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The IAC Standards
and Guidelines |
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Echocardiography Standards |
STANDARD
– Instrumentation
3.1B Cardiac
Ultrasound Systems
3.1.1B Ultrasound
instruments utilized for stress echocardiographic studies must include, at a
minimum, hardware and software to perform:
3.1.1.2B 2-D
imaging. The system
must include harmonic capabilities.
3.1.1.3B Spectral
display for pulsed (PW) and continuous wave (CW) Doppler studies and tissue Doppler imaging;
3.1.1.5B Monitor
or other display method of suitable size and quality for observation and
interpretation of all modalities.
Comment: The display or DICOM header must identify the parent institution, the name of the patient, second patient identifier (such as MRN or DOB), the date and time of the study. The ECG must also be displayed.
3.1.1.6B Range
or depth markers must be available on all displays
3.1.1.7B Capabilities
to measure the distance between two points, an area on a 2-D image, blood flow
velocities, time intervals, and peak and mean gradients from spectral Doppler
studies.
3.1.1.8B At
least two imaging transducers, one of low frequency (2-2.5 MHz) and one of high
frequency (3.5 MHz or higher); or a multi-frequency transducer which includes a
range of frequencies specific to the clinical needs in adult echo.
Comment: A transducer dedicated to the
performance of non-imaging continuous wave Doppler must be available at each
site.
3.1.1.9B An
audible output must be present at the time of acquisition.
3.1.1.10B Instrument settings to enable optimization of ultrasound enhancing agents.
3.2B Stress
Echocardiography Acquisition Systems
3.2.1B Acquisition
of the stress echocardiographic images must be available and utilized for the
performance and interpretation of Stress Echocardiography.
3.2.1.1B The
system must allow for accurate “triggered” acquisition of images and
side-by-side image display. An image acquisition timer must be displayed.
3.2.1.2B The
acquisition system must have adequate memory to allow performance of
multi-stage stress echocardiogram studies.
3.2.1.3B The
capability of side-by-side comparison of images from baseline and different
stages of stress. Side by side review may be accomplished within the ultrasound
stress package or on a dedicated offline workstation.
3.3B The
annual procedure volume must be sufficient to maintain proficiency in
examination performance and interpretation.
3.4B Stress
Echocardiography is performed for appropriate indications.1
3.4.1B Verification
of the Indication – A process must be in place for obtaining and
recording the indication. Before a study is performed, the indication must be
verified and any additional
3.5B Stress
echocardiographic studies are appropriately ordered and scheduled.
3.5.1B Ordering
Process – The stress echocardiogram order and/or requisition must
indicate the type of study to be performed, the reason(s) for the study and the
clinical question(s) to be answered. The signed order/requisition must be
retained in the medical record of the patient.
3.5.1.1B
Immediately prior to performing the test, the facility staff must
assess the patient for the ability to exercise safely or undergo a pharmacologic stress test. Staff must confirm that the type of stress (exercise or pharmacologic) requested is most appropriate. If
indicated, the type of stress may be changed with input from the
supervising physician. The ordering provider must subsequently be
notified if the test is cancelled or if an alternative stress modality
(e.g., nuclear perfusion imaging) is more appropriate.
3.5.2B Definition
of Procedure Types –
3.5.2.1B Two-phase
stress Echocardiography examines and compares left ventricular wall segments
before stress and after stress and is usually accomplished using treadmill
exercise.
3.5.2.2B Three-phase
stress Echocardiography examines and compares left ventricular wall segments
before, during, and after stress, and is usually accomplished using treadmill
exercise or bicycle exercise ergometry.
3.5.2.3B Four-phase
stress Echocardiography examines and compares left ventricular wall segments
before, during and/or after stress, and is usually accomplished using pharmacological
stress agents or supine bicycle ergometry.
3.5.2.4B Doppler stress echocardiography (in
addition to left ventricular and/or right ventricular imaging) may be
employed to assess valvular heart disease, hypertrophic cardiomyopathy,
diastolic function or pulmonary hypertension and may be performed with treadmill, bicycle or pharmacological stress.
