IJCA-18026; No of Pages 2 International Journal of Cardiology xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Appropriate use of transesophageal echocardiography at a primary care medical center Craig William Raphael a,1, Darcy Green Conaway a,b,⁎,1 a b
University of Missouri-Kansas City School of Medicine, United States Truman Medical Center, United States
a r t i c l e
i n f o
Article history: Received 6 April 2014 Accepted 9 April 2014 Available online xxxx Keywords: Transesophageal Echocardiography Appropriate use criteria
In response to the increased rate of cardiovascular imaging studies being performed annually and to encourage a rationale use of cardiovascular imaging, the Appropriate Use Criteria (AUC) for Echocardiography was established in 2007, with an update in 2011 [1–11]. These criteria defined a standard set of procedural indications for performing echocardiography and classified each indication as being appropriate, uncertain, or inappropriate [2,3]. A number of medical centers have used these AUC to assess their own utilization of transesophageal echocardiography (TEE). Whereas many studies have taken place at tertiary centers where patients are referred for cardiac consultation, none to our knowledge has been conducted at a primary care hospital where patients come for medical care on their own accord. The majority of our patients are relatively young and indigent, and they typically rely upon our hospital rather than seek medical care elsewhere. The objectives of this study were three-fold: 1) to evaluate whether the procedural indications for TEEs at our primary care institution differed from previous studies given the different characters of our patient population, 2) to determine whether TEEs conducted on our patient population complied with the most recent AUC criteria, and 3) to assess whether performing these TEEs impacted the downstream management of our patients.
⁎ Corresponding author at: 2301 Holmes Street, Kansas City, MO 64108, United States. Tel.: +1 913 449 3495; fax: +1 816 404 1257. E-mail address: [email protected] (D.G. Conaway). 1 This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
Medical records from 412 consecutive patients who underwent TEEs at Truman Medical Center, a large city-based primary care hospital, during a 4-year period (January 2007–December 2010) were retrospectively reviewed. Clinical demographics included patient's age, sex, race, procedural indication, TEE findings, and findings from prior transthoracic studies. TEE results were reviewed by a board-certified cardiologist (DGC), and appropriateness scores were assigned according to the 2011 AUC [3]. Results were further evaluated for a) no abnormalities, b) abnormal findings related to valvular structure, function, and intracardiac thrombi or masses, and c) clinically important abnormal findings that were not noted on prior imaging studies or were newly identified. Regarding bacteremia, important TEE abnormal findings included intracardiac vegetations not previously seen on transthoracic echocardiography (TTE), or significant interval changes from a prior TTE. For TEEs performed to evaluate a cardiac source of emboli (CSE) or atrial fibrillation/flutter (A-fib/flutter), important abnormal findings included left atrial appendage thrombi or thrombi elsewhere within the heart. In order to simplify data analysis, we regrouped the 15 different TEE clinical indications defined by the 2011 AUC into 5 broad categories: 1) evaluation of possible bacteremia, 2) evaluation of a possible CSE, 3) evaluation of A-fib/flutter to make clinical decisions regarding cardioversion, 4) evaluation of cardiac valvular structure and function prior to surgery, and 5) other (such as poor visualization of the heart by TTE). Of the 412 consecutive patients, 170 (41.0%) were female and 242 (59.0%) were male, ranging in age from 18 to 94 (mean age of 53 years). This population was 49.5% African American, 40.0% Caucasian, 7.3% Hispanic, and 3.2% had mixed racial backgrounds. The largest group of patients (38.4%) at our institution had TEEs performed for evaluation of bacteremia with an organism considered high risk for endocarditis: Staphylococcus (76.9%), Streptococcus (11.1%), Enterococcus (6.5%), and various organisms (5.4%). Of these 158 patients, 50 (31.6%) were managed with hemodialysis. Following bacteremia, TEEs were performed for evaluating valvular structure and function (24.7%), identifying a potential CSE (19.4%), and deciding upon cardioversion for patient with A-fib/flutter (13.3%). All 412 procedures reviewed in this study were classifiable by the 2011 AUC. Of procedures performed, 388 (94.1%) were “appropriate”, 6 studies (1.5%) were “uncertain”, and 18 studies (4.4%) were “inappropriate”. As shown in Table 1, TEEs identified important abnormal findings in 12.7% of the bacteremic patients, 6.4% of patients evaluated for CSE, and in 23.6% of the patients with A-fib/flutter. Of the 20 bacteremic patients with important abnormal findings, one-half were on hemodialysis.
http://dx.doi.org/10.1016/j.ijcard.2014.04.125 0167-5273/© 2014 Published by Elsevier Ireland Ltd.
