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ADULT STRESS ECHOCARDIOGRAPHIC TESTING
PART IV

Click here for a printer-friendly PDF of the ICAEL Standards

 

SECTION 3:
Elements and Components of Examination Performance

STANDARD - Training and Supervision

3.1  

Stress echocardiography is a diagnostic test which, if performed and/or interpreted incorrectly, can lead to serious consequences for the patient.

 

                           3.1.1

Accurate performance of stress echocardiography requires that the performing sonographer and interpreting physician are adequately trained and experienced to perform and interpret stress echocardiograms.

                           3.1.2

All personnel directly supervising stress procedures must have appropriate training/experience. While physician presence during stress testing is not required, the facility must assure that appropriate staff is present based upon the types of procedures being performed and the patients' risks of adverse events.

                           3.1.3

If a nonphysician (e.g. properly trained nurse, physician assistant, nurse practitioner, exercise physiologist) practicing under the physician's license is supervising the stress test, the Medical Director or physician director of the stress laboratory must provide written attestation of appropriate training and competence as outlined in the American College of Cardiology/American Heart Association Clinical Competence Statement on Stress Testing. (See Bibliography).

Note: See Bibliography for specific training and competence requirements.

                           3.1.4

At a minimum, at least two qualified people are required to be in attendance during stress testing.

                           3.1.5

Basic Life Support - All personnel, including physicians, directly supervising stress procedures must have appropriate training/experience and must be