Direct Access Echocardiogram

Scope

Direct Access Echocardiogram is suitable for a new murmur in a well patient.

For suspected heart failure a Serum natriuretic peptides is a prerequisite to triage for cardiology assessment with echo, or to rule out heart failure (unless patient has a previous history of myocardial infarction (MI) then refer for cardiology assessment with echo within 2 weeks, no need to test) ( Heart Failure guideline)

Atrial Fibrillation (AF): NICE guidelines suggest cardiology assessment with echo may be appropriate for AF (see Investigations)

Please note pre-referral criteria are applicable in this referral.

Key pre-referral criteria summary:

Echo requests will be returned to the referrer if:

  • Not on the correct form
  • Not accompanied by a recent ECG
  • NTproBNP level not included (except in previous proven MI or male patient with ankle oedema)

Out of scope

Patients under 18 years of age

Investigation

  1. If heart failure is suspected in a patient who has a previous history of a myocardial infarction (MI) arrange echo within 2 weeks
  2. Patients confirmed with a new diagnosis of Atrial Fibrillation (AF), NICE (2006) suggest the following patients are referred for echocardiography:
    • If a baseline echocardiogram is important for long-term management (such as in a younger patient)
    • If considering a rhythm-control strategy that includes electrical or pharmacological cardioversion
    • If you suspect underlying structural or functional heart disease (failure or murmur) that would influence management, such as choice of antiarrhythmic drug
    • Where needed to help with stratifying stroke risk for antithrombotic therapy, but only where clinical evidence is needed of left ventricular dysfunction or valve disease.
  3. Patients with a new murmur who are otherwise fit and well
  4. Suspected heart failure with no previous history of MI - do a NTproBNP blood test or BNP
    • NTproBNP level less than 400 pg/ml or BNP of less than 100 in an untreated patient makes a diagnosis of heart failure unlikely
    • NTproBNP = 400-2000pg/ml or BNP of 100-400ng/l is an indication of heart failure. Refer patients with suspected heart failure to have transthoracic Doppler 2D echocardiography within 6 weeks
    • NTproBNP = greater than 2000pg/ml or BNP of more than 400ng/l is a significant indication of heart failure and should be referred within 2 weeks
Serum natriuretic peptides also raised in:
  • Other causes of left ventricular strain e.g:
    aortic stenosis, uncontrolled hypertension
  • Atrial fibrillation
  • Right ventricular strain e.g:
    pulmonary embolus, pulmonary hypertension
  • Renal failure, rheumatoid arthritis
Serum natriuretic peptides can be suppressed by:
  • Diuretics
  • ACEI/ARB
  • Beta blockers

Interpret with care

Patients with Serum natriuretic peptides in the normal range will not be routinely offered echo. Therefore, where a patient's Serum natriuretic peptides level is equal to, or below, those relevant for their gender and age, their referral will be returned to practice for consideration for re-referral directly for cardiological opinion.

Referral

Referral Criteria

Echo requests will be returned to the referrer if:

  • Not on the correct form
  • Not accompanied by a recent ECG
  • Serum natriuretic peptides level not included (except in previous proven MI or male patient with ankle oedema)

Referrals will be returned if the criteria are not evident in the referral.

*All other patients should be referred directly for cardiological opinion* and DRSS will now be returning any referrals outside of the agreed criteria for re-referral through the correct route with immediate effect.

Patients with a new murmur or Atrial Fibrillation can be referred for an Echocardiogram but do not require a NTproBNP level.

Referral Instructions

Referral for Echocardiogram

Complete proforma below and attach to e-Referrals

  • Specialty: Diagnostics
  • Clinic Type: Echocardiography
  • Service: DRSS-Eastern-Echocardiogram-Devon CCG- 15N
Referral to Cardiology
  • Specialty: Cardiology
  • Clinic Type: Not Otherwise Specified
  • Service: DRSS-Eastern-Cardiology-Devon CCG- 15N

Referral Forms

Direct Access Echocardiography request form - emisweb

Direct Access Echocardiography request from - Microtest

Direct Access Echocardiography request from - No merge fields

Direct Access Echocardiography request form - Systmone

Supporting Information

Pathway Group

This guideline has been signed off by the Eastern Locality on behalf of NEW Devon CCG.

Publication date: January 2017

 

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