Principal brand mark To be used in the majority of situations.
Provider ID: 1-126775129
2.1 BASIC ELEMENTS
A General Practitionerâ€™s Guide ISSUE 5
Dr R Sharma Consultant Cardiologist and Echotech Clinical Lead
Keli Elton Echotech Clinical Operations Director
A General Practitionerâ€™s Guide ISSUE 5 The images and text provided within this handbook are the property of Echotech. Any reproduction of the contents without written permission from Echotech is strictly prohibited. Produced 2013
Foreword The NHS landscape continues to change with one major direction being the transfer of services from acute trusts to community settings. Community based diagnostic services have formed the vanguard of this ‘shift’. The drivers steering this new direction in service delivery are clinical, political, financial and technological. Furthermore, transforming the provision of community services is considered to be a top priority for the NHS in terms of improving quality and efficiency. Transforming the care and lives of those with long term conditions and delivering truly integrated, efficient and people-centred community services has the potential to improve the quality of millions of people’s lives. It will also release annual savings of up to £2.7 billion by enabling people to better manage their own conditions, treating them closer to their own homes avoiding unnecessary hospital visits. With the transfer of commissioning responsibility to CCGs completed there exists enormous scope and flexibility in delivering services which improve local primary care provision. These services should offer greater choice to patients, be integrated, of a high quality and operate efficiently/cost effectively. Standard adult transthoracic echocardiography (echo) is now well established as being ideally suited to an out-of-hospital setting, where the benefits of prompt, convenient patient-centred access have been clearly demonstrated. Echotech is the UK’s largest and longest established provider of these services. Alongside the benefits of community echo services, continues the challenge of supporting general practitioners in meaningfully interpreting echocardiography reports, so they are confident in deciding the best path for their patients. This handbook has been written with the intention of aiding GPs in this area, and thus facilitates the smooth transfer of standard, adult transthoracic echo services into primary care.
Tissue Doppler Imaging
Assessment of Left Ventricular Function Assessment of LV systolic function Assessment LV diastolic function
10 10 13
Assessment of Valvular Disease Aortic Stenosis Aortic Regurgitation Mitral Stenosis Mitral Regurgitation Tricuspid Regurgitation and Estimation of Pulmonary Artery Pressure Left Ventricular Hypertrophy
15 15 17 19 20 22 23
Frequently Asked GP Questions
Appendix 1 Community Echocardiography Referral Form Appendix 2 Community Echocardiography Report Form Appendix 3 Echotech Reporting Guidelines Appendix 4 Common Echo Abbreviations
30 31 33 43
Introduction This handbook aims to cover the use of echocardiography in the management of clinical disease processes. The detailed principles of ultrasound are not covered but it is hoped the reader will gain information that will allow better understanding of the reasons for requesting an echo and how the results should be interpreted in a clinical context. Thousands of transthoracic echocardiograms are performed each year in the UK. This figure will continue to rise because transthoracic echocardiography is relatively inexpensive, accurate and non invasive. Access to general practitioners also continues to rise with the introduction of â€˜Open Accessâ€™ and community-based echo clinics across the UK. Mobilisation of echo services in the community has been supported by the availability in recent years of high resolution hand-held systems. The vast majority of scans are performed and reported by trained cardiac physiologists rather than doctors.
Referral Criteria Patients may be referred to a community echo service based on any one of the following six referral criteria2: Patients with suspected heart failure 1. 2. 3.
Suspected CCF based on clinical findings - dyspnoea or peripheral oedema Suspected CCF based on abnormal ECG or abnormal chest X ray Suspected CCF based on raised BNP or NT pro-BNP
Patients with heart murmur
4. 5. 6.
Heart murmur with cardiac symptoms Asymptomatic heart murmur with abnormal ECG or abnormal chest X-ray Known valve disease
Suspected cardiomyopathy or left ventricular hypertrophy (LVH) based on clinical findings or abnormal ECG or abnormal chest X ray Atrial Fibrillation
See Appendix 1 on page 30 of this handbook for an example of a community echo referral form template. This handbook discusses the role of echocardiography in common referral conditions.
Principle The transducer generates ultrasonic waves in pulses that travel through tissue. Most of the sound waves are absorbed or scattered within the body but some are reflected back towards the transducer every time an ultrasound wave crosses interfaces of tissues with different density - typically the junctions between blood, myocardium and heart valves. Frequencies of 2 â€“ 5 MHz are required for routine adult cardiac work. The transducer is placed on the chest wall at standard positions or acoustic â€˜windowsâ€™. Standard transthoracic views of the heart include parasternal long axis, parasternal short axis, apical 4, 5 and 2 chamber, apical long axis, subcostal and suprasternal. Several modes of imaging are recognised. These include: M-mode Two-dimensional echo Doppler echo Tissue Doppler Imaging (TDI) M-mode Ultrasonic pulses are transmitted and received along a single scan line and the interfaces displayed as a graph of depth against time. It is especially useful for recording moving structures, timing events within the heart and measuring cardiac dimensions. An example is shown in Figure 1 on page 6.
Figure 1 Parasternal long axis M-mode at the level of the mitral valve leaflets.
1 E 2 A 3 RV LV IVS LVPW
At the end of systole the mitral valve begins to open Maximum excursion of anterior mitral leaflet Initial diastolic closing wave Reopening of mitral valve caused by atrial systole Mitral valve closes at onset of ventricular systole Right ventricle Left ventricle Interventricular septum Left ventricular posterior wall
Two-dimensional echocardiography The information is displayed as a fan-shaped image. Detailed information about cardiac structures and their movement can be obtained. LA Left atrium LV Left ventricle RA Right atrium RV Right ventricle Ao Aorta Figure 2(a) Parasternal long axis view of the heart.
Figure 2(b) Apical 4chamber view of the heart.
Doppler echocardiography Velocity measurements can be derived using the Doppler principle i.e. the frequency shift that occurs between transmitted and reflected ultrasound waves from moving red blood cells. Continuous Wave (CW) and Pulsed Wave (PW) Doppler recordings allow direct velocity measurements within the heart and across valves. Intracardiac and valvular pressure differences are derived from the measured velocities (v) according to the modified Bernoulli equation: 4v2. An example is shown in Figure 5b (page 16). However, in patients with depressed cardiac function and therefore reduced myocardial blood velocity, valve gradients and stenosis severity may be underestimated with this technique. In this situation, valve area should be calculated. Colour encoded Doppler velocity (colour flow mapping) displayed on a twodimensional image allows semi-quantitative assessment of valve regurgitation severity. Velocities directed towards the transducer are generally displayed in red and those away in blue. Increasing velocities are displayed as progressively lighter shades.
