischemic changes or with LBBB or electronically paced ventricular rhythm Low-risk TIMI score Negative troponin levels Possible ACS ECG: no ischemic changes or with LBBB or electronically paced ventricular rhythm Low-risk TIMI score Peak troponin: borderline. I.1138 Douglas et al. 131. exercise induced VT. minimally elevated Possible ACS ECG: no ischemic changes or with LBBB or electronically paced ventricular rhythm High-risk TIMI score Negative troponin levels Possible ACS ECG: no ischemic changes or with LBBB or electronically paced ventricular rhythm High-risk TIMI score Peak troponin: borderline. equivocal. uncertain. ● ● ● ● A (7) 123. 2011 . 9. 130. Appropriate Use Criteria for Echocardiography JACC Vol. 133. 126. 132. ● ● ● ● ● ● Appropriate Use Score (1–9) Low global CAD risk Intermediate global CAD risk ECG interpretable Intermediate global CAD risk ECG uninterpretable High global CAD risk I (1) I (2) U (5) U (5) I indicates inappropriate. or nonsustained VT Infrequent PVCs New-onset atrial fibrillation Syncope With Stress Echocardiography Low global CAD risk Intermediate or high global CAD risk Elevated Troponin With Stress Echocardiography Troponin elevation without symptoms or additional evidence of ACS ● ● I (3) A (7) A (7) ● A indicates appropriate. 135. 125. Table 11. and U. 127. No. Continued Indication Acute Chest Pain With Stress Echocardiography 119. 57. minimally elevated Definite ACS A (7) 120. ● I (1) A indicates appropriate. and U. ● Appropriate Use Score (1–9) No prior CAD evaluation and no planned coronary angiography Arrhythmias With Stress Echocardiography ● ● ● ● A (7) A (7) A (7) I (3) U (6) Sustained VT Frequent PVCs. 129. and I. Table 10. Stress Echocardiography for Detection of CAD/Risk Assessment: Asymptomatic (Without Ischemic Equivalent) Indication General Patient Populations With Stress Echocardiography 124.onlinejacc. 2011 March 1. ● ● ● ● A (7) 122. Stress Echocardiography for Detection of CAD/Risk Assessment: Asymptomatic (Without Ischemic Equivalent) in Patient Populations With Defined Comorbidities Indication New-Onset or Newly Diagnosed HF or LV Systolic Dysfunction With Stress Echocardiography 128. Downloaded from content.org by on April 19. uncertain. equivocal. 2011:1126–66 Table 9. ● ● ● ● A (7) 121. 134. inappropriate.

2011 March 1. inappropriate.g. 151.. 143. uncertain. 2011 . 153. ● ● ● ● ● ● ● Appropriate Use Score (1–9) Coronary calcium Agatston score 100 I (2) U (5) U (6) A (7) U (5) Low to intermediate global CAD risk Coronary calcium Agatston score between 100 and 400 High global CAD risk Coronary calcium Agatston score between 100 and 400 Coronary calcium Agatston score 400 Abnormal carotid intimal medial thickness ( 0. ● ● ● ● ● ● ● ● Low global CAD risk Last stress imaging study Low global CAD risk Last stress imaging study I (1) 2 y ago I (2) 2 y ago I (2) U (4) Intermediate to high global CAD risk Last stress imaging study 2 y ago Intermediate to high global CAD risk Last stress imaging study 2 y ago Asymptomatic or Stable Symptoms With Stress Echocardiography Abnormal Coronary Angiography or Abnormal Prior Stress Study No Prior Revascularization 146. Appropriate Use Criteria for Echocardiography 1139 Table 12. 57.g. 144. Duke) High-risk treadmill score (e.. ● ● ● I (1) A (7) A (7) A (7) U (6) A (8) ● ● ● A indicates appropriate. 9. and U. Stress Echocardiography Following Prior Test Results Indication Asymptomatic: Prior Evidence of Subclinical Disease With Stress Echocardiography 136. 147. or discordant stress testing where obstructive CAD remains a concern I (3) U (5) 148. 2011:1126–66 Douglas et al. 152. 139. No.JACC Vol. 149.org by on April 19. 150. ● ● ● ● Known CAD on coronary angiography or prior abnormal stress imaging study Last stress imaging study 2 y ago Known CAD on coronary angiography or prior abnormal stress imaging study Last stress imaging study 2 y ago Treadmill ECG Stress Test With Stress Echocardiography Low-risk treadmill score (e. borderline.9 mm and/or the presence of plaque encroaching into the arterial lumen) Coronary Angiography (Invasive or Noninvasive) With Stress Echocardiography Coronary artery stenosis of unclear significance Asymptomatic or Stable Symptoms With Stress Echocardiography Normal Prior Stress Imaging Study 141. 145. Duke) Intermediate-risk treadmill score (e.. 138. 137. I. 140.onlinejacc. ● A (8) 142. Duke) New or Worsening Symptoms With Stress Echocardiography Abnormal coronary angiography or abnormal prior stress imaging study Normal coronary angiography or normal prior stress imaging study Prior Noninvasive Evaluation With Stress Echocardiography Equivocal.g. Downloaded from content.

