1. Locally Agreed Guidelines May Reduce Inappropriate Preoperative Echocardiography Requests Dr Sheila Carey Anaesthetic SpR Northern Deanery

2. Background: Preoperative Echocardiography Assessment of perioperative cardiac risk is part of anaesthetic preoperative assessment. Echocardiography can give useful information on cardiac function but has its limitations.

3. Background: Sunderland Experience Disquiet from cardiology regarding quality and appropriateness of echo requests. Uncertainty about indications for pre- operative echo amongst PAAC staff and junior surgical medical staff.

4. Aims Audit all preoperative echocardiogram requests Produce local guidelines – Survey local consultant opinion regarding pre operative echo – Literature review Evaluate impact of guidelines

5. Preoperative Echo Survey: Who needs investigating? New murmur with other indicators of AS New murmur with no suggestive features of AS Stable angina Decompensated heart failure Known AS. No change in symptoms, no recent echo ( >1 year )

6. Published Literature / Guidance ACC/ AHA Guideline – Recommendations for pre-op non-invasive evaluation LV Function Patients with current or poorly controlled HF* ( Class I) Patients with prior HF / patients with dyspnoea unknown origin ( Class II) – Valvular heart disease If a murmur is present, the clinician will need to decide whether or not it represents significant valvular disease AS poses the greatest risk

7. Published Literature / Guidance NCEPOD – 1994/5 Patient with ESM in association with LVH or myocardial ischaemia should be referred for assessment – 2001 Patients can be asymptomatic despite mod – severe AS and hence an asymptomatic cardiac murmur should be investigated preoperatively by echocardiography NCEPOD recognises the spiralling increase in workload this causes but echocardiography services should be accorded an appropriate priority with regards funding

8. Published Literature / Guidance Appropriateness Criteria for TTE and TOE (ACCF / ASE / ACEP et al) – Symptoms due to suspected cardiac aetiology (not previously investigated) (9) – Initial investigation of murmur where there is reasonable suspicion of valvular or structural disease (9) – Re-evaluation of a patient with known valvular heart disease with a change in clinical status (9) – Routine ( yearly) evaluation of an asymptomatic patient with severe stenosis (7)

9. Published Literature / Guidance Pandit (2004) – Maximising the benefit from pre-operative cardiac evaluation – The uninvestigated murmur NCEPOD guidelines extremely cautious Implementation would increase demand greatly on echo services Local guidelines should be jointly developed

10. Proposed Guidelines for Preoperative Echocardiography 1) Dyspnoea of unknown origin where there is suspicion of cardiac component or known IHD with poor functional capacity. 2) Previously undiagnosed systolic murmur with elements suggestive of aortic stenosis, ECG abnormalities or symptoms. 3) Known aortic stenosis with a change in symptoms since last echo, or if due for routine follow-up echo 4) Patients with current / poorly controlled heart failure (NYHA grade III-IV) and no echo in past two years confirming moderate - severe LV dysfunction.

11. Review of Echocardiogram requests Preoperative requests collected over a 6 week period. Reviewed by Consultant Cardiologist to determine appropriateness. Inappropriate requests – patient note review. Indications compared against new guidelines

12. Results Twenty eight requests for preoperative echocardiography 7/28 ( 25%) deemed as acceptable by Cardiology 21 (75%) unacceptable requests – 14 murmurs / added sounds – 4 Left ventricular Function – 3 nature of surgery

13. Analysis of Unacceptable Requests 16 Unacceptable requests from Trauma & Orthopaedic Department 12 sets of notes reviewed 9 requests could have been prevented (75%) using guidelines

14. Conclusions 1 No consensus amongst senior medical staff regarding who requires investigation Personal preference probably dictates choice except when clear cut suspicion of AS Advice given to other staff, (e.g. trainees, PAAC nurses) likely to be inconsistent Guidelines may improved this

15. Sunderland echocardiogram request

16. Conclusions 2 A significant proportion preoperative echocardiogram requests are unacceptable Retrospective application of guidelines suggests inappropriate requests could be reduced Potential for a rise in number of requests if patients selected more appropriately

17. Limitations Cardiology review subjective Retrospective analysis Prospective Audit needed to clarify the effect of introducing guidelines

18. Recommendations Investigation should only be considered if management will be affected Information given on request form has to be relevant and detailed Local guidelines can help direct appropriate use of resources