Tissue Doppler Imaging Doppler assessment of myocardial motion was first proposed in 1989. The principles are the same as for colour flow mapping except high amplitude low velocity filters are used to detect myocardial motion in preference to blood flow. Images are processed in spectral pulsed wave, colour M-mode and colour two-dimensional mode. Accurate quantification of regional myocardial motion in both systole and diastole, from multiple sites, can be acquired in seconds. Lack of widespread clinical application is largely because of lack of training and old machines with inadequate frame rates.
Assessment of Left Ventricular Function This is the most common reason for requesting an echo. An accurate assessment is therefore essential as it provides the requesting physician not only with a potential cause for symptoms but also important prognostic information. Assessment of LV systolic function In experienced hands, visual estimation of LV systolic function is reliable. In echocardiography, LV ejection fraction (LVEF) is also calculated as a marker of systolic function. Generally, an LVEF less than 55%3 represents impaired systolic function and should prompt appropriate treatment and investigation. This can be calculated in several ways by echocardiography Figure 3a
Left ventricular end diastolic dimension (LVEDd) and left ventricular end systolic dimension (LVEDs) are usually measured from parasternal long axis M-mode recordings of the LV, with the cursor at the tips of the mitral valve leaflets. From this, LV volumes at end diastole and end systole are calculated using the Teicholz formula. An example is shown in Figure 3a. The LVEF is then derived from this as a measure of the change in LV volume during systole. The volumes derived from M-mode measurements assume the LV has an ellipsoid shape. In cardiac disease, the LV assumes a more spherical shape so volumes will be 10
overestimated by this technique. Moreover, it is assumed that the volumes calculated from minor axis dimensions represent motion of all cardiac segments. This technique will therefore underestimate or overestimate volumes and LVEF in patients with wall motion abnormalities. In this situation, LVEF is calculated from two-dimensional measurements in apical 4 and 2 chamber views by the modified biplane Simpson technique. The endocardial border of the LV is traced in both systole and diastole and volumes calculated using Simpsonâ€™s rule which assumes that ventricular volume is the volume of adjacent sets of discs of varying depth and cross sectional area. From this, LVEF is determined. Figure 3b shows an example of this technique. Figure 3b
Volumes derived from two-dimensional echo are limited by endocardial border definition. LVEF may also be under or overestimated with this technique in the presence of regional wall motion abnormalities which are too complex to be represented by only two cardiac views. An experienced cardiac physiologist will only quote a calculated LVEF when he or she is confident it is accurate. If the cardiac physiologist feels the calculated LVEF does not truly reflect the LV systolic function, then a visual estimate is detailed in the report.
Despite these limitations, the methods described for LV dimensions and systolic function have widespread clinical and research use and have been validated by many studies. Wall motion may be described as normal, hypokinetic (<50% normal function), akinetic (absent movement), dyskinetic (movement out of phase with the rest of the ventricle) or aneurysmal. Global LV systolic dysfunction (LVSD) may be graded as mild, moderate or severe.3
Normal LVSF Mild LVSD Moderate Severe LVSD
LVEF â‰Ľ 55% LVEF 45 to 54% LVSD LVEF 36 to 44% LVEF â‰¤ 35%
Assessment of LV diastolic function The assessment of diastolic dysfunction is becoming increasingly important as we recognise this as a potential cause of both symptoms and long term morbidity4. An assessment is especially useful when left ventricular systolic function is normal. Generally, echo parameters of diastolic dysfunction are only clinically useful in patients over 40 years age. Pulsed wave Doppler of mitral valve flow is the most commonly used method of assessing diastolic function. Figure 4 on page 14 shows the flow patterns that can occur. In the presence of sinus rhythm two waves, ‘E’ and ‘A’ are produced, reflecting early filling of the left ventricle in diastole and atrial contraction respectively. Peak velocity of early filling (E), peak velocity of atrial filling (A), the E/A ratio, E-deceleration time (ms) are measured. The Doppler pattern may be either3: Normal A slow relaxation pattern (E/A ratio ≤ 0.8, E deceleration time ≥ 240ms) A restrictive filling pattern (E/A ratio ≥ 2.0, E deceleration time ≤ 140ms) However, the normal and abnormal patterns are physiological descriptions and patients may move between them depending on the state of their disease, loading conditions or treatment. It is therefore possible for a ‘pseudonormal’ transmitral Doppler pattern to occur in a patient with significant diastolic dysfunction depending on the loading conditions and treatment at the time. Therefore, in the case of a normal transmitral Doppler pattern, other echo modes of assessment must be made before one can confidently exclude diastolic dysfunction. These include a Doppler assessment of pulmonary vein flow and an E/Ea ratio from TDI. Their role in the assessment of LV diastolic dysfunction is detailed in the ‘LV diastolic dysfunction algorithm’3 (see page 36 of this handbook).
LV diastolic dysfunction is graded in order of severity as: Normal Grade 1 diastolic dysfunction (slow relaxation pattern) Grade 2 diastolic dysfunction (pseudonormal pattern) Grade 3-4 diastolic dysfunction (restrictive filling pattern) Figure 4 Conventional patterns of pulsed Doppler mitral flow velocity and tissue Doppler mitral annular velocity6. Note in the pseudonormal pattern a normal mitral inflow Doppler signal is matched by an abnormal relaxation pattern of mitral annulus velocity.
Assessment of Valvular Disease Aortic Stenosis (AS) The most common cause of AS in the western world is a calcified, degenerative tricuspid aortic valve. A bicuspid aortic valve occurs in approximately 2% of the population. The peak pressure difference across the aortic valve can be calculated from the velocity according to the modified Bernoulli equation, 4v2. An example is shown in Figure 5b (page 16). In low flow states, when the velocity is reduced, the gradient will be underestimated so the valve area should be determined. Echo criteria for severe aortic stenosis include3: Peak aortic jet velocity > 4 m/s Peak aortic valve gradient > 64 mmHg Valve area < 1 cm2 In general, the Bernoulli equation tends to overestimate pressure differences for velocities < 2 m/sec and underestimate for velocities > 5m/sec. On average, the aortic valve gradient will rise by 5 â€“ 8 mmHg per year. More rapid progression is seen in those with moderate-severe aortic valve calcification, a baseline aortic jet velocity > 3m/sec and coronary artery disease. Statins may reduce the rate of disease progression but the results of on-going trials are awaited before this can be confirmed. Once patients with severe aortic stenosis develop symptoms, 3 year mortality is approximately 75% without surgery. For patients with mild or moderate aortic stenosis, annual echocardiography and clinical evaluation are advised.