inappropriate. Table 15. and U. Stress Echocardiography for Risk Assessment: Perioperative Evaluation for Noncardiac Surgery Without Active Cardiac Conditions Indication Low-Risk Surgery With Stress Echocardiography 154.onlinejacc. and I. ● Appropriate Use Score (1–9) Ischemic equivalent Asymptomatic With Stress Echocardiography ● ● ● ● ● ● A (8) A (7) I (2) U (6) I (2) U (5) Cardiac Rehabilitation With Stress Echocardiography I (3) Incomplete revascularization Additional revascularization feasible 5 y after CABG 5 y after CABG 2 y after PCI 2 y after PCI Prior to initiation of cardiac rehabilitation (as a stand-alone indication) ● A indicates appropriate. 2011:1126–66 Table 13. 9. I. I. inappropriate. Appropriate Use Criteria for Echocardiography JACC Vol. uncertain. 161.org by on April 19. 172. noninvasive test. or mechanical complications UA/NSTEMI With Stress Echocardiography Hemodynamically stable.1140 Douglas et al. 168. 171. 175. inappropriate. 162. Downloaded from content. signs of cardiogenic shock. 157. noninvasive test. ● ● ● ● ● Appropriate Use Score (1–9) Primary PCI with complete revascularization No recurrent symptoms Hemodynamically stable. 156. or previous revascularization Vascular Surgery With Stress Echocardiography ● ● ● ● ● Moderate to good functional capacity ( 4 METs) No clinical risk factors 1 clinical risk factor Poor or unknown functional capacity ( 4 METs) Asymptomatic 1 y post normal catheterization. and U. or previous revascularization A indicates appropriate. 170. 174. 155. 158. 160. 2011 March 1. 173. Table 14. 57. 159. Stress Echocardiography for Risk Assessment: Postrevascularization (PCI or CABG) Indication Symptomatic With Stress Echocardiography 169. uncertain. ● I (1) I (3) ● A indicates appropriate. 2011 . 166. No. Stress Echocardiography for Risk Assessment: Within 3 Months of an ACS Indication STEMI With Stress Echocardiography 163. or no signs of HF To evaluate for inducible ischemia No prior coronary angiography since the index event Hemodynamically unstable. no recurrent chest pain symptoms. ● Appropriate Use Score (1–9) Perioperative evaluation for risk assessment Intermediate-Risk Surgery With Stress Echocardiography ● ● ● ● ● I (1) I (3) I (2) U (6) I (1) I (3) I (2) A (7) I (2) Moderate to good functional capacity ( 4 METs) No clinical risk factors 1 clinical risk factor Poor or unknown functional capacity ( 4 METs) Asymptomatic 1 y post normal catheterization. ● I (1) A (8) ● ● ● 167. no recurrent chest pain symptoms. or no signs of HF To evaluate for inducible ischemia No prior coronary angiography since the index event ACS—Asymptomatic Postrevascularization (PCI or CABG) With Stress Echocardiography Prior to hospital discharge in a patient who has been adequately revascularized Cardiac Rehabilitation With Stress Echocardiography Prior to initiation of cardiac rehabilitation (as a stand-alone indication) I (2) A (7) 165. 164.

180. 198. No. 183. Appropriate Use Score (1–9) I (1) A (8) ● ● ● ● Routine use of contrast All LV segments visualized on noncontrast images Selective use of contrast 2 contiguous LV segments are not seen on noncontrast images A indicates appropriate. Appropriate Use Criteria for Echocardiography 1141 Table 16. 195. 2011:1126–66 Douglas et al.org by on April 19. 193. 2011 March 1. 187. and I. 179. Stress Echocardiography for Assessment of Viability/Ischemia Indication Ischemic Cardiomyopathy/Assessment of Viability With Stress Echocardiography 176. 196.JACC Vol. ● ● ● ● U (4) A (7) I (3) 197. 200. Stress Echocardiography for Hemodynamics (Includes Doppler During Stress) Indication Chronic Valvular Disease—Asymptomatic With Stress Echocardiography 177. inappropriate. 182. 185. I. 184. 57. 191. inappropriate.onlinejacc. ● I (3) U (5) I (3) U (5) ● ● ● ● A indicates appropriate. and U. 190. Table 17. ● ● ● ● ● ● ● ● ● ● ● ● ● ● Appropriate Use Score (1–9) Mild mitral stenosis Moderate mitral stenosis Severe mitral stenosis Mild aortic stenosis Moderate aortic stenosis Severe aortic stenosis Mild mitral regurgitation Moderate mitral regurgitation Severe mitral regurgitation LV size and function not meeting surgical criteria Mild aortic regurgitation Moderate aortic regurgitation Severe aortic regurgitation LV size and function not meeting surgical criteria Chronic Valvular Disease—Symptomatic With Stress Echocardiography Mild mitral stenosis Moderate mitral stenosis Severe mitral stenosis Severe aortic stenosis Evaluation of equivocal aortic stenosis Evidence of low cardiac output or LV systolic dysfunction (“low gradient aortic stenosis”) Use of dobutamine only Mild mitral regurgitation Moderate mitral regurgitation Severe mitral regurgitation Severe LV enlargement or LV systolic dysfunction Acute Valvular Disease With Stress Echocardiography Acute moderate or severe mitral or aortic regurgitation Pulmonary Hypertension With Stress Echocardiography Suspected pulmonary artery hypertension Normal or borderline elevated estimated right ventricular systolic pressure on resting echocardiographic study Routine evaluation of patients with known resting pulmonary hypertension Re-evaluation of patient with exercise-induced pulmonary hypertension to evaluate response to therapy I (2) U (5) A (7) I (3) U (6) U (5) I (2) U (5) A (7) I (2) U (5) A (7) 189. 2011 . Downloaded from content. Table 18. ● ● ● ● ● ● ● U (5) A (7) I (3) I (1) A (8) 194. 202. 181. ● ● ● Appropriate Use Score (1–9) Known moderate or severe LV dysfunction Patient eligible for revascularization Use of dobutamine stress only A (8) A indicates appropriate. 178. Contrast Use in TTE/TEE or Stress Echocardiography Indication 201. 192. 9. 188. 199. uncertain. 186.

