Perspective:

The following are 10 points to remember regarding the Appropriate Use Criteria for Transthoracic Echocardiography in Outpatient Pediatric Cardiology. The scope of the report is limited to patients without known heart disease under consideration for an initial echocardiogram in the outpatient setting:

1. Appropriate indications for echocardiography in pediatric patients with palpitations include those with known cardiomyopathy, family history of cardiomyopathy, family history at age <50 years of sudden cardiac arrest or death, and/or pacemaker or defibrillator placement.

2. The presence of supraventricular or ventricular tachycardia on electrocardiogram (ECG) is an appropriate indication for echocardiography.

3. Echocardiography is indicated for pediatric patients with syncope in the setting of an abnormal ECG, concerning family history, exertional syncope, and unexplained post-exertional syncope.

4. Echocardiography is rarely appropriate for pediatric patients with nonexertional chest pain and a normal ECG.

5. Echocardiography is appropriate in patients with chest pain with family history of sudden unexplained death or cardiomyopathy, as well as for those with exertional chest discomfort.

6. Echocardiography is rarely appropriate in patients with a presumptively innocent murmur with no symptoms, signs, or findings of cardiovascular disease and a benign family history. Echocardiography is appropriate for those with a presumptively innocent murmur and abnormal signs, symptoms, or cardiac symptoms. Echocardiography is appropriate if a pathologic murmur is heard. The document does not specifically discuss cases in which the clinician cannot discern an innocent versus pathologic murmur on auscultation.

7. Echocardiography is appropriate in patients with symptoms and signs consistent with congestive heart failure, as well as those with central cyanosis.

8. Testing suggesting an appropriate indication for echocardiography includes genotype positive for cardiomyopathy, abnormal chest x-ray findings suggestive of cardiovascular disease, abnormal ECG without symptoms, and desaturation on pulse oximetry.

9. Echocardiography is appropriate in the setting of many systemic disorders. Examples include sickle cell disease, connective tissue disease including Marfan, Loeys-Dietz, and other aortopathies, and mitrochondrial/metabolic/storage diseases.

10. Echocardiography is appropriate in asymptomatic patients with a family history (first-degree relative) of cardiomyopathy, including hypertrophic and dilated cardiomyopathies, genetic disorders with high rate of cardiovascular involvement, and aortopathies. Echocardiography may be appropriate for asymptomatic patients with congenital left-sided obstructive lesions including bicuspid aortic valve, among others.