Figure 5a Calcific aortic stenosis. In this parasternal long axis view, the aortic valve cusps appear markedly thickened and calcified. Note the hypertrophy of the septum and posterior wall.
Figure 5b The peak velocity (v) across the valve is 4m/sec from this CW Trace.
The calculated peak valve gradient is 64 mmHg (4v2) by modified Bernoulli equation.
Aortic Regurgitation (AR) Aortic regurgitation is difficult to quantify and a balanced judgement should be made based on a number of echocardiographic techniques, clinical examination and aortography if necessary. In general, Doppler can diagnose severe AR but cannot reliably distinguish between mild and moderate regurgitation. The Doppler signal is deflected positively with AR. Using colour flow mapping, severe aortic regurgitation is indicated when the width of the jet is greater than 65% of the LV outflow tract diameter. In the example shown in Figure 6, the regurgitant jet fills 100% of the LV outflow tract.
Figure 6 Parasternal long axis view showing severe aortic regurgitation with colour flow mapping. In early diastole there is a broad based regurgitant jet (yellow â€“ blue) filling the whole of the left ventricular outflow tract.
When continuous wave Doppler is used, severe AR is associated with a steep deceleration slope (> 3m/sec) and short pressure half time (< 250ms). This represents a rapid fall in the pressure difference across the valve in early diastole with severe regurgitation. Other measures of severe AR include flow reversal of high velocity and long duration in the aortic arch, vena contracta (the narrowest portion of the regurgitant jet) > 0.6cm and effective regurgitant orifice area (EROA) > 0.3cm2. Surgery for severe AR is recommended even with mild symptoms because delay further worsens prognosis. In asymptomatic patients, surgery is advised before the LVEF falls below 55% and the LVEDs exceeds 4.5cm. For patients with mild or moderate AR, annual echocardiography and clinical evaluation are advised.
Mitral Stenosis (MS) In mitral stenosis there is resistance to diastolic flow. Consequently the left ventricle is small with an enlarged left atrium. Stenosis severity is calculated from the continuous wave (CW) Doppler of the mitral valve. By convention, the time taken for the peak gradient to fall to half its original value (the pressure half time, PHT) is measured. A pressure half time > 220ms indicates severe MS3 The mitral orifice area is calculated from the formula 220/PHT. An area < 1.0 cm2 indicates severe MS3 Alternatively, the valve area may be measured directly by planimetry of the mitral orifice in the short axis view. However, reverberation arterfact from calcifications may make accurate tracing of the orifice impossible. Tracing the CW Doppler recording of the mitral valve gives the mean gradient. A mean gradient > 10 mmHg indicates severe MS3 Mitral valve surgery is indicated for severe MS when symptoms occur as prognosis worsens with symptom severity. Pulmonary hypertension increases surgical mortality by up to four fold. Thus surgery is advised once pulmonary hypertension is detected, irrespective of the presence of symptoms. Patients with minimal leaflet or subvalvar calcification, no more than mild mitral regurgitation and no evidence of left atrial thrombus, should be considered for percutaneous mitral balloon valvotomy. For patients with mild or moderate MS, annual echocardiography and clinical evaluation are advised.
Mitral Regurgitation (MR) The commonest causes are: Mitral valve prolapse Ischaemic heart disease Cardiomyopathy Quantification is based on a number of echocardiographic techniques and clinical examination. Colour flow mapping is useful for quantification but may underestimate eccentric jets. An example is shown in Figure 7. Figure 7
Apical 4 chamber view of a patient with prolapse of the posterior mitral valve leaflet.
An anteriorly directed jet of mitral regurgitation can be seen with colour flow mapping (coloured green).
The best technique for quantification of ischaemic MR is calculation of the effective regurgitant orifice area (EROA) by the flow convergence method. An EROA > 0.2 cm2 indicates severe MR when the aetiology is ischaemic. For non ischaemic MR an EROA > 0.4 cm2 indicates severe regurgitation. Other markers of severe MR include a peak forward velocity > 1.2 m/s and vena contracta (the narrowest portion of the regurgitant jet) > 0.5 cm. Pulmonary vein flow reversal may occur with moderate regurgitant jets. 20
Surgery for severe MR is recommended even with mild symptoms because delay further worsens prognosis. In asymptomatic patients, surgery is advised before the LVEF falls below 55% and the LVEDs exceeds 4.0cm. For patients with mild or moderate MR, annual echocardiography and clinical evaluation are advised.
Tricuspid Regurgitation and Estimation of Pulmonary Artery Pressure Tricuspid regurgitation (TR) may arise from: Organic valve disease Pulmonary hypertension Disease of the right ventricle The area of the TR colour flow map acts as a guide to severity. Figure 8 Tricuspid regurgitation. A broad band seen mainly as blue/yellow extends back into the right atrium.
The pressure difference across the tricuspid valve can be calculated from the peak velocity (v) of the TR jet using the modified Bernoulli equation (4v2) as discussed earlier. An estimation of the right atrial (RA) pressure can be made from the size of the inferior vena cava (IVC) and the degree to which it collapses with inspiration. By adding the pressure difference (4v2) to the RA pressure, the pulmonary artery pressure is estimated. See an example of reporting PA pressure (PAP) in Appendix 3.
Left Ventricular Hypertrophy An echocardiogram is often requested if a patient is suspected of having left ventricular hypertrophy (LVH) from an ECG. In echocardiography, the hypertrophy may be concentric (involving all left ventricular walls) or asymmetric (involving usually the septum, apex or anterior wall only). Common causes of LVH include: Hypertension Aortic stenosis Hypertrophic Cardiomyopathy (HCM) Amyloid Athletic heart From echocardiography, it is very difficult to distinguish between LVH due to hypertension and HCM. A full clinical review is required to make this distinction. HCM should always be suspected in (often younger) patients with LVH that cannot be explained by a potential primary cause such as hypertension, underlying valve disease, amyloidosis, renal or endocrine disease. Distinguishing HCM from an athletic heart can be very difficult and may require complex imaging such as contrast echo, three-dimensional echo or cardiac MRI. Such patients should be investigated in a specialist cardiac unit.