● Acute chest pain with suspected MI and nondiagnostic ECG when a resting echocardiogram can be performed during pain Evaluation of a patient without chest pain but with other features of an ischemic equivalent or laboratory markers indicative of ongoing MI Suspected complication of myocardial ischemia/infarction. or thrombus TTE for Cardiovascular Evaluation in an Acute Setting Evaluation of Ventricular Function After ACS A (9) A (8) A (9) ● ● 24. ECG. 9. 31.org by on April 19. pericardial effusion. ventricular septal defect. baseline scout images for stress echocardiogram. or HF) Syncope when there are no other symptoms or signs of cardiovascular disease TTE for General Evaluation of Cardiac Structure and Function Pulmonary Hypertension A (9) A (7) ● 15. 2. Appropriate Use Criteria for Echocardiography JACC Vol. right ventricular involvement. SVT. ● Hypotension or hemodynamic instability of uncertain or suspected cardiac etiology TTE for Cardiovascular Evaluation in an Acute Setting Myocardial Ischemia/Infarction A (9) 21. HF. shock. or peripheral embolic event Prior testing that is concerning for heart disease or structural abnormality including but not limited to chest X-ray. 17. ● ● Initial evaluation when there is a reasonable suspicion of valvular or structural heart disease Re-evaluation of known valvular heart disease with a change in clinical status or cardiac exam or to guide therapy A (9) A (9) Downloaded from content. ● ● Initial evaluation of ventricular function following ACS Re-evaluation of ventricular function following ACS during recovery phase when results will guide therapy TTE for Cardiovascular Evaluation in an Acute Setting Respiratory Failure A (9) A (9) 26.1142 Douglas et al. ● ● Known acute pulmonary embolism to guide therapy (e. thrombectomy and thrombolytics) Re-evaluation of known pulmonary embolism after thrombolysis or thrombectomy for assessment of change in right ventricular function and/or pulmonary artery pressure TTE for Cardiovascular Evaluation in an Acute Setting Cardiac Trauma A (8) A (7) 32.onlinejacc. ● ● Frequent VPCs or exercise-induced VPCs Sustained or nonsustained atrial fibrillation. 57. 22. ● Respiratory failure or hypoxemia of uncertain etiology TTE for Cardiovascular Evaluation in an Acute Setting Pulmonary Embolism A (8) 29. or cardiac biomarkers TTE for General Evaluation of Cardiac Structure and Function Arrhythmias A (9) A (9) ● 4. or VT TTE for General Evaluation of Cardiac Structure and Function Lightheadedness/Presyncope/Syncope A (8) A (9) 7. 5.g. 2011 March 1. hypertrophic cardiomyopathy. 2011:1126–66 8. ● Evaluation of suspected pulmonary hypertension including evaluation of right ventricular function and estimated pulmonary artery pressure Routine surveillance ( 1 y) of known pulmonary hypertension without change in clinical status or cardiac exam Re-evaluation of known pulmonary hypertension if change in clinical status or cardiac exam or to guide therapy TTE for Cardiovascular Evaluation in an Acute Setting Hypotension or Hemodynamic Instability A (9) A (7) A (9) ● ● 19. ● Severe deceleration injury or chest trauma when valve injury. 25. shortness of breath. palpitations. TIA. Appropriate Indications (Median Score 7–9) Indication TTE for General Evaluation of Cardiac Structure and Function Suspected Cardiac Etiology—General 1. 37. including but not limited to acute mitral regurgitation. 23. free-wall rupture/tamponade. 2011 . Echocardiography Appropriate Use Criteria (by Appropriate Use Rating) Table 19. No. stroke.. ● Clinical symptoms or signs consistent with a cardiac diagnosis known to cause lightheadedness/presyncope/ syncope (including but not limited to aortic stenosis. or cardiac injury are possible or suspected TTE for Evaluation of Valvular Function Murmur or Click A (9) 34. ● Appropriate Use Score (1–9) Symptoms or conditions potentially related to suspected cardiac etiology including but not limited to chest pain. 18. 9.

83.g. 49. Appropriate Use Criteria for Echocardiography 1143 Table 19. HF. 82. Continued Indication TTE for Evaluation of Valvular Function Native Valvular Stenosis 39. 62. signs. ● ● ● Appropriate Use Score (1–9) Routine surveillance ( 3 y) of mild valvular stenosis without a change in clinical status or cardiac exam Routine surveillance ( 1 y) of moderate or severe valvular stenosis without a change in clinical status or cardiac exam Routine surveillance ( 1 y) of moderate or severe valvular regurgitation without change in clinical status or cardiac exam TTE for Evaluation of Valvular Function Prosthetic Valves A (7) A (8) A (8) 47. ● ● ● ● ● To determine candidacy for ventricular assist device Optimization of ventricular assist device settings Re-evaluation for signs/symptoms suggestive of ventricular assist device-related complications Monitoring for rejection in a cardiac transplant recipient Cardiac structure and function evaluation in a potential heart donor A (9) A (7) A (9) A (7) A (9) Downloaded from content. 9. or abnormal test results Re-evaluation of known HF (systolic or diastolic) with a change in clinical status or cardiac exam without a clear precipitating change in medication or diet Re-evaluation of known HF (systolic or diastolic) to guide therapy TTE for Evaluation of Hypertension. 64. ICD. 46. or Cardiomyopathy Device Evaluation (Including Pacemaker. 41. 59. ● Initial evaluation of suspected hypertensive heart disease TTE for Evaluation of Hypertension. 84. HF. HF. HF. 55. ● Initial evaluation or re-evaluation after revascularization and/or optimal medical therapy to determine candidacy for device therapy and/or to determine optimal choice of device Known implanted pacing device with symptoms possibly due to device complication or suboptimal pacing device settings TTE for Evaluation of Hypertension. 65. or CRT) A (9) A (8) A (9) ● 76. 71. ● ● ● ● Initial postoperative evaluation of prosthetic valve for establishment of baseline Routine surveillance ( 3 y after valve implantation) of prosthetic valve if no known or suspected valve dysfunction Evaluation of prosthetic valve with suspected dysfunction or a change in clinical status or cardiac exam Re-evaluation of known prosthetic valve dysfunction when it would change management or guide therapy TTE for Evaluation of Valvular Function Infective Endocarditis (Native or Prosthetic Valves) A (9) A (7) A (9) A (9) 52. 73. 2011:1126–66 Douglas et al.. 78. or Cardiomyopathy Hypertension A (9) A (9) 57. or Cardiomyopathy Ventricular Assist Devices and Cardiac Transplantation A (9) A (8) ● 81. 2011 . 85. septal ablation. ● ● Initial evaluation of suspected infective endocarditis with positive blood cultures or a new murmur Re-evaluation of infective endocarditis at high risk for progression or complication or with a change in clinical status or cardiac exam TTE for Evaluation of Intracardiac and Extracardiac Structures and Chambers Suspected cardiac mass Suspected cardiovascular source of embolus Suspected pericardial conditions Re-evaluation of known pericardial effusion to guide management or therapy Guidance of percutaneous noncoronary cardiac procedures including but not limited to pericardiocentesis. 50.org by on April 19.JACC Vol. Marfan syndrome) Re-evaluation of known ascending aortic dilation or history of aortic dissection to establish a baseline rate of expansion or when the rate of expansion is excessive Re-evaluation of known ascending aortic dilation or history of aortic dissection with a change in clinical status or cardiac exam or when findings may alter management or therapy TTE for Evaluation of Hypertension. 51. 58. No. or right ventricular biopsy TTE for Evaluation of Aortic Disease Evaluation of the ascending aorta in the setting of a known or suspected connective tissue disease or genetic condition that predisposes to aortic aneurysm or dissection (e. 61. ● A (9) A (9) A (9) ● ● 67. or Cardiomyopathy HF A (8) 70.onlinejacc. 2011 March 1. ● ● ● ● ● A (9) A (9) A (9) A (8) A (9) 63. 57. ● ● Initial evaluation of known or suspected HF (systolic or diastolic) based on symptoms.

