When it comes to heart tests, order wisely

Jody Welborn, M.D.

Jody Welborn, M.D.
Medical director, echocardiography
Providence Portland Medical Center
Cardiologist, Providence Heart Clinic at The Oregon Clinic Gateway

Published June 2013

Overtesting has become a topic of debate in medicine – the result of increased scrutiny under health reform and the growing trend of health care providers to order more tests than are clinically justified. 

A little more than a year ago, the national Choosing Wisely initiative was launched to help cut the use of inappropriate tests and procedures while also maintaining quality of care. 
Nine partners, including the American College of Cardiology, provided guidelines for evidence-based care in their specialties. The hope was that the initiative would spark conversations between patients and doctors about appropriate care.

After the success with the original nine subspecialties, the American Society of Echocardiography was invited to join the Choosing Wisely initiative. In February of this year it published its first set of evidence-based guidelines. We’re republishing these guidelines with permission from Choosing Wisely:

  1. Don’t order follow-up or serial echocardiograms for surveillance after a finding of trace valvular regurgitation on an initial echocardiogram. Trace mitral, tricuspid and pulmonic regurgitation can be detected in 70 to 90 percent of normal individuals and has no adverse clinical implications. The clinical significance of a small amount of aortic regurgitation with an otherwise normal echocardiographic study is unknown.

  2. Don’t repeat echocardiograms in stable, asymptomatic patients with a murmur or click, where a previous exam revealed no significant pathology. Repeat imaging to address the same question, when no pathology has been previously found and there has been no clinical change in the patient’s condition, is not indicated.

  3. Avoid echocardiograms for preoperative/perioperative assessment of patients with no history or symptoms of heart disease. Perioperative echocardiography is used to clarify signs or symptoms of cardiovascular disease, or to investigate abnormal heart tests. Resting left ventricular (LV) function is not a consistent predictor of perioperative ischemic events; even reduced LV systolic function has poor predictive value for perioperative cardiac events.

  4. Avoid using stress echocardiograms on asymptomatic patients who meet “low-risk” scoring criteria for coronary disease. Stress echocardiography is used mostly in symptomatic patients to assist in the diagnosis of obstructive coronary artery disease. There is very little information on using stress echocardiography in asymptomatic individuals for the purposes of cardiovascular risk assessment, as a stand-alone test or in addition to conventional risk factors.

  5. Avoid transesophageal echocardiography (TEE) to detect cardiac sources of embolization if a source has been identified and patient management will not change. Tests whose results will not alter management should not be ordered. Protocol-driven testing can be useful if it serves as a reminder not to omit a test or procedure, but should always be individualized to the particular patient. While TEE is safe, even the small degree of risk associated with a procedure is not justified if there is no expected clinical benefit.

These guidelines are just the beginning. However, they’re an important beginning because the recommendations are coming from physicians. We know what does and doesn’t work, and our best minds are beginning to emphasize thoughtful diagnostic and therapeutic testing. These guidelines give us a tool to help educate our patients about appropriate testing.
Stay tuned – there’s more to come.