Pericardial Effusion A pericardial effusion produces an echo free space around the heart. Effusions less than 1 cm are described as small and those greater than 2 cm large. However, the haemodynamic consequences of an effusion are more important than the size. A rapid accumulation of only 100mls of fluid in the pericardial space may cause more haemodynamic compromise than a gradual accumulation of up to 1L of fluid. Generally, all patients with a pericardial effusion should be referred for further evaluation. As well as considering the need for drainage of the effusion, these patients should be investigated for an underlying cause, especially malignancy.
Frequently Asked Questions How should I manage a young patient with regional wall motion abnormalities with no previous history of MI? Whilst patients under 40 often have left ventricular ejection fractions at the lower limit of normal, regional wall motion abnormalities should not occur and should therefore be investigated in the absence of significant valve disease. The commonest conditions causing this feature in the young are cardiomyopathy, myocarditis and coronary artery disease. At what point should I administer heart failure treatment for a patient with LV systolic dysfunction? The diagnosis of heart failure is clinical so treatment with diuretics should be administered based on clinical features alone. Echo and BNP support the diagnosis and provide prognostic information. Patients with systolic heart failure benefit from ACE inhibitors, beta blockers and aldosterone antagonists. When should diastolic dysfunction be considered significant? In the community, diastolic dysfunction with preserved LV systolic function is responsible for 40% of all cases of heart failure. Echo is critical for the diagnosis. Generally, patients with echo evidence of preserved left ventricular systolic function and grade 2 or above (moderate or severe) diastolic dysfunction in combination with an elevated BNP or significant left atrial dilatation (> 4.3cm) should be considered as having diastolic heart failure if they have supporting clinical features. How should I manage grades 2 to 4 LV diastolic dysfunction? Unfortunately, beta blockers, ACE inhibitors and aldosterone antagonists do not have the same benefits in patients with diastolic heart failure. The main purpose of echo is to establish a diagnosis for the patient. Underlying coronary artery disease should be excluded in these patients. Should I refer a patient with a PFO? PFO (patent foramen ovale) occurs in one third of the population so generally such patients do not need referral. The only exception is young patients with cryptogenic stroke or possibly refractory migraine.
Do I need to arrange routine repeat echoâ€™s for mild valve disease? Patients with mild valve disease should have a repeat echo in 2 years to look for disease progression. Is diastolic dysfunction important in the elderly? Grade 1 (mild) diastolic dysfunction is extremely common in the elderly and is of little significance. However, the presence of Grade 2 to 4 diastolic dysfunction in conjunction with a dilated left atrium or left ventricular hypertrophy would suggest significant diastolic dysfunction in these patients. How should I manage a patient with a mildly dilated aortic root and what should the follow up be? In a young patient with no evidence of hypertension, these patients should be referred to look for an underlying cause. In patients with hypertension, good blood pressure control should be achieved and annual echocardiograms organised to look for disease progression. Once the aortic root is > 4.5cm, the patient should be referred. If a study is technically difficult and an alternative imaging modality is suggested, which imaging modality should I choose for a patient with suspected heart failure? There are several possibilities depending on local expertise. These include a contrast echocardiogram, a cardiac MRI or a MUGA scan. What should the follow up be for a patient with LVH? Generally, if the left ventricular hypertrophy (LVH) is unexplained by valve disease or hypertension, a referral should be considered to look for an underlying cause. If the patient has hypertension, a referral should still be considered for symptoms such as chest pain, breathlessness, dizziness or syncope or a family history of sudden death. Hypertrophic cardiomyopathy needs to be excluded. How should I manage a patient with a bicuspid aortic valve? Patients with moderate or severe disease with symptoms should be referred. Patients with mild disease should have a repeat echo at 2 years. Patients with moderate disease who are asymptomatic should have a repeat echo after 1 year.
How should I manage a patient with RV systolic dysfunction? Patients with RV systolic dysfunction do not benefit from ACE inhibitors, beta blockers or aldosterone antagonists. If there are signs of right heart failure, diuretics should be administered. Referral should be considered to look for an underlying cause. These include arrythmogenic right ventricular complex, intracardiac shunt, underlying respiratory disease, pulmonary embolus and pulmonary hypertension. I have a patient with 0.5cm global pericardial effusion. Is this significant? A small pericardial effusion < 0.5 cm seen only in the anterior space is a normal finding. However, any size pericardial effusion that is global should be considered pathological and investigated.
Limitations Due to the way images are acquired by echo, certain patients are technically difficult. Obese patients: ultrasound is refracted through the fat, image quality is reduced and accurate measurement is made very difficult. Patients with lung disease: the lungs are less mobile and therefore interfere with the ultrasound. Immobile patients: if patients are unable to turn onto their left side, imaging is made difficult, as again the lung obstructs the ultrasound. Only standard adult transthoracic echocardiography services should be provided in the community, therefore the following exclusion criteria applies: Age less than 18 Known complex congenital heart disease A congenital disorder in which cardiac disease may be suspected E.g. Down’s syndrome, Noonan’s syndrome, William’s syndrome Finally, the quality of echo report provided is highly dependent on the experience and skill level of the Cardiac Physiologist performing the scan.
References 1. Our Health, Our Care, Our Say: A New Direction for Community Services. DH White Paper. January 2006. 2. Echotech referral criteria for community echocardiography. 3. Echotech community echocardiography reporting guidelines (Appendix 3). 4. Mottram P, Marwick T. Assessment of diastolic function: What the general cardiologist needs to know. Heart 2005; 91: 681-695. 5. A minimum dataset for a standard adult transthoracic echocardiogram. BSE Education Committee. October 2005. 6. Sohn DW, et al JACC 1997:30:474-80 7. NHS Next Stage Review Final Report. High Quality Care for All. June 2008. Department of Health. 8. NHS 2010 - 2015: from Good to Great. Preventative, people-centred, productive. December 2009. Department of Health. 9. The Operating Framework for the NHS in England 2011/12. December 2010. Department of Heath. 28
Appendix 1 Community Echocardiography Referral Form
Echotech Community Echocardiography Referral Form
All relevant fields MUST be completed otherwise referral may be returned
Please fax the completed form to: 023 9282 3041 or post to: Echotech Ltd, 64 Goldsmith Avenue, Southsea, Hampshire PO4 8FH
DATE OF REFERRAL
NHS number Title Name Telephone Gender Date of birth
EXCLUSION CRITERIA GP DETAILS
Age less than 18 years Congenital Heart Disease GP name Telephone Fax
GP email address SPECIAL REQUIREMENTS
REASON FOR REFERRAL (Please ensure to select at least ONE) Patients with suspected heart failure 1. Suspected heart failure based on clinical findings (dyspnoea or peripheral oedema) 2. Suspected heart failure based on abnormal ECG or abnormal chest X ray 3. Suspected heart failure based on raised BNP or NT proBNP (see levels below) Patients with heart murmur 4. Heart murmur with cardiac symptoms 5. Asymptomatic heart murmur with abnormal ECG or abnormal chest X ray 6. Known valve disease Other 7. Suspected cardiomyopathy or left ventricular hypertrophy based on clinical findings or abnormal ECG or abnormal chest X ray 8. Atrial Fibrillation If this echo service wasn’t available, would you have referred this patient to the Acute Trust?
