Locally Agreed Guidelines May Reduce Inappropriate Preoperative

Echocardiography Requests

Dr Sheila Carey Anaesthetic SpR

Northern Deanery

Background:Preoperative Echocardiography

• Assessment of perioperative cardiac risk is part of anaesthetic preoperative assessment.

• Echocardiography can give useful information on cardiac function but has its limitations.

Background:Sunderland Experience

• Disquiet from cardiology regarding quality and appropriateness of echo requests.

• Uncertainty about indications for pre-operative echo amongst PAAC staff and junior surgical medical staff.

Aims

• Audit all preoperative echocardiogram requests

• Produce local guidelines– Survey local consultant opinion regarding pre

operative echo– Literature review

• Evaluate impact of guidelines

Preoperative Echo Survey: Who needs investigating?

• New murmur with other indicators of AS

• New murmur with no suggestive features of AS

• Stable angina

• Decompensated heart failure

• Known AS. No change in symptoms , no recent echo ( >1 year )

Published Literature / Guidance

• ACC/ AHA Guideline– Recommendations for pre-op non-invasive

evaluation LV Function• Patients with current or poorly controlled HF* ( Class I)• Patients with prior HF / patients with dyspnoea

unknown origin ( Class II)

– Valvular heart disease• If a murmur is present, the clinician will need to decide

whether or not it represents significant valvular disease• AS poses the greatest risk

Published Literature / Guidance

• NCEPOD– 1994/5• Patient with ESM in association with LVH or myocardial

ischaemia should be referred for assessment– 2001• Patients can be asymptomatic despite mod – severe AS

and hence an asymptomatic cardiac murmur should be investigated preoperatively by echocardiography• NCEPOD recognises the spiralling increase in workload

this causes but echocardiography services should be accorded an appropriate priority with regards funding

Published Literature / Guidance

• Appropriateness Criteria for TTE and TOE (ACCF / ASE / ACEP et al)– Symptoms due to suspected cardiac aetiology (not

previously investigated) (9)– Initial investigation of murmur where there is

reasonable suspicion of valvular or structural disease (9)– Re-evaluation of a patient with known valvular heart

disease with a change in clinical status (9)– Routine ( yearly) evaluation of an asymptomatic patient

with severe stenosis (7)

Published Literature / Guidance

• Pandit (2004)– Maximising the benefit from pre-operative cardiac

evaluation– The uninvestigated murmur• NCEPOD guidelines extremely cautious• Implementation would increase demand greatly on

echo services• Local guidelines should be jointly developed

Proposed Guidelines for Preoperative Echocardiography

1) Dyspnoea of unknown origin where there is suspicion of cardiac component or known IHD with poor functional capacity.

2) Previously undiagnosed systolic murmur with elements suggestive of aortic stenosis, ECG abnormalities or symptoms.

3) Known aortic stenosis with a change in symptoms since last echo , or if due for routine follow-up echo

4) Patients with current / poorly controlled heart failure (NYHA grade III-IV) and no echo in past two years confirming moderate - severe LV dysfunction.

Review of Echocardiogram requests

• Preoperative requests collected over a 6 week period.

• Reviewed by Consultant Cardiologist to determine appropriateness.

• Inappropriate requests – patient note review.

• Indications compared against new guidelines

Results

• Twenty eight requests for preoperative echocardiography

• 7/28 ( 25%) deemed as acceptable by Cardiology

• 21 (75%) unacceptable requests– 14 murmurs / added sounds– 4 Left ventricular Function– 3 nature of surgery

Analysis of Unacceptable Requests

• 16 Unacceptable requests from Trauma & Orthopaedic Department

• 12 sets of notes reviewed

• 9 requests could have been prevented (75%) using guidelines

Conclusions 1• No consensus amongst senior medical staff

regarding who requires investigation

• Personal preference probably dictates choice except when clear cut suspicion of AS

• Advice given to other staff, (e.g. trainees, PAAC nurses) likely to be inconsistent

• Guidelines may improved this

Sunderland echocardiogram request

Conclusions 2

• A significant proportion preoperative echocardiogram requests are unacceptable

• Retrospective application of guidelines suggests inappropriate requests could be reduced

• Potential for a rise in number of requests if patients selected more appropriately

Limitations

• Cardiology review subjective

• Retrospective analysis

• Prospective Audit needed to clarify the effect of introducing guidelines

Recommendations

• Investigation should only be considered if management will be affected

• Information given on request form has to be relevant and detailed

• Local guidelines can help direct appropriate use of resources