106. 98. 87. Appropriate Use Criteria for Echocardiography JACC Vol. fungemia.g. ● Use of TEE when there is a high likelihood of a nondiagnostic TTE due to patient characteristics or inadequate visualization of relevant structures Re-evaluation of prior TEE finding for interval change (e. 92. 2011 March 1.. resolution of thrombus after anticoagulation. 104. minimally elevated A (7) 120. 103. or genetic cardiomyopathy) Re-evaluation of known cardiomyopathy with a change in clinical status or cardiac exam or to guide therapy Screening evaluation for structure and function in first-degree relatives of a patient with an inherited cardiomyopathy Baseline and serial re-evaluations in a patient undergoing therapy with cardiotoxic agents TTE for Adult Congenital Heart Disease Initial evaluation of known or suspected adult congenital heart disease Known adult congenital heart disease with a change in clinical status or cardiac exam Re-evaluation to guide therapy in known adult congenital heart disease Routine surveillance ( 1 y) of adult congenital heart disease following incomplete or palliative repair X with residual structural or hemodynamic abnormality X without a change in clinical status or cardiac exam TEE as Initial or Supplemental Test—General Uses A (9) A (9) A (9) A (9) A (9) A (9) A (9) A (8) ● ● ● ● ● ● ● 99. equivocal.g. and assist in planning of. 90. staph bacteremia. cardioversion. 9. restrictive. and/or radiofrequency ablation Stress Echocardiography for Detection of CAD/Risk Assessment: Symptomatic or Ischemic Equivalent Evaluation of Ischemic Equivalent (Nonacute) A (8) A (8) A (9) A (9) A (9) A (9) ● ● ● ● ● 109. radiofrequency ablation. 94. ● ● ● ● A (7) 122. HF. ● A (7) A (9) ● 115. No. infiltrative. prosthetic heart valve. ● ● ● ● Possible ACS ECG: no ischemic changes or with LBBB or electronically paced ventricular rhythm Low-risk TIMI score Negative troponin levels Possible ACS ECG: no ischemic changes or with LBBB or electronically paced ventricular rhythm Low-risk TIMI score Peak troponin: borderline. resolution of vegetation after antibiotic therapy) when a change in therapy is anticipated Guidance during percutaneous noncoronary cardiac interventions including but not limited to closure device placement.1144 Douglas et al.onlinejacc. 118. minimally elevated Possible ACS ECG: no ischemic changes or with LBBB or electronically paced ventricular rhythm High-risk TIMI score Negative troponin levels Possible ACS ECG: no ischemic changes or with LBBB or electronically paced ventricular rhythm High-risk TIMI score Peak troponin: borderline. 57. 116. 108. ● Appropriate Use Score (1–9) Initial evaluation of known or suspected cardiomyopathy (e. or intracardiac device) TEE as Initial or Supplemental Test—Embolic Event Evaluation for cardiovascular source of embolus with no identified noncardiac source TEE as Initial Test—Atrial Fibrillation/Flutter Evaluation to facilitate clinical decision making with regards to anticoagulation. ● ● ● ● A (7) Downloaded from content. and percutaneous valve procedures Suspected acute aortic pathology including but not limited to dissection/transsection TEE as Initial or Supplemental Test—Valvular Disease Evaluation of valvular structure and function to assess suitability for. ● ● ● ● A (7) 121. 117. equivocal. dilated.org by on April 19. 112.. ● ● ● ● ● ● ● ● Low pretest probability of CAD ECG uninterpretable or unable to exercise Intermediate pretest probability of CAD ECG interpretable and able to exercise Intermediate pretest probability of CAD ECG uninterpretable or unable to exercise High pretest probability of CAD Regardless of ECG interpretability and ability to exercise Stress Echocardiography for Detection of CAD/Risk Assessment: Symptomatic or Ischemic Equivalent Acute Chest Pain A (7) A (7) A (9) A (7) 119. 93. Continued Indication TTE for Evaluation of Hypertension. an intervention To diagnose infective endocarditis with a moderate or high pretest probability (e. 101. 91. hypertrophic. 2011:1126–66 Table 19. or Cardiomyopathy Cardiomyopathies 86. 2011 ..g.