RELEVANT PAST MEDICAL HISTORY Myocardial Infarction
Alcohol / Drug abuse
Chronic Obstructive Pulmonary Disease
OTHER RELEVANT INFORMATION RELEVANT MEDICATION (Drug and Dose) INVESTIGATIONS (where relevant) 12 lead ECG CXR BMI BP
Please enter values: Normal Abnormal (Please attach) Normal Abnormal (Please attach) Normal levels (BNP < 100pg/ml or NTproBNP < 400pg/ml) 1 BNP or NTproBNP Raised levels -‐ Echo within 6 weeks (BNP 100-‐400pg/ml or NTproBNP 400-‐2000 pg/ml) 1 High levels -‐ Echo within 2 weeks (BNP >400pg/ml or NTproBNP > 2000pg/ml) 1.NICE Guideline for Chronic Heart Failure (update) August 2010 CQC Registered Provider ID: 1-‐126775129 Date
ppendix 1 ďż˝ Appendix 2 Community Echocardiography Report Form Echotech Community Echocardiography Report Form Echo Report Referrer Details Referrer Title Referrer Name Referrer Address Referrer Telephone Number Referrer Fax Number Referrer Organisation Name
Patient Details Patient Name Patient Date of Birth Gender Date of Patient Referral Patient Allocated ID Number Study ID Number
Reason For Echo: Core Measurements Aortic Root Left Atrium Septum LV End Diastolic Dimension Posterior LV Wall LV End Systolic Dimension Estimated Ejection Fraction
Study Quality: Good
cm cm cm cm cm cm %
LV Systolic Function
E Deceleration Time (ms)
Peer Review Required
Valve Stenosis and Valve Regurgitation Valve Stenosis Mild
Atrial Fibrillation Diastolic Dysfunction
RV Systolic Dysfunction
Significant Valve Disease
Technical Report Right Heart Assessment
LV Assessment Valves
Cardiac Physiologist Name: Digitally signed by Echotech Ltd on 2008-09-02 11:33:52 If you would like to discuss the results of this scan please phone 023 9265 8330 (Echotech Ltd). To access our GP handbook, visit: www.echotech.co.uk. The decision to refer a patient to a Cardiologist is based on clinical criteria and the echo report forms only a part of this.
Echotech Service Details
Appendix 3 Echotech Reporting Guidelines - Version 13 Rationale These guidelines have been devised to: • promote both the quality and consistency of all Echotech reports • encourage a systematic approach to reporting and • facilitate the accurate comparison of echocardiograms performed by different Echotech Cardiac Physiologists at different sites In terms of the echocardiographic views (see section 1) and measurements, the BSE guidelines for ‘A Minimum Dataset for a Standard Adult Transthoracic Echocardiogram’1 are followed. In terms of reference values, this document reflects the BSE Guidelines for Chamber and Valve Quantification2. 1.
Recommended Views (for recording)
Parasternal long axis (with and without colour)
Parasternal long axis M mode of LV and aorta / LA
Parasternal long axis inflow (TV) and outflow (PV) views (with and without colour)
Parasternal short axis: LV level (from papillary muscle level to apex), MV level and AV level (including colour flow and Doppler of PV)
Apical 4 chamber (with and without colour) • MV Doppler assessment • PW for inflow pattern • CW for MR / PHT • CW Doppler assessment of TV • Colour Doppler assessment of MV and TV • Pulmonary vein flow assessment (PW and colour)
Apical 5 chamber • Colour Doppler assessment of AV • CW assessment of AV • PW assessment of LVOT
Apical 2 chamber • Colour Doppler assessment of MV • CW assessment of MV
Apical long axis • Colour Doppler assessment of MV and AV • CW assessment of MV and AV
Subcostal • Assessment of IAS / IVS, IVC, pericardial effusion and abdominal aorta • Assessment of chambers and valves, with and without colour (when other views unobtainable)
Suprasternal notch • Assessment of distal ascending aorta, aortic arch, proximal descending aorta and right pulmonary artery • Assessment of left pulmonary artery (modified suprasternal view)
NB. Regional wall motion abnormalities assessed from all views where the LV is visualised.
Echotech Reporting Guidelines
Core Measurements (normal ranges) Male
Female 2.2 – 3.6 cm
Aortic Root 3.0 – 4.0 cm
2.7 – 3.8 cm 0.6 – 1.2 cm
Septum 4.2 – 5.9 cm
LV End Diastolic Diameter
3.9 – 5.3 cm
Posterior LV Wall
0.6 – 1.2 cm
LV End Systolic Diameter
2.5 – 4.0 cm
Reporting LV Systolic Function LV Systolic Ranges
45 to 54%
36 to 44%
≤ 35 %
Ejection Fraction • Where possible, an EF will be calculated (Biplane Simpson’s Method, M Mode or 2D). If not possible, a visual assessment will be stated, with a range of no greater than 10% • Any regional wall motion abnormality will be detailed in the technical report section • It is critical that the visual and calculated LVEF are consistent with the report comments
Long Axis Function • Perform PW TDI at lateral wall, septum or both of MV annulus
Normal LV systolic function
> 7.5 cm/sec
Abnormal LV systolic function < 7.5 cm/sec • Normal Mitral Annular Peak Systolic Excursion (MAPSE) Men
Wall Motion Assessment • The left ventricle should be assessed according to a 17 segment model • The thickening and endocardial motion of each segment should be described as normal, hypokinetic, akinetic or dyskinetic Basal Segments
1. basal anterior
7. mid anterior
13. apical anterior
2. basal anteroseptal
8. mid anteroseptal
14. apical septal
3. basal inferoseptal
9. mid inferoseptal
15. apical inferior
4. basal inferior
10. mid inferior
16. apical lateral
5. basal inferolateral
11. mid inferolateral
6. basal anterolateral
12. mid anterolateral
Echotech Reporting Guidelines
Recommended 17 LV Segment Model recognises LV apical segment
inferior apex 17
Horizontal Long Axis (HLA) (4 chamber)
16 15 inferior
Short Axis (SA)
Vertical Long Axis (VLA) (2 chamber)
33 Echotech Reporting Guidelines
Left Atrium Key Points • LA diameter is measured in PLAX, perpendicularly to the LA walls. • In m-mode, measure the LA diameter in end-systole, from outer edge of the posterior aortic wall to the outer edge of the posterior LA wall. • 2-D, measure the LA diameter in end-systole, from inner edge to inner edge. • If the anterosposterior LA diameter cannot be measured, assess the LA volume by biplane technique from the apical 4 and 2 chamber views • For Biplane LA volume measurement, note that the largest LA volume is measured in diastole before mitral valve opening. The LA appendage, the pulmonary vein origins, and the funnel of the mitral valve are excluded from the measurement.
