Abstract 602: Prospective Evaluation of the Clinical Application of the ACCF/ASE Appropriateness Criteria for Stress Echocardiography
Background: The ACCF/ASE appropriateness criteria (AC) for stress echocardiography have recently been published, though the application of these criteria on current clinical practice remains unknown. Our goal was to prospectively evaluate the clinical application of published criteria in a single center university hospital.
Methods: AC indications for Stress Echocardiography were prospectively determined in consecutive patients referred for inpatient or outpatient stress testing. Each study indication was categorized according to the AC, as appropriate (A), Uncertain (U) or inappropriate (I). Patient and referring physician characteristics and results of the stress echocardiograms were recorded.
Results: Of the 477 studies prospectively enrolled, 188 (39%) were excluded from the final analysis as they were specifically related to university transplant programs. Of the remaining 289 studies, 253 (88%) were ordered for indications outlined in the AC document, while 36 (12%) were not. Of the 253 studies for which the AC document could be applied, 180 (71%) studies were A, 23 (9%) were U and 50 (20%) were I studies. Indication #1 (i.e. Evaluation of chest pain syndrome or anginal equivalent in patients who with low pre-test probability of CAD, with interpretable EKG and able to exercise) accounted for 44% of the all I indications. I studies were more likely to be ordered on females (28% of female studies were I vs. 16% of male studies, p= 0.03), and younger patients (mean age for I studies 50 years, vs. 63 years for A studies, p<0.001). Cardiologists were less likely to order I studies compared to non-cardiologists (17% vs. 28%, p=0.05). I studies were most frequently ordered by anesthesiologists from an anesthesia pre-operative clinic (38% of all I studies). Among indications not addressed by AC document, a number of potential additions/gaps were identified. Abnormal stress echocardiograms were more frequent in A compared to I studies, (14% vs. 2%, p=0.03).
Conclusions: Overall, the AC for stress echocardiography appears to reasonably stratify stress test ordering and encompasses the majority of its clinical indications. However, revisions to the AC for stress echocardiography will be needed to fully capture and stratify appropriate clinical practice.