● Abnormal coronary angiography or abnormal prior stress imaging study Stress Echocardiography Following Prior Test Results Prior Noninvasive Evaluation A (7) 153.g.onlinejacc. No. 57. Continued Indication Stress Echocardiography for Detection of CAD/Risk Assessment: Asymptomatic (Without Ischemic Equivalent) in Patient Populations With Defined Comorbidities New-Onset or Newly Diagnosed HF or LV Systolic Dysfunction 128. ● Coronary calcium Agatston score 400 Stress Echocardiography Following Prior Test Results Coronary Angiography (Invasive or Noninvasive) A (7) 141. 2011:1126–66 Douglas et al. 130. ● Appropriate Use Score (1–9) No prior CAD evaluation and no planned coronary angiography Stress Echocardiography for Detection of CAD/Risk Assessment: Asymptomatic (Without Ischemic Equivalent) in Patient Populations With Defined Comorbidities Arrhythmias A (7) 129. or discordant stress testing where obstructive CAD remains a concern Stress Echocardiography for Risk Assessment: Perioperative Evaluation for Noncardiac Surgery Without Active Cardiac Conditions Vascular Surgery A (8) 161.JACC Vol. ● ● Intermediate-risk treadmill score (e. ● Intermediate or high global CAD risk Stress Echocardiography for Detection of CAD/Risk Assessment: Asymptomatic (Without Ischemic Equivalent) in Patient Populations With Defined Comorbidities Elevated Troponin A (7) 135. ● ● ● Hemodynamically stable. ● Equivocal. no recurrent chest pain symptoms. ● Ischemic equivalent Stress Echocardiography for Risk Assessment: Postrevascularization (PCI or CABG) Asymptomatic A (8) 170.g. 2011 March 1.. or nonsustained VT Stress Echocardiography for Detection of CAD/Risk Assessment: Asymptomatic (Without Ischemic Equivalent) in Patient Populations With Defined Comorbidities Syncope A (7) A (7) 134. Appropriate Use Criteria for Echocardiography 1145 Table 19. or no signs of HF To evaluate for inducible ischemia No prior coronary angiography since the index event Stress Echocardiography for Risk Assessment: Postrevascularization (PCI or CABG) Symptomatic A (8) 169. 150. exercise-induced VT.org by on April 19. Duke) Stress Echocardiography Following Prior Test Results New or Worsening Symptoms A (7) A (7) 151. ● ● Incomplete revascularization Additional revascularization feasible A (7) Downloaded from content. 2011 . ● Coronary artery stenosis of unclear significance Stress Echocardiography Following Prior Test Results Treadmill ECG Stress Test A (8) 149. borderline. Duke) High-risk treadmill score (e. ● Troponin elevation without symptoms or additional evidence of ACS Stress Echocardiography Following Prior Test Results Asymptomatic: Prior Evidence of Subclinical Disease A (7) 139. or no signs of HF To evaluate for inducible ischemia No prior coronary angiography since the index event Stress Echocardiography for Risk Assessment: Within 3 Months of an ACS UA/NSTEMI A (7) 166. ● ● 1 clinical risk factor Poor or unknown functional capacity ( 4 METs) Stress Echocardiography for Risk Assessment: Within 3 Months of an ACS STEMI A (7) 164.. no recurrent chest pain symptoms. ● ● ● Hemodynamically stable. ● ● Sustained VT Frequent PVCs. 9.

● Routine surveillance ( 1 y) of known cardiomyopathy without a change in clinical status or cardiac exam U (5) Downloaded from content. ● ● Routine surveillance ( 3 y) of mild valvular regurgitation without a change in clinical status or cardiac exam Routine surveillance ( 1 y) of moderate or severe valvular regurgitation without a change in clinical status or cardiac exam TTE for Evaluation of Hypertension. 2011:1126–66 Table 19.onlinejacc. 2011 . ● Re-evaluation of known hypertensive heart disease without a change in clinical status or cardiac exam TTE for Evaluation of Hypertension. HF. No. or Cardiomyopathy HF U (4) 72. ● Initial evaluation for CRT device optimization after implantation TTE for Evaluation of Hypertension. 57.1146 Douglas et al. or CRT) U (4) U (6) ● 77. HF. 9. 2011 March 1. ● Respiratory failure or hypoxemia when a noncardiac etiology of respiratory failure has been established TTE for Evaluation of Valvular Function Native Valvular Regurgitation U (5) 44. or Cardiomyopathy Cardiomyopathies U (6) 89. Continued Indication Stress Echocardiography for Assessment of Viability/Ischemia Ischemic Cardiomyopathy/Assessment of Viability 176. Uncertain Indications (Median Score 4 – 6) Indication TTE for General Evaluation of Cardiac Structure and Function Perioperative Evaluation 14. 188. ● ● ● Appropriate Use Score (1–9) Known moderate or severe LV dysfunction Patient eligible for revascularization Use of dobutamine stress only Stress Echocardiography for Hemodynamics (Includes Doppler During Stress) Chronic Valvular Disease—Asymptomatic A (8) 179. HF.org by on April 19. ● A (7) A (8) ● ● A indicates appropriate. Appropriate Use Criteria for Echocardiography JACC Vol. HF. ● Appropriate Use Score (1–9) Routine perioperative evaluation of cardiac structure and function prior to noncardiac solid organ transplantation TTE for Cardiovascular Evaluation in an Acute Setting Hypotension or Hemodynamic Instability U (6) 20. Table 20. 202. 185. ● Re-evaluation of known HF (systolic or diastolic) with a change in clinical status or cardiac exam with a clear precipitating change in medication or diet Routine surveillance ( 1 y) of HF (systolic or diastolic) when there is no change in clinical status or cardiac exam TTE for Evaluation of Hypertension. or Cardiomyopathy Hypertension U (4) U (6) 69. ICD. 193. or Cardiomyopathy Device Evaluation (Including Pacemaker. ● ● ● ● Moderate mitral stenosis Evaluation of equivocal aortic stenosis Evidence of low cardiac output or LV systolic dysfunction (“low gradient aortic stenosis”) Use of dobutamine only Moderate mitral regurgitation Contrast Use in TTE/TEE or Stress Echocardiography Selective use of contrast 2 contiguous LV segments are not seen on noncontrast images A (7) A (8) 195. 75. ● ● ● ● ● Severe mitral stenosis Severe mitral regurgitation LV size and function not meeting surgical criteria Severe aortic regurgitation LV size and function not meeting surgical criteria Stress Echocardiography for Hemodynamics (Includes Doppler During Stress) Chronic Valvular Disease—Symptomatic A (7) A (7) A (7) 190. ● Assessment of volume status in a critically ill patient TTE for Cardiovascular Evaluation in an Acute Setting Respiratory Failure U (5) 27. 45.