Left Atrial Size
LA Diameter (cm)
LA Volume (ml)
LA Diameter (cm)
LA Volume (ml)
LA Diameter (cm/m2)
LA Volume (ml/m2)
LA size WOMEN
LA size MEN
LA size INDEX
Reporting LV Diastolic Function
Ages 35 and above
0.8 to 1.4
E deceleration time (ms)
140 to 240
[Grade 1] Slow Relaxation or Mild LVDD
E deceleration time (ms)
[Grade 2] Pseudo normalisation or Moderate LVDD
0.8 to 1.4
E deceleration time (ms)
140 to 240
[Grade 3] Restrictive or Severe LVDD
E deceleration time
(Any one of these)
[Grade 4] Irreversible LVDD • Restrictive pattern that does not reverse with valsalva manoeuvre
Key Notes • Place sample volume at septal and lateral mitral annulus • If septal Ea > 8 cm/sec and lateral Ea > 10 cm/sec then no diastolic dysfunction • If either site has a reduced Ea then diastolic dysfunction may exist and transmitral Doppler should be assessed • If the transmitral Doppler is normal, take the averaged E/Ea value from the septal and lateral mitral annulus • If the averaged mitral E/Ea value is < 8, the patient will have normal diastolic function • If the averaged mitral E/Ea value is > 13, the patient will have diastolic dysfunction • If the averaged mitral E/Ea value is between 8 and 12, determine whether diastolic dysfunction exists from the pulmonary venous flow pattern • If the averaged mitral E/Ea value is between 8 and 12 and pulmonary venous flow cannot be obtained or indeterminate check LA size. If LA size ≥ 4.3, significant diastolic function cannot be excluded; if LA size < 4.3 cm, significant diastolic dysfunction unlikely
Echo assessment of diastolic function uncertain • Age < 40 with no history cardiomyopathy • Prosthetic mitral valve • Mitral Stenosis • Severe mitral regurgitation • Paced rhythm Suggest recording mitral inflow and Ea from septal and lateral mitral annulus but do not make assumptions on diastolic function
Summary: If septal Ea > 8 cm/sec and lateral Ea > 10 cm/sec then no diastolic dysfunction
E:A ratio<0.8 Or E decel>240ms
E:A ratio & E decel within normal ranges
LA < 4.3
E:A ratio>2.0 Or E decel<140ms
LA Size ≥ 4.3 Pulmonary Vein Flow
Slow filling (Grade 1) LVDD
A Vel<0.35m/s A Dur<30ms
A Vel≥0.35m/s A Dur≥30ms
Pseudonormal (Grade 2) LVDD
Restrictive (Grade 3-4) LVDD
No significant left ventricular diastolic dysfunction (LVDD)
Echotech Reporting Guidelines
MV area (cm2)
Mean MV gradient (VTI) (mmHg)
60 to 120
120 to 220
1.0 to 1.5
5 to 10
This is made from several parameters. Visual analysis of the regurgitant jet with colour flow mapping may underestimate the regurgitation severity with eccentric jets and overestimate severity with central jets. Indirect indicators of severe mitral regurgitation include: • Peak mitral valve PW velocity > 1.2 m/sec • Pulmonary venous flow reversal • Mitral jet area/atrial jet area ratio > 40% • Dense CW mitral regurgitant signal Direct indicators of severe mitral regurgitation include: • Vena Contracta > 5 mm • Effective regurgitant orifice area > 0.4 cm2 (or > 0.2 cm2 for ischemic mitral regurgitation) Comment on mitral valve morphology, annular size and leaflet tethering. Classify mitral valve as: • Excess leaflet motion (usually due to mitral valve prolapse) • Restricted leaflet motion (usually due to ischaemic heart disease or rheumatic heart disease) • Normal leaflet morphology and motion with annular disease and possible leaflet tethering • If valve and annulus are completely normal and there is no obvious LV dysfunction state ‘mechanism for MR unknown’ 6.3
Peak AV gradient (mmHg)
AV area (cm2)
1.7 - 2.9
1.5 - 2.0
36 - 64
1.0 - 1.4
>4 > 64 < 1.0 • Ensure CW Doppler tracings recorded from 5 and 3 chamber views and right parasternal view with stand alone probe • Aortic valve area is mandatory in patients with moderate and severe aortic stenosis • Aortic valve area should always be calculated when aortic flow rate is affected by conditions such as LV dysfunction, AR, MR, pregnancy • Comment on whether aortic valve is bi or tricuspid, site and extent of calcification and if calcification extends into mitral valve apparatus. With rheumatic aortic stenosis, comment on the degree of commissural fusion • The pattern and extent of left ventricular hypertrophy, LVEF, coexistent valve disease and any dilatation of aorta should always be mentioned in the conclusion • Aortic dimensions should be given at level of aortic annulus, sinus of valsalva, sinotubular junction • Aortic sclerosis is calcified and thickend aortic valve with peak CW velocity < 1.7 m/s and valve area > 2 cm2 • If aortic valve peak CW velocity is between 1.7 and 1.9 m/s and valve looks entirely normal with normal excursion, valve area should be calculated (if >2 cm² then no AS) • In atrial fibrillation, obtain CW tracings of 5 consecutive beats and quote the maximal value obtained
36 Echotech Reporting Guidelines
Aortic Regurgitation • Visually assess by use of colour flow and CW Doppler • Detailed evaluation of aortic valve, aortic root, LV size and LVEF essential • Comment on whether aortic valve bicuspid or tricuspid, rheumatic or degenerative • Measure aortic root at aortic annulus, sinus of valsalva and sinotubular junction • All quantification techniques have limitations and severity grade should be based on a combination of parameters • Reliance on colour flow mapping and PHT alone will underestimate eccentric jets, underestimated due to poor Doppler alignment
Quantification of Aortic Regurgitation Mild
Jet decel rate (PHT) ms
Diastolic flow in descending aorta
Brief, early diastolic
Prominent, holodiastolic reversal
