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Impact of appropriate use criteria for transthoracic echocardiography in valvular heart disease on clinical outcomes

Amadio JA, Bouck Z, Sivaswamy A, Chu C, Austin PC, Dudzinski D, Nesbitt GC, Edwards J, Yared K, Wong B, Hansen M, Weinerman A, Thavendiranathan P, Johri AM, Rakowski H, Picard MH, Weiner RB, Bhatia RS. J Am Soc Echocardiogr. 2020; 33(12):1481-9. Epub 2020 Sep 3. DOI:

Background — The association between appropriate use criteria for transthoracic echocardiography (TTE) and clinical outcomes is unknown for patients with valvular heart disease (VHD). The aim of this study was to identify the association of TTE appropriateness with downstream cardiac tests and clinical outcomes in patients with VHD over 365 days.

Methods — A subset of 2,297 patients with VHD across six Ontario academic hospitals was selected from the Echo WISELY (Will Inappropriate Scenarios for Echocardiography Lessen Significantly) trial and linked to administrative databases. Each patient's index TTE was classified as “rarely appropriate” (rA) versus “appropriate” (comprising “appropriate” and “may be appropriate” TTE according to the 2011 appropriate use criteria). Overall, 431 of 452 patients with rA TTE were matched 1:1 with patients with appropriate TTE using propensity scores to account for measured confounding.

Results — Matched patients with rA TTE were less likely to undergo repeat TTE (relative risk, 0.46; 95% CI, 0.33–0.66) or cardiac catheterization (relative risk, 0.27; 95% CI, 0.16–0.47) at 90 days compared with patients with appropriate TTE. rA TTE was significantly associated with a decreased hazard of aortic valve intervention (hazard ratio, 0.40; 95% CI, 0.14–0.42), all-cause hospitalization (hazard ratio, 0.44; 95% CI, 0.34–0.57), and death (hazard ratio, 0.31; 95% CI, 0.15–0.66) over 365 days of follow-up.

Conclusions — Patients with appropriate TTE for VHD were more likely to undergo subsequent cardiac testing within 90 days and valve intervention within 1 year than those with a rA TTE. The 2011 appropriate use criteria for TTE have important clinical implications for outcomes in patient with VHD.