138. 2011:1126–66 Douglas et al. 9. Continued Indication TTE for Adult Congenital Heart Disease 96. ● ● 1 clinical risk factor Poor or unknown functional capacity ( 4 METs) Stress Echocardiography for Risk Assessment: Postrevascularization (PCI or CABG) Asymptomatic U (6) 172. ● ● ● ● ● Low to intermediate global CAD risk Coronary calcium Agatston score between 100 and 400 High global CAD risk Coronary calcium Agatston score between 100 and 400 Abnormal carotid intimal medial thickness ( 0. No. Appropriate Use Criteria for Echocardiography 1147 Table 20. 140.9 mm and/or the presence of plaque encroaching into the arterial lumen) Stress Echocardiography Following Prior Test Results Asymptomatic or Stable Symptoms Normal Prior Stress Imaging Study U (5) U (6) U (5) 145. 2011 . ● Appropriate Use Score (1–9) Routine surveillance ( 2 y) of adult congenital heart disease following complete repair X without residual structural or hemodynamic abnormality X without a change in clinical status or cardiac exam Routine surveillance ( 1 y) of adult congenital heart disease following incomplete or palliative repair with residual structural or hemodynamic abnormality X without a change in clinical status or cardiac exam X U (6) 97.org by on April 19. ● ● ● ● ● Moderate mitral stenosis Moderate aortic stenosis Severe aortic stenosis Moderate mitral regurgitation Moderate aortic regurgitation U (5) U (6) U (5) U (5) U (5) Downloaded from content. 57. ● Evaluation for cardiovascular source of embolus with a previously identified noncardiac source Stress Echocardiography for Detection of CAD/Risk Assessment: Asymptomatic (Without Ischemic Equivalent) General Patient Populations U (5) 126. 174. ● New-onset atrial fibrillation Stress Echocardiography Following Prior Test Results Asymptomatic: Prior Evidence of Subclinical Disease U (6) 137. 127. ● ● Known CAD on coronary angiography or prior abnormal stress imaging study Last stress imaging study 2 y ago Stress Echocardiography Following Prior Test Results New or Worsening Symptoms U (5) 152. 187. ● ● Intermediate to high global CAD risk Last stress imaging study 2 y ago Stress Echocardiography Following Prior Test Results Asymptomatic or Stable Symptoms Abnormal Coronary Angiography or Abnormal Prior Stress Study No Prior Revascularization U (4) 147.onlinejacc. ● U (5) TEE as Initial or Supplemental Test—Embolic Event 110. 184. ● ● ● Intermediate global CAD risk ECG uninterpretable High global CAD risk Stress Echocardiography for Detection of CAD/Risk Assessment: Asymptomatic (Without Ischemic Equivalent) in Patient Populations With Defined Comorbidities Arrhythmias U (5) U (5) 132. 182. ● Normal coronary angiography or normal prior stress imaging study Stress Echocardiography for Risk Assessment: Perioperative Evaluation for Noncardiac Surgery Without Active Cardiac Conditions Intermediate-Risk Surgery U (6) 157. 2011 March 1.JACC Vol. ● ● 5 y after CABG 2 y after PCI Stress Echocardiography for Hemodynamics (Includes Doppler During Stress) Chronic Valvular Disease—Asymptomatic U (6) U (5) 178. 181.

● ● Suspected pulmonary embolism in order to establish diagnosis Routine surveillance of prior pulmonary embolism with normal right ventricular function and pulmonary artery systolic pressure TTE for Cardiovascular Evaluation in an Acute Setting Cardiac Trauma I (2) I (1) 33. 200.onlinejacc. 194. 40. CT. 43. SPECT MPI. Table 21. screening) with no symptoms or signs of cardiovascular disease Routine surveillance of ventricular function with known CAD and no change in clinical status or cardiac exam Evaluation of LV function with prior ventricular function evaluation showing normal function (e. 2011:1126–66 Table 20. 9. ● Routine perioperative evaluation of ventricular function with no symptoms or signs of cardiovascular disease TTE for General Evaluation of Cardiac Structure and Function Pulmonary Hypertension I (2) 16. 57. ● ● Initial evaluation when there are no other symptoms or signs of valvular or structural heart disease Re-evaluation in a patient without valvular disease on prior echocardiogram and no change in clinical status or cardiac exam TTE for Evaluation of Valvular Function Native Valvular Stenosis I (2) I (1) 38. ● ● ● Suspected pulmonary hypertension Normal or borderline elevated estimated right ventricular systolic pressure on resting echocardiographic study Re-evaluation of patient with exercise-induced pulmonary hypertension to evaluate response to therapy U (5) U (5) U indicates uncertain. 2011 . ● ● Appropriate Use Score (1–9) Infrequent APCs or infrequent VPCs without other evidence of heart disease Asymptomatic isolated sinus bradycardia TTE for General Evaluation of Cardiac Structure and Function Lightheadedness/Presyncope/Syncope I (2) I (2) 8. prior echocardiogram.. 2011 March 1. Inappropriate Indications (Median Score 1–3) Indication TTE for General Evaluation of Cardiac Structure and Function Arrhythmias 3. left ventriculogram. 30. Continued Indication Stress Echocardiography for Hemodynamics (Includes Doppler During Stress) Chronic Valvular Disease—Symptomatic 189. 11. 36. ● ● Routine surveillance ( 3 y) of mild valvular stenosis without a change in clinical status or cardiac exam Routine surveillance ( 1 y) of moderate or severe valvular stenosis without a change in clinical status or cardiac exam TTE for Evaluation of Valvular Function Native Valvular Regurgitation I (3) I (3) 42. 6. ● Routine evaluation in the setting of mild chest trauma with no electrocardiographic changes or biomarker elevation TTE for Evaluation of Valvular Function Murmur or Click I (2) 35.g. ● Lightheadedness/presyncope when there are no other symptoms or signs of cardiovascular disease TTE for General Evaluation of Cardiac Structure and Function Evaluation of Ventricular Function I (3) 10. ● Routine surveillance ( 1 y) of known pulmonary hypertension without change in clinical status or cardiac exam TTE for Cardiovascular Evaluation in an Acute Setting Pulmonary Embolism I (3) 28.. No. 12. ● ● Appropriate Use Score (1–9) Mild mitral stenosis Mild mitral regurgitation Stress Echocardiography for Hemodynamics (Includes Doppler During Stress) Pulmonary Hypertension U (5) U (4) 198. ● ● ● Initial evaluation of ventricular function (e. CMR) in patients in whom there has been no change in clinical status or cardiac exam TTE for General Evaluation of Cardiac Structure and Function Perioperative Evaluation I (2) I (3) I (1) 13.1148 Douglas et al.org by on April 19.g. Appropriate Use Criteria for Echocardiography JACC Vol. ● ● Routine surveillance of trace valvular regurgitation Routine surveillance ( 3 y) of mild valvular regurgitation without a change in clinical status or cardiac exam I (1) I (2) Downloaded from content.