Vena contracta (cm)
Jet width / LVOT Diameter (%)
Regurgitant volume (ml/beat)
31 - 59
30 - 50
0.11 - 0.29
Tricuspid Stenosis Normal
Mean gradient (mmHg) Valve Area (cm²) 6.6
Jet Area (cm²)
VC Width (cm) PISA radius (cm)
Hepatic Vein Flow
Normal systolic predominance
0.6 – 0.9
Dense with early peaking
Peak PV gradient (mmHg)
40 to 75
Jet size (CFM) (cm)
Regurgitant Fraction (%)
40 - 60
CW jet density/deceleration rate
• Visually assess by use of colour flow and CW Doppler
37 Echotech Reporting Guidelines
Assessment of Prosthetic Valves • Key measurements are (i) peak velocity and (ii) calculated mean gradient (CW) [See reference book for valve size and type] • Visual assessment of regurgitation by use of colour flow and CW Doppler • Assess whether regurgitant jet is within (closure jet) or outside (paravalvular) the sewing ring • Visually assess stability of valve
7. Reporting Right Heart Function and Size 7.1
RV Systolic Function • This should be based on a combination of visual assessment, quantitative and semiquantitative techniques • The quantitative technique is fractional area change but should only be used when there is good endocardial border definition • Semiquantitative techniques include tricuspid annular peak systolic excursion via m-mode and tricuspid annular peak systolic velocity via tissue Doppler imaging. The semiquantitative techniques cannot reliably distinguish between mild and moderate disease
RV Fractional Area Change (%)
Tricuspid annular peak systolic excursion
Tricuspid annular peak systolic velocity
RV dimension (apical 4 chamber)
PA diameter (parasternal SAX)
Basal RV diameter (RVD1) (cm)
Main PA (PA1) (cm)
Mid RV diameter (RVD2) (cm)
Base to apex length (RVD3) (cm)
RVOT diameters (parasternal SAX)
RVOT at AV level (RVOT1) (cm)
RV diastolic area (cm2)
RVOT at PV annulus (RVOT2) (cm)
RV systolic area (cm2)
RA size • Apical 4 chamber view and sub costal view best reflects RA size • RA size ≤ 3.5 cm
PA pressure estimation • Where possible, the PA pressure should always be estimated from the tricuspid regurgitation peak velocity (4v²) and the inferior vena cava size and motion with respiration (an estimate of RA pressure)
IVC size (cm) Respiratory/sniff variation
< 1.5 collapse
>25 No Change
Other RA size Hepatic vein size
An example of reporting PA pressure (PAP) is: Pressure difference (4v2) = 30mmHg from TR jet RA pressure = 10 – 15 from IVC PAP = 4v2 + RA = 40 – 45 mmHg
• If PAP measures between 35 and 60 mmHg, state elevated PAP • If PAP > 60 mmHg, state severe pulmonary hypertension Echotech Reporting Guidelines
Reporting the Aorta
Measurements should be made in 2D mode, from inner edge to inner edge in mid to late systole A detailed assessment is required for the following referrals: • Hypertension • Aortic valve disease • Marfan’s syndrome or other disorders with aortopathy Site
Normal Range Diameter (cm) Best views
1.7 to 2.5
PLAX, PSAX (AV level)
Sinus of Valsalva *
2.2 to 3.6
Sinotubular Junction *
1.8 to 2.6
PLAX, PSAX, Suprasternal, Apical 5 Chamber
1.4 to 2.9
1.1 to 2.3
Abdominal 1.0 to 2.2 * Mandatory measurements for all patients • All measured at maximum points 9.
Pericardial Disease • Visually assess for pericardial effusion on all patients
Pericardial Effusion Size Normal amount of fluid
< 0.8cm (anterior space only)
1 - 2 cm
Large effusion > 2 cm * Should be measured in end diastole • State whether global or loculated - If loculated, state area • State measurement of fluid • State if any wall compromise • Look at the IVC and measure size and amount of respiratory collapse • Any sized global pericardial effusion should be considered pathological 9.2
Signs of Pericardial Tamponade
• The rate of accumulation of fluid is as important as the size of the pericardial effusion • RV diastolic collapse > 35% • > 25% drop in mitral inflow E wave with inspiration • > 25% rise in tricuspid inflow E wave with inspiration Pericardial Constriction • Abrupt flattening of posterior wall in mid diastole • Double septal motion in diastole • > 25% drop in mitral inflow E wave with inspiration • > 25% rise in tricuspid inflow E wave with inspiration • > 25% drop in subaortic outflow with inspiration • Preserved mitral annular peak systolic velocity
No single sign can exclude or diagnose pericardial constriction and the diagnosis should be made based on a combination of parameters.
39 Echotech Reporting Guidelines
Technical Report Comments • The technical report section is divided into 5 areas: LV assessment, Right Heart Assessment, Valves, Other and Conclusion
For each cardiac structure both morphology and function is described • The Echotech report is primary care focussed and is therefore written in clear, descriptive terms, stating all key findings, whether normal or abnormal • Abbreviations are not used in the conclusion • All measurements that are not detailed elsewhere on the report but are relevant to the findings (e.g. aortic valve gradient) are stated within the technical report section (LV Assessment, Right Heart Assessment, Valves and Other) • Measurements are not detailed in the Conclusion • When a finding requires clarification / peer review then the term ‘suspicion of /query of…’ is used within the technical report and the ‘peer review required’ box is ticked • The report states a conclusion / summary which 1) Details the LV systolic function and the LV diastolic function (where appropriate) 2) Emphasises the abnormal findings and 3) Answers the question(s) posed by the referring clinician 11.