Please cite this article as: Raphael CW, Conaway DG, Appropriate use of transesophageal echocardiography at a primary care medical center, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.04.125
2
C.W. Raphael, D.G. Conaway / International Journal of Cardiology xxx (2014) xxx–xxx
Table 1 TEE findings based upon clinical indications. Clinical indication
No findings
Abnormal findingsa
Important abnormal findings
Bacteremia CSE A-fib/flutter
69 (43.7%) 48 (61.5%) 14 (25.4%)
89 (56.3%) 30 (38.5%) 41 (74.5%)
20 (12.7%) 5 (6.4%) 13 (23.6%)
A-fib/flutter — atrial fibrillation or flutter. CSE — cardiac source of emboli. TEE — transesophageal echocardiography. a Any variation from a normal TEE.
Our study population differed from those previously reported in several ways. First, our study took place at a primary care hospital where the relatively younger, mainly indigent population rarely seeks preventative medical care. Additionally, the largest subgroup of TEEs performed in our study was ordered for the clinical indication of bacteremia at a substantially higher rate (38.4%) than that seen in other studies. Only 18% of the patients studied by Ogbara et al., 10.5% of the patients studied by Aggarwal et al., 10.0% of the patients reported by Rao et al., and none of the patients evaluated by Alquarqaz et al. had bacteremia as a primary clinical indication for performing TEEs [1,4,5,8]. Perhaps the unusually high percentage of bacteremia seen at our center reflects the fact that many of our patients have end stage renal disease (on dialysis) and/or intravenous drug abuse, predisposing them to bacteremia. The remaining clinical indications for TEEs at our facility were in fact similar to tertiary medical center studies, but the relative proportions of each indication differed from those previously reported, differentiating our patient population from the others. Despite the different populations, the TEEs performed at our primary care hospital were highly appropriate and complied with the 2011 AUC standards. Perhaps the most critical parameter to consider, however, is whether performing TEEs impacted the subsequent medical care of our patients. In our study, conducting TEEs on patients presenting with bacteremia was instrumental in identifying 20 patients (12.7%) with clinically important abnormal findings compatible with new or worsening bacterial endocarditis. With an annual mortality rate approaching 40% in bacteremic patients who develop endocarditis, or have progression of their valvular disease, it is essential to confidently identify cardiac vegetations and rapidly intervene with aggressive medical care in order to limit the risk of heart failure, conduction abnormalities, and/or embolic phenomena that frequently causes morbidity and mortality [12–14]. The results of these TEEs were promptly provided to the patients' primary care physicians, allowing them to modify the subsequent clinical management of these 20 patients diagnosed with active endocarditis.
In conclusion, TEEs ordered and conducted at this primary care hospital complied highly with the 2011 AUC, were critically important in establishing the diagnosis of new or worsening endocarditis, and significantly impacted the subsequent clinical care and management of our patient population. References [1] Rao GA, Sajnani NV, Kusnetzky LL, Main ML. Appropriate utilization of transesophageal echocardiography. Am J Cardiol 2009;103(5):727–9. [2] Douglas PS, Khandheria B, Stainback RF, et al. ACCF/ASE/ACEP/ASNC/SCAI/SCCT/ SCMR 2007 appropriateness criteria for transthoracic and transesophageal echocardiography: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American Society of Echocardiography, American College of Emergency Physicians, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and the Society for Cardiovascular Magnetic Resonance endorsed by the American College of Chest Physicians and the Society of Critical Care Medicine. J Am Soc Echocardiogr 2007;20:787–805. [3] Douglas PS, Garcia MJ, Haines DE, et al. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/ SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance American College of Chest Physicians. J Am Soc Echocardiogr 2011;24(3):229–67. [4] Ogbara J, Logani S, Ky B, et al. The utility of prescreening transesophageal echocardiograms: a prospective study. Echocardiography 2011;28(7):767–73. [5] Alquarqaz M, Koneru J, Mahan M, Ananthasubramaniam K. Applicability, limitations and downstream impact of echocardiography utilization based on the appropriateness use criteria for transthoracic and transesophageal echocardiography. Int J Cardiovasc Imaging 2012;28(8):1951–8. [6] Kirkpatrick JH, Ky B, Rahmouni HW, et al. Application of appropriateness criteria in outpatient transthoracic echocardiography. J Am Soc Echocardiogr 2009;22 (1):53–9. [7] Bhave NM, Mansour IN, Veronesi F, Razi RR, Lang RM, Ward RP. Use of a web-based application of the American College of Cardiology Foundation/American Society of Echocardiography appropriateness use criteria for transthoracic echocardiography: a pilot study. J Am Soc Echocardiogr 2011;24:271–6. [8] Aggarwal NR, Wurthiwaropas P, Karon BL, Miller FA, Pellikka PA. Application of the appropriateness criteria for echocardiography in an academic medical center. J Am Soc Echocardiogr 2010;23:267–74. [9] Mansour IN, Lang RM, Furlong KT, Ryan A, Ward RP. Evaluation of the application of the ACCF/ASE appropriateness criteria for transesophageal echocardiography in an academic medical center. J Am Soc Echocardiogr 2009;22(5):517–22. [10] Mansour IN, Razi RR, Bahave NM, Ward RP. Comparison of the updated 2011 appropriate use criteria for echocardiography to the original criteria for transthoracic, transesophageal, and stress echocardiography. J Am Soc Echocardiogr 2012;25 (11):1153–61. [11] Bhatia RS, Carne DM, Picard MH, Weiner RB. Comparison of the 2007 and 2011 appropriate use criteria for transeophageal echocardiography. J Am Soc Echocardiogr 2012;25(11):1170–5. [12] Powe NP, Jaar B, Furth SL, Hermann J, Briggs W. Septicemia in dialysis patients: incidence, risk factors, and prognosis. Kidney Int 1999;55:1081–90. [13] Kini J, Logani S, Ky B, et al. Transthoracic and transesophageal echocardiography for the indication of suspected infective endocarditis: vegetations, blood cultures and imaging. J Am Soc Echocardiogr 2010;23(4):396–402. [14] Jacob S, Tong AT. Role of echocardiography in the diagnosis and management of infective endocarditis. Curr Opin Cardiol 2002;17:478–85.
Please cite this article as: Raphael CW, Conaway DG, Appropriate use of transesophageal echocardiography at a primary care medical center, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.04.125
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Appropriate use of transesophageal echocardiography at a primary care medical center Craig William Raphael a,1, Darcy Green Conaway a,b,⁎,1 a b
University of Missouri-Kansas City School of Medicine, United States Truman Medical Center, United States
a r t i c l e
i n f o
Article history: Received 6 April 2014 Accepted 9 April 2014 Available online xxxx Keywords: Transesophageal Echocardiography Appropriate use criteria
In response to the increased rate of cardiovascular imaging studies being performed annually and to encourage a rationale use of cardiovascular imaging, the Appropriate Use Criteria (AUC) for Echocardiography was established in 2007, with an update in 2011 [1–11]. These criteria defined a standard set of procedural indications for performing echocardiography and classified each indication as being appropriate, uncertain, or inappropriate [2,3]. A number of medical centers have used these AUC to assess their own utilization of transesophageal echocardiography (TEE). Whereas many studies have taken place at tertiary centers where patients are referred for cardiac consultation, none to our knowledge has been conducted at a primary care hospital where patients come for medical care on their own accord. The majority of our patients are relatively young and indigent, and they typically rely upon our hospital rather than seek medical care elsewhere. The objectives of this study were three-fold: 1) to evaluate whether the procedural indications for TEEs at our primary care institution differed from previous studies given the different characters of our patient population, 2) to determine whether TEEs conducted on our patient population complied with the most recent AUC criteria, and 3) to assess whether performing these TEEs impacted the downstream management of our patients.