3.5.2.5B Ultrasound enhancing agents
may be used in conjunction with treadmill, bicycle or pharmacological
stress to optimize endocardial border definition or enhance Doppler
signals.
3.5.3B Scheduling
– Sufficient time is allotted for each study according to the procedure
type. The performance time allotted for a stress echocardiogram is 45 to 60
minutes from patient encounter to departure. An additional 15 to 30 minutes per
study may be needed for the performance of a pharmacologic stress
echocardiogram since these procedures require that intravenous access be
obtained. Additional time will also be required when adding Doppler to any
standard stress echocardiogram.
3.6B Stress
Echocardiography is a diagnostic test which, if performed and/or interpreted
incorrectly, can lead to serious consequences for the patient.
3.6.1B
Accurate performance of stress echocardiography requires that the
performing sonographer and interpreting physician are adequately
trained and experienced to perform and interpret stress echocardiograms
and must meet current training recommendations.
3.6.2B All
personnel directly supervising stress procedures must have appropriate
training/experience. While physician presence during stress testing is not
required, the facility must assure that appropriate staff is present based upon
the types of procedures being performed and the patients' risks of adverse events.
3.6.3B If
a non-physician (e.g. properly trained nurse, physician assistant, nurse
practitioner, exercise physiologist) practicing under the physician's license
is supervising the stress test, the Medical Director or physician director of
the stress facility must provide written attestation of appropriate training
and competence as outlined in the American College of Cardiology/American Heart
Association Clinical Competence Statement on Stress Testing.
Comment: For specific training and competence requirements, see Bibliography.
3.6.4B At
a minimum, at least two qualified people are required to be in attendance
during stress testing.
3.6.5B
Basic Life Support – All personnel, including physicians, directly
supervising stress procedures must have appropriate training/experience
and must be certified in basic life support (BLS) and/or Advanced Cardiac Life Support (ACLS).
3.6.6B Advanced
Cardiac Life Support: There must be ACLS certified personnel on-site and
immediately available during cardiac stress procedures.
3.7B Examination
performance must include proper technique.
3.7.1B Elements
of study performance include, but are not limited to:
3.7.1.1B proper
patient positioning during image acquisition (beds with imaging drop sections
are strongly recommended);
3.7.1.2B appropriate
transducer selection and placement;
3.7.1.3B achievement
of optimal heart rate;
3.7.1.4B optimization
of the ultrasound equipment gain and display settings;
3.7.1.5B Use
of Ultrasound Enhancing Agents (UEAs) for Suboptimal Image Quality –
UEAs should be used when two or more LV segments or any coronary
territory cannot be adequately visualized for the assessment of LV
function or regional wall motion. [8][9]
3.7.1.6B depth
settings and view orientation must be the same at all stages for
the purpose of side by side comparisons;
3.7.1.7B
for treadmill stress, post stress images must be obtained within 60-90
seconds of peak stress. Timer must be started at the time peak exercise is terminated (if images are obtained beyond 90 seconds it must be noted in the report).
3.7.1.8B for
pharmacologic echo, images must be obtained within the last 60 seconds of each
stage;
3.7.1.9B optimization
of digitized images for side by side comparison;
3.7.1.10B appropriate ECG preparation and lead placement to ensure accurate interpretation and digital triggering purposes;
3.7.1.11B utilization
of appropriate Doppler technique (including proper alignment) and measurements;
and
3.7.1.12B performance
of a stress echocardiogram according to the facility specific and appropriate
protocol that incorporates all views and imaging planes mandated by the
Standards 3.7B.