or Cardiomyopathy Hypertension I (2) I (3) I (2) I (2) I (3) ● ● ● 68.JACC Vol. 66.g. ● Routine evaluation of systemic hypertension without symptoms or signs of hypertensive heart disease TTE for Evaluation of Hypertension. ● ● Routine surveillance ( 1 y) of implanted device without a change in clinical status or cardiac exam Routine surveillance ( 1 y) of implanted device without a change in clinical status or cardiac exam TTE for Evaluation of Hypertension. 95. HF. 60. transient fever. ● I (1) 113. ● Routine use of TEE when a diagnostic TTE is reasonably anticipated to resolve all diagnostic and management concerns Surveillance of prior TEE finding for interval change (e. 2011 . HF. ● Routine surveillance ( 1 y) of known cardiomyopathy without a change in clinical status or cardiac exam TTE for Adult Congenital Heart Disease Routine surveillance ( 2 y) of adult congenital heart disease following complete repair without a residual structural or hemodynamic abnormality X without a change in clinical status or cardiac exam X I (2) I (3) ● TEE as Initial or Supplemental Test—General Uses 100. 105.g. ● Appropriate Use Score (1–9) Routine surveillance ( 3 y after valve implantation) of prosthetic valve if no known or suspected valve dysfunction TTE for Evaluation of Valvular Function Infective Endocarditis (Native or Prosthetic Valves) I (3) 53. 80.. 107.org by on April 19. 102. resolution of vegetation after antibiotic therapy) when no change in therapy is anticipated Routine assessment of pulmonary veins in an asymptomatic patient status post pulmonary vein isolation TEE as Initial or Supplemental Test—Valvular Disease To diagnose infective endocarditis with a low pretest probability (e.. 2011 March 1. ● ● Transient fever without evidence of bacteremia or a new murmur Transient bacteremia with a pathogen not typically associated with infective endocarditis and/or a documented nonendovascular source of infection Routine surveillance of uncomplicated infective endocarditis when no change in management is contemplated TTE for Evaluation of Intracardiac and Extracardiac Structures and Chambers Routine surveillance of known small pericardial effusion with no change in clinical status TTE for Evaluation of Aortic Disease Routine re-evaluation for surveillance of known ascending aortic dilation or history of aortic dissection without a change in clinical status or cardiac exam when findings would not change management or therapy TTE for Evaluation of Hypertension. or Cardiomyopathy Cardiomyopathies I (1) I (3) 88. 9. ● Definite ACS I (1) Downloaded from content. ICD. 54. resolution of thrombus after anticoagulation. Appropriate Use Criteria for Echocardiography 1149 Table 21. known alternative source of infection. No. or Cardiomyopathy HF I (3) 74. or CRT) I (2) 79. or Cardiomyopathy Device Evaluation (Including Pacemaker. ● I (2) 114.onlinejacc. ● ● Low pretest probability of CAD ECG interpretable and able to exercise Stress Echocardiography for Detection of CAD/Risk Assessment: Symptomatic or Ischemic Equivalent Acute Chest Pain I (3) 123. 56. or negative blood cultures/atypical pathogen for endocarditis) TEE as Initial or Supplemental Test—Embolic Event Evaluation for cardiovascular source of embolus with a known cardiac source in which a TEE would not change management TEE as Initial Test—Atrial Fibrillation/Flutter Evaluation when a decision has been made to anticoagulate and not to perform cardioversion Stress Echocardiography for Detection of CAD/Risk Assessment: Symptomatic or Ischemic Equivalent Evaluation of Ischemic Equivalent (Nonacute) I (1) I (2) I (3) I (3) ● ● ● 111. HF. 57. 2011:1126–66 Douglas et al. Continued Indication TTE for Evaluation of Valvular Function Prosthetic Valves 48. HF. ● Routine surveillance ( 1 y) of HF (systolic or diastolic) when there is no change in clinical status or cardiac exam TTE for Evaluation of Hypertension.