⁎ Corresponding author at: 2301 Holmes Street, Kansas City, MO 64108, United States. Tel.: +1 913 449 3495; fax: +1 816 404 1257. E-mail address: [email protected] (D.G. Conaway). 1 This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
Medical records from 412 consecutive patients who underwent TEEs at Truman Medical Center, a large city-based primary care hospital, during a 4-year period (January 2007–December 2010) were retrospectively reviewed. Clinical demographics included patient's age, sex, race, procedural indication, TEE findings, and findings from prior transthoracic studies. TEE results were reviewed by a board-certified cardiologist (DGC), and appropriateness scores were assigned according to the 2011 AUC [3]. Results were further evaluated for a) no abnormalities, b) abnormal findings related to valvular structure, function, and intracardiac thrombi or masses, and c) clinically important abnormal findings that were not noted on prior imaging studies or were newly identified. Regarding bacteremia, important TEE abnormal findings included intracardiac vegetations not previously seen on transthoracic echocardiography (TTE), or significant interval changes from a prior TTE. For TEEs performed to evaluate a cardiac source of emboli (CSE) or atrial fibrillation/flutter (A-fib/flutter), important abnormal findings included left atrial appendage thrombi or thrombi elsewhere within the heart. In order to simplify data analysis, we regrouped the 15 different TEE clinical indications defined by the 2011 AUC into 5 broad categories: 1) evaluation of possible bacteremia, 2) evaluation of a possible CSE, 3) evaluation of A-fib/flutter to make clinical decisions regarding cardioversion, 4) evaluation of cardiac valvular structure and function prior to surgery, and 5) other (such as poor visualization of the heart by TTE). Of the 412 consecutive patients, 170 (41.0%) were female and 242 (59.0%) were male, ranging in age from 18 to 94 (mean age of 53 years). This population was 49.5% African American, 40.0% Caucasian, 7.3% Hispanic, and 3.2% had mixed racial backgrounds. The largest group of patients (38.4%) at our institution had TEEs performed for evaluation of bacteremia with an organism considered high risk for endocarditis: Staphylococcus (76.9%), Streptococcus (11.1%), Enterococcus (6.5%), and various organisms (5.4%). Of these 158 patients, 50 (31.6%) were managed with hemodialysis. Following bacteremia, TEEs were performed for evaluating valvular structure and function (24.7%), identifying a potential CSE (19.4%), and deciding upon cardioversion for patient with A-fib/flutter (13.3%). All 412 procedures reviewed in this study were classifiable by the 2011 AUC. Of procedures performed, 388 (94.1%) were “appropriate”, 6 studies (1.5%) were “uncertain”, and 18 studies (4.4%) were “inappropriate”. As shown in Table 1, TEEs identified important abnormal findings in 12.7% of the bacteremic patients, 6.4% of patients evaluated for CSE, and in 23.6% of the patients with A-fib/flutter. Of the 20 bacteremic patients with important abnormal findings, one-half were on hemodialysis.
http://dx.doi.org/10.1016/j.ijcard.2014.04.125 0167-5273/© 2014 Published by Elsevier Ireland Ltd.
Please cite this article as: Raphael CW, Conaway DG, Appropriate use of transesophageal echocardiography at a primary care medical center, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.04.125
2
C.W. Raphael, D.G. Conaway / International Journal of Cardiology xxx (2014) xxx–xxx
Table 1 TEE findings based upon clinical indications. Clinical indication
No findings
Abnormal findingsa
Important abnormal findings
Bacteremia CSE A-fib/flutter
69 (43.7%) 48 (61.5%) 14 (25.4%)
89 (56.3%) 30 (38.5%) 41 (74.5%)
20 (12.7%) 5 (6.4%) 13 (23.6%)
A-fib/flutter — atrial fibrillation or flutter. CSE — cardiac source of emboli. TEE — transesophageal echocardiography. a Any variation from a normal TEE.
Our study population differed from those previously reported in several ways. First, our study took place at a primary care hospital where the relatively younger, mainly indigent population rarely seeks preventative medical care. Additionally, the largest subgroup of TEEs performed in our study was ordered for the clinical indication of bacteremia at a substantially higher rate (38.4%) than that seen in other studies. Only 18% of the patients studied by Ogbara et al., 10.5% of the patients studied by Aggarwal et al., 10.0% of the patients reported by Rao et al., and none of the patients evaluated by Alquarqaz et al. had bacteremia as a primary clinical indication for performing TEEs [1,4,5,8]. Perhaps the unusually high percentage of bacteremia seen at our center reflects the fact that many of our patients have end stage renal disease (on dialysis) and/or intravenous drug abuse, predisposing them to bacteremia. The remaining clinical indications for TEEs at our facility were in fact similar to tertiary medical center studies, but the relative proportions of each indication differed from those previously reported, differentiating our patient population from the others. Despite the different populations, the TEEs performed at our primary care hospital were highly appropriate and complied with the 2011 AUC standards. Perhaps the most critical parameter to consider, however, is whether performing TEEs impacted the subsequent medical care of our patients. In our study, conducting TEEs on patients presenting with bacteremia was instrumental in identifying 20 patients (12.7%) with clinically important abnormal findings compatible with new or worsening bacterial endocarditis. With an annual mortality rate approaching 40% in bacteremic patients who develop endocarditis, or have progression of their valvular disease, it is essential to confidently identify cardiac vegetations and rapidly intervene with aggressive medical care in order to limit the risk of heart failure, conduction abnormalities, and/or embolic phenomena that frequently causes morbidity and mortality [12–14]. The results of these TEEs were promptly provided to the patients' primary care physicians, allowing them to modify the subsequent clinical management of these 20 patients diagnosed with active endocarditis.