3.7.2B Elements
of study quality include, but are not limited to:
3.7.2.1B definition
of endocardium;
3.7.2.2B display
of standard, on axis, imaging planes (e.g., avoidance of foreshortening);
3.7.2.3B measurements
of left ventricular dimensions (when performed) obtained from standard
orthogonal imaging planes;
3.7.2.4B accurate
digital triggering (from ECG R wave);
3.7.2.5B appropriate
side by side image display;
3.7.2.6B adherence
to the facility specific and appropriate protocol; and
3.7.2.7B avoidance
of artifacts when using ultrasound enhancing agents.
3.8B Stress
echocardiograms must be performed in a facility designed to assure patient
safety.
3.8.1B Elements
of the stress Echocardiography facility arrangement include, but are not
limited to (Section 2A: Facility, 2.1A, 2.12A and Section 4A: Facility Safety, 4.1A and 4.1.1A):
3.8.1.1B Proper
placement of emergency equipment (crash cart and oxygen) such that they are
easily accessible.
3.9B Stress
echocardiograms must be comprehensive and include standard components.
3.9.1B Components
of the Examination
– Separate protocols must be in place that defines the components of
each type of stress echocardiograms performed in the facility (i.e.,
diastolic function, hypertrophic cardiomyopathy, valve and pulmonary
hypertension assessment). Prioritization of image acquisition sequence
(left ventricular assessment vs. Doppler assessment) should be made
based on the primary indication for the test. Indications for
the performance of a pharmacologic stress echocardiogram and/or a
standard exercise stress echocardiogram must be included.
Comment: Alternate views may be obtained if contrast is used.
3.9.1.1B
Treadmill Stress Echo: Images must be obtained at baseline and
immediately post exercise. All LV segments need to be visualized and
compared side by side (baseline vs. peak exercise). The standard
views are parasternal long axis view, parasternal short axis view,
apical four-chamber view and apical two-chamber view, or apical long
axis, apical four-chamber view, apical two-chamber view and apical
short-axis view. Alternative windows may be substituted if standard views are not adequate.
3.9.1.2B
Bicycle Stress Echo Protocols: At a minimum, images must be obtained at
baseline and immediately post exercise. All LV segments need to be
visualized and compared side by side. The standard
views are parasternal long axis view, parasternal short axis view,
apical four-chamber view and apical two-chamber view or apical long
axis, apical four-chamber view, apical two-chamber view and apical
short-axis view. Alternative windows may be substituted if standard views are not adequate.
3.9.1.3B
Pharmacologic Stress Echo: Images must be obtained at baseline and
three other phases. Common protocols include digitizing rest, low-dose,
pre-peak and peak, or rest, low-dose, peak and recovery. All LV
segments need to be visualized and compared side by side. The standard
views are parasternal long axis view, parasternal short axis view,
apical four-chamber view and apical two-chamber view, or apical long
axis, apical four-chamber view, apical two-chamber view and apical
short-axis view. Alternative windows may be substituted if standard views are not adequate.
3.9.1.4B A
Doppler stress echocardiogram includes interrogations of flow velocities (from
the same site) before, during and/or immediately following stress. Doppler
stress Echocardiography may be utilized to document gradient changes that occur
with stress, or to evaluate diastolic filling pattern changes that occur with
stress.
3.9.2B Patient
Preparation – To adequately perform stress echocardiogram studies,
appropriate safety guidelines must be in place.
3.9.2.1B All
stress echocardiogram procedures must be explained to the patient and/or the
guardian of those unable to give
3.9.2.2B Patients undergoing pharmacologic or ultrasound enhancing agent stress echocardiography must have a functioning intravenous access in place.
3.9.2.3B A
fully-equipped cardiac arrest cart (crash cart) as outlined in Section
4A: Facility Safety, 4.2.1A of the Standards with additional medications
utilized for reversing the effect of the pharmacologic stress agent(s) must be
available at all times.
3.9.3.1B During
the image acquisition phase and during the recovery phase of the examination,
the vital signs of the patient must be periodically evaluated in accordance
with the stress testing protocol.
3.9.3.2B Cardiac
monitoring with standard stress testing leads must be utilized.
3.9.3.3B A method to track procedural complications must be maintained.