144. 125. noninvasive test. 2011 . Continued Indication Stress Echocardiography for Detection of CAD/Risk Assessment: Asymptomatic (Without Ischemic Equivalent) General Patient Populations 124. 143. 165. signs of cardiogenic shock. ● Low-risk treadmill score (e.g. ● Perioperative evaluation for risk assessment I (1) Stress Echocardiography for Risk Assessment: Perioperative Evaluation for Noncardiac Surgery Without Active Cardiac Conditions Intermediate-Risk Surgery 155. ● Low global CAD risk Stress Echocardiography Following Prior Test Results Asymptomatic: Prior Evidence of Subclinical Disease I (3) 136.org by on April 19. 160. ● ● ● ● ● ● Low global CAD risk Last stress imaging study Low global CAD risk Last stress imaging study I (1) 2 y ago I (2) 2 y ago I (2) Intermediate to high global CAD risk Last stress imaging study 2 y ago Stress Echocardiography Following Prior Test Results Asymptomatic or Stable Symptoms Abnormal Coronary Angiography or Abnormal Prior Stress Study No Prior Revascularization 146.onlinejacc. 9. ● Infrequent PVCs Stress Echocardiography for Detection of CAD/Risk Assessment: Asymptomatic (Without Ischemic Equivalent) in Patient Populations With Defined Comorbidities Syncope I (3) 133. ● ● Known CAD on coronary angiography or prior abnormal stress imaging study Last stress imaging study 2 y ago Stress Echocardiography Following Prior Test Results Treadmill ECG Stress Test I (3) 148. ● Coronary calcium Agatston score 100 Stress Echocardiography Following Prior Test Results Asymptomatic or Stable Symptoms Normal Prior Stress Imaging Study I (2) 142. or mechanical complications Stress Echocardiography for Risk Assessment: Within 3 Months of an ACS ACS—Asymptomatic Postrevascularization (PCI or CABG) I (2) I (1) 167. ● ● ● Primary PCI with complete revascularization No recurrent symptoms Hemodynamically unstable. 162. 57. 158.1150 Douglas et al. No. 2011:1126–66 Table 21. ● ● ● Appropriate Use Score (1–9) Low global CAD risk Intermediate global CAD risk ECG interpretable Stress Echocardiography for Detection of CAD/Risk Assessment: Asymptomatic (Without Ischemic Equivalent) in Patient Populations With Defined Comorbidities Arrhythmias I (1) I (2) 131. ● ● ● Moderate to good functional capacity ( 4 METs) No clinical risk factors Asymptomatic 1 y post normal catheterization. or previous revascularization I (3) I (2) I (1) Stress Echocardiography for Risk Assessment: Perioperative Evaluation for Noncardiac Surgery Without Active Cardiac Conditions Vascular Surgery 159. or previous revascularization Stress Echocardiography for Risk Assessment: Within 3 Months of an ACS STEMI I (3) I (2) I (2) 163.. 156. Duke) I (1) Stress Echocardiography for Risk Assessment: Perioperative Evaluation for Noncardiac Surgery Without Active Cardiac Conditions Low-Risk Surgery 154. Appropriate Use Criteria for Echocardiography JACC Vol. ● ● ● Moderate to good functional capacity ( 4 METs) No clinical risk factors Asymptomatic 1 y post normal catheterization. ● Prior to hospital discharge in a patient who has been adequately revascularized I (1) Downloaded from content. 2011 March 1. noninvasive test.

● ● 5 y after CABG 2 y after PCI Stress Echocardiography for Risk Assessment: Postrevascularization (PCI or CABG) Cardiac Rehabilitation I (2) I (2) 175. 186. 2011 March 1.onlinejacc. 201. Figure 1.org by on April 19. No. Continued Indication Stress Echocardiography for Risk Assessment: Within 3 Months of an ACS Cardiac Rehabilitation 168. ● Acute moderate or severe mitral or aortic regurgitation Stress Echocardiography for Hemodynamics (Includes Doppler During Stress) Pulmonary Hypertension I (3) 199. ● Appropriate Use Score (1–9) Prior to initiation of cardiac rehabilitation (as a stand-alone indication) Stress Echocardiography for Risk Assessment: Postrevascularization (PCI or CABG) Asymptomatic I (3) 171.JACC Vol. ● Routine evaluation of patients with known resting pulmonary hypertension Contrast Use in TTE/TEE or Stress Echocardiography Routine use of contrast All LV segments visualized on noncontrast images I (3) I (1) ● ● I indicates inappropriate. 2011:1126–66 Douglas et al. 1 to 6). Selected flow diagrams for several categories of indications are included here (Figs. 183. 173. 2011 . Appropriate Use Criteria for Echocardiography 1151 Table 21. 9. 180. 192. Stress Echocardiography for Detection of CAD/Risk Assessment: Symptomatic or Ischemic Equivalent Downloaded from content. 196. 57. ● ● ● ● Mild mitral stenosis Mild aortic stenosis Mild mitral regurgitation Mild aortic regurgitation Stress Echocardiography for Hemodynamics (Includes Doppler During Stress) Chronic Valvular Disease—Symptomatic I (2) I (3) I (2) I (2) 191. ● Prior to initiation of cardiac rehabilitation (as a stand-alone indication) Stress Echocardiography for Hemodynamics (Includes Doppler During Stress) Chronic Valvular Disease—Asymptomatic I (3) 177. ● ● ● ● Severe mitral stenosis Severe aortic stenosis Severe mitral regurgitation Severe LV enlargement or LV systolic dysfunction Stress Echocardiography for Hemodynamics (Includes Doppler During Stress) Acute Valvular disease I (3) I (1) I (3) 197. Visual representations (flow diagrams) for all indications are included in the Online Appendix.

57. Stress Echocardiography for Detection of CAD/Risk Assessment: Asymptomatic (Without Ischemic Equivalent) Figure 3. 2011 .1152 Douglas et al. Coronary Calcium Scoring. 2011:1126–66 Figure 2.onlinejacc. 9. 2011 March 1.org by on April 19. No. Appropriate Use Criteria for Echocardiography JACC Vol. Stress Echocardiography Following Prior Treadmill ECG. or Carotid Intimal Medial Thickness Test Results Downloaded from content.

2011 March 1. No. Stress Echocardiography for Risk Assessment—Perioperative Evaluation for Noncardiac Surgery Without Active Cardiac Conditions Downloaded from content.org by on April 19. Appropriate Use Criteria for Echocardiography 1153 Figure 4. Stress Echocardiography Following Prior Stress Imaging or Coronary Angiogram Test Results Figure 5. 2011 . 9. 2011:1126–66 Douglas et al.onlinejacc.JACC Vol. 57.