In conclusion, TEEs ordered and conducted at this primary care hospital complied highly with the 2011 AUC, were critically important in establishing the diagnosis of new or worsening endocarditis, and significantly impacted the subsequent clinical care and management of our patient population. References [1] Rao GA, Sajnani NV, Kusnetzky LL, Main ML. Appropriate utilization of transesophageal echocardiography. Am J Cardiol 2009;103(5):727–9. [2] Douglas PS, Khandheria B, Stainback RF, et al. ACCF/ASE/ACEP/ASNC/SCAI/SCCT/ SCMR 2007 appropriateness criteria for transthoracic and transesophageal echocardiography: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American Society of Echocardiography, American College of Emergency Physicians, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and the Society for Cardiovascular Magnetic Resonance endorsed by the American College of Chest Physicians and the Society of Critical Care Medicine. J Am Soc Echocardiogr 2007;20:787–805. [3] Douglas PS, Garcia MJ, Haines DE, et al. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/ SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance American College of Chest Physicians. J Am Soc Echocardiogr 2011;24(3):229–67. [4] Ogbara J, Logani S, Ky B, et al. The utility of prescreening transesophageal echocardiograms: a prospective study. Echocardiography 2011;28(7):767–73. [5] Alquarqaz M, Koneru J, Mahan M, Ananthasubramaniam K. Applicability, limitations and downstream impact of echocardiography utilization based on the appropriateness use criteria for transthoracic and transesophageal echocardiography. Int J Cardiovasc Imaging 2012;28(8):1951–8. [6] Kirkpatrick JH, Ky B, Rahmouni HW, et al. Application of appropriateness criteria in outpatient transthoracic echocardiography. J Am Soc Echocardiogr 2009;22 (1):53–9. [7] Bhave NM, Mansour IN, Veronesi F, Razi RR, Lang RM, Ward RP. Use of a web-based application of the American College of Cardiology Foundation/American Society of Echocardiography appropriateness use criteria for transthoracic echocardiography: a pilot study. J Am Soc Echocardiogr 2011;24:271–6. [8] Aggarwal NR, Wurthiwaropas P, Karon BL, Miller FA, Pellikka PA. Application of the appropriateness criteria for echocardiography in an academic medical center. J Am Soc Echocardiogr 2010;23:267–74. [9] Mansour IN, Lang RM, Furlong KT, Ryan A, Ward RP. Evaluation of the application of the ACCF/ASE appropriateness criteria for transesophageal echocardiography in an academic medical center. J Am Soc Echocardiogr 2009;22(5):517–22. [10] Mansour IN, Razi RR, Bahave NM, Ward RP. Comparison of the updated 2011 appropriate use criteria for echocardiography to the original criteria for transthoracic, transesophageal, and stress echocardiography. J Am Soc Echocardiogr 2012;25 (11):1153–61. [11] Bhatia RS, Carne DM, Picard MH, Weiner RB. Comparison of the 2007 and 2011 appropriate use criteria for transeophageal echocardiography. J Am Soc Echocardiogr 2012;25(11):1170–5. [12] Powe NP, Jaar B, Furth SL, Hermann J, Briggs W. Septicemia in dialysis patients: incidence, risk factors, and prognosis. Kidney Int 1999;55:1081–90. [13] Kini J, Logani S, Ky B, et al. Transthoracic and transesophageal echocardiography for the indication of suspected infective endocarditis: vegetations, blood cultures and imaging. J Am Soc Echocardiogr 2010;23(4):396–402. [14] Jacob S, Tong AT. Role of echocardiography in the diagnosis and management of infective endocarditis. Curr Opin Cardiol 2002;17:478–85.
Please cite this article as: Raphael CW, Conaway DG, Appropriate use of transesophageal echocardiography at a primary care medical center, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.04.125
