BSE procedure guidelines for the clinical application of stress echocardiography, recommendations for performance and interpretation of stress echocardiography

1. BACKGROUND The objective of guidelines is to enhance appropriateness of practice, improve quality of care, lead to better patient outcomes, and help authorities to decide on the approval of diagnostic or therapeutic procedures. For patients with coronary artery disease (CAD), one of the greatest challenges of our heath care system, a variety of diagnostic procedures is available at varying financial burdens. In order to improve cost effectiveness precise guidelines are needed to advise physicians. Stress echocardiography has become a valuable method for cardiovascular stress testing. It plays a crucial role in the initial detection of coronary artery disease, in determining prognosis and in therapeutic decision making. 3 These recommendations refer to the use of stress echocardiography to assess myocardial ischaemia or viability in patients with coronary artery disease. Evaluation of valvar heart disease or cardiomyopathies is not included but the BSE will provide separate guidelines for these indications in the future. Stress echocardiography is part of a diagnostic process, which often includes several diagnostic modalities, some of them complementary (for example, stress ECG), others competitive (for example, myocardial scintigraphy or magnetic resonance imaging (MRI)). This is reflected in this document, which outlines the indications and contraindications for stress echocardiography, the recommended methodology, and the clinical use of this technique. This document is intended to supplement other guidelines for cardiovascular stress testing, including the recently published guidelines for myocardial scintigraphy. 5 Guidelines have to reflect the specific situation of the local health system and have to be updated to reflect the technical developments of the procedure and the developments of competing procedures. In particular there has been an increasing use of new imaging technologies for stress echocardiography such as contrast echocardiography and Doppler tissue imaging (DTI). There are no comprehensive documents available on how to implement these recent technologies in clinical stress echocardiography. The Policy Committee of the BSE established a working group to prepare this document and address this issue. All recommendations are based on evidence from clinical studies, previous published guidelines of other societies such as the American Society of Echocardiography, or expert consensus of the writing and advisory groups. A writing group was composed of clinicians from BSE members all with subspecialty expertise in stress echocardiography. The advisory group consisted of nominated representatives of the BSE. Every effort was made to avoid conflict of interest from non-clinical relationships. All members of the writing group are asked to provide disclosure statements of such relationships, which might be perceived as real or potential conflicts of interest. The guidelines are intended to establish standards for the clinical use of stress echocardiography. Therefore all applications/protocols refer to currently available technology and protocols, which are licensed for assessment of left ventricular (LV) wall motion alone. However, since simultaneous assessment of perfusion is also possible with these protocols and available contrast agents, these methodologies are also described. Protocols which exclusively make the diagnosis from perfusion images are excluded, although this may be an option in the future with broader evidence of the value of this approach. The guidelines have been assembled from the knowledge available at the time of writing. The authors cannot assume liability for changes of dose regimens, machine settings, etc, due to advancing technology. However, regular review by the BSE Policy Committee will be undertaken to implement clinically relevant advances. This document will be available on the homepage of the BSE (www.bcs.com/restricted/affiliates/bse.html).