NEW YORK (Reuters Health) - Most assessments of nonvalvular heart disease should begin with transthoracic echocardiogram (TTE), according to 2019 Appropriate Use Criteria (AUC) from several U.S. medical societies.
The AUC address the use of multimodality imaging for the initial evaluation of cardiac structure and function in nonvalvular heart disease, sequential or follow-up testing and evaluation of patients undergoing transcatheter interventions for structural heart disease. Detailed tables provide recommendations for 103 clinical scenarios.
"Rather than controversial, the recommendations are systematic," said Dr. John U. Doherty from Sidney Kimmel Medical College, Thomas Jefferson University, in Philadelphia, who chaired the writing group and co-chaired the AUC Task Force.
"They present a layered approach to the diagnosis and treatment of structural heart disease. This often involves initial transthoracic echocardiography followed by advanced imaging where necessary," he told Reuters Health by email.
The new advice - from the American College of Cardiology, the American Association for Thoracic Surgery, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the Heart Rhythm Society, the Society for Cardiovascular Angiography and Interventions, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance and the Society of Thoracic Surgeons - was published online January 7 in the Journal of the American College of Cardiology.
For the initial evaluation of asymptomatic patients, TTE is the appropriate imaging strategy for all clinical scenarios, according to the authors. TTE is also appropriate for the initial evaluation of most patients with clinical signs and/or symptoms of cardiac disease.
Coronary angiography is deemed appropriate for the evaluation of patients with sustained ventricular tachycardia or ventricular fibrillation, whereas cardiac MR and cardiac CT may be appropriate for evaluating mechanical complications of myocardial infarction.
For sequential testing to clarify the initial diagnosis, cardiac MR was ranked appropriate and of significant diagnostic utility across a variety of disease states. Cardiac MR, cardiac CT and transesophageal echocardiography can be useful for evaluating aortic sinuses and the ascending aorta when TTE does not prove definitive.
Sequential or follow-up testing to assess for clinical stability once a diagnosis is established and the patient is asymptomatic or stable is rarely appropriate in less than one year in most patients.
On the other hand, repeat imaging with TTE, strain imaging and radionuclide ventriculography is appropriate in less than a year in patients who require imaging after having undergone therapy with potentially cardiotoxic agents, including chemotherapy.
In the setting of new or worsening symptoms or to guide therapy, TTE was generally ranked appropriate for most clinical scenarios, although there was a significant role for transesophageal echocardiography in such specific indications as evaluation of the thoracic aorta and resolution of intracardiac thrombus. Cardiac MR and CT were also useful for a variety of indications.
The AUC also address imaging for the evaluation of TIA or ischemic stroke; preprocedural, intraprocedural and postoperative assessment for closure of patent foramen ovale or atrial septal defect; and preprocedural, intraprocedural and postoperative assessment for left atrial appendage occlusion.
"A systematic approach to the patient at risk of heart disease, with asymptomatic heart disease and with symptomatic heart disease, can be fashioned using transthoracic echocardiography as well as advanced imaging techniques," Dr. Doherty said. "The expectation is that the manuscript with its tables will provide guidance to clinicians when they encounter a specific cardiac diagnosis or where there is suspicion of a specific cardiac diagnosis."
The recommendations have been reprinted in the Journal of the American Society of Echocardiography, Catheterization and Cardiovascular Interventions, the Journal of Cardiovascular Computed Tomography, the Journal of Nuclear Cardiology and the Journal of Thoracic and Cardiovascular Surgery.
J Am Coll Cardiol 2019.