Report Tick Boxes • The use of tick boxes is used extensively to further enhance the clarity of the report
LV Systolic Function
Tick relevant box as detailed in Section 3.1
Mitral Valve / Aortic Valve
Tick severity of stenosis and / or regurgitation as either mild, moderate or severe
Tick if patient is in AF
Tick if patient [ages 35 and above] has any degree of LVDD [grades 1 to 4] as detailed in Section 4
RV Systolic Dysfunction
Tick if patient has any degree of RVSD [mild to severe]
Significant Valve Disease
Tick if patient has valve disease of moderate severity or above
Tick the technical quality of the study as either good, fair or poor
Tick if a second opinion is required [study images will be reviewed]
Tick if urgent action is required and dealt with
40 Echotech Reporting Guidelines
Referral not suggested based on Echo criteria alone
• Normal and Mild pathologies
1. No Action Required from Echotech (GP may still wish to refer on clinical grounds)
Suggest Cardiology Referral
• LV / RV systolic dysfunction of moderate or above • Grade 2 and above diastolic dysfunction with LA size > 4.0cm • Any unexplained left ventricular hypertrophy and/ or significant left ventricular hypertrophy (> 1.6cm) • Moderate or above valve disease • Any global pericardial effusion or anterior space effusion > 0.8cm • Suspected intra cardiac shunt (except PFO) • Ascending aorta measurement ≥ 4.5cm [or ascending aorta measurement ≥ 4.0cm for patients with suspected Marfan’s syndrome] • Aneurysmal LV wall
1. Write: ‘Suggest Cardiology Referral’ in the Cardiac Referral Comments box on the Access Report
• Severe pathologies
1. Write: ‘Suggest Urgent Cardiology Referral’ in the Cardiac Referral Comments box on the Access Report 2. Send a copy of the report (via FAX) to the referring practice on the same day of the scan and confirm the report has been received (via Phone) 3. Tick the ‘Urgent Findings Processed On Day of Scan’ box on the Access Report
Suggest Urgent Cardiology Referral
Urgent Clinical Advice Required prior to patient discharge
Onward Cardiology Referral Recommendations
•Post MI - ventricular septal rupture - severe MR - pseudo aneurysm • Aortic dissection • Large pericardial effusion • Cardiac mass (myxoma, thrombus, vegetation)
1. MUST be discussed with referring GP or duty Dr prior to patient discharge with a view to strong consideration of hospital admission 2. Write: ‘Suggest Urgent Cardiology Referral’ in the Cardiac Referral Comments box on the Access Report 3. Email the UltraLinq ‘refer exam’ link to Dr Raj Sharma (for Cardiology review) and Line Clinical Operations Manager and/or Keli Elton (where possible) 4. Send a copy of the report (via FAX) to the referring practice on the same day of the scan and confirm the report has been received (via Phone) 5. Tick the ‘Urgent Findings Processed On Day of Scan’ box on the Access Report
13. Patients in Atrial Fibrillation (AF) • If AF is noted, state this in the conclusion, as well as ticking ‘Atrial Fibrillation’ box • In the conclusion, state a mean heart rate • An average of three Doppler and Ejection Fraction measurements should be taken • At least three beat loops should be recorded
Appendix 4 Common Echo Abbreviations A4C A2C A5C AF Ao APLAX AR AS ASD ASH AV AVA AVG AVR BNP CCF CFM CO CW DCM DET ECG EF EROA HCM HTN IAS IHD IVC IVRT IVS LA LV LVDD LVEDd LVEDs LVEF LVH LVOT LVPW LVSD LVSF
Apical 4 Chamber Apical 2 Chamber Apical 5 Chamber Atrial Fibrillation Aorta Apical Parasternal Long Axis Aortic Regurgitation Aortic Stenosis Atrial Septal Defect Asymmetrical Septal Hypertrophy Aortic Valve Aortic Valve Area Aortic Valve Gradient Aortic Valve Replacement Brain Natriuretic Peptide Congestive Cardiac Failure Colour Flow Mapping Cardiac Output Continuous Wave Dilated Cardiomyopathy Deceleration Time Electrocardiogram Ejection Fraction Effective Regurgitant Orifice Area Hypertrophic Cardiomyopathy Hypertension Inter Atrial Septum Ischemic Heart Disease Inferior Vena Cava Isovolumic Relaxation Time Inter Ventricular Septum Left Atrium Left Ventricle Left Ventricular Diastolic Dysfunction Left Ventricular End Diastolic Dimension Left Ventricular End Systolic Dimension Left Ventricular Ejection Fraction Left Ventricular Hypertrophy Left Ventricular Outflow Tract Left Ventricular Posterior Wall Left Ventricular Systolic Dysfunction Left Ventricular Systolic Function
Appendix 4 Common Echo Abbreviations MR MS MV MVA MVG MVR PA PAP PDA PFO PHT PLAX PPM PR PSAX PV PVG PW RA RSE RV RVEDd RVEDs RVH RVOT RVSP SAM SAX SOB SOBOE SV SVC TDI TIA TOE TR TTE TV VSD
Mitral Regurgitation Mitral Stenosis Mitral Valve Mitral Valve Area Mitral Valve Gradient Mitral Valve Replacement Pulmonary Artery Pulmonary Artery Pressure Patent Ductus Arteriosus Patent Foramen Ovale Pressure Half Time Parasternal Long Axis Permanent Pacemaker Pulmonary Regurgitation Parasternal Short Axis Pulmonary Valve Pulmonary Valve Gradient Pulse Wave Right Atrium Right Sternal Edge Right Ventricle Right Ventricular End Diastolic Dimension Right Ventricular End Systolic Dimension Right Ventricular Hypertrophy Right Ventricular Outflow Tract Right Ventricular Systolic Pressure Systolic Anterior Motion of the Mitral Valve Short Axis Shortness of Breath Shortness of Breath on Exercise Stroke Volume Superior Vena Cava Tissue Doppler Imaging Transient Ischaemic Attack Transoesophageal Echocardiography Tricuspid Regurgitation Transthoracic Echocardiography Tricuspid Valve Ventricular Septal Defect For further information about the Echotech service visit www.echotech.co.uk
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2.1 BASIC ELEMENTS
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www.echotech.co.uk With the expansion of imaging diagnostic services in primary care, this handbook aims to cover the use of echocardiography in the management of clinical disease processes. The detailed principles of ultrasound are not covered but it is hoped the reader will gain information that will allow better understanding of the reasons for requesting an echo and how the results should be interpreted in a clinical context.
Published on Feb 29, 2012
This handbook aims to cover the use of echocardiography in the management of clinical disease processes. The detailed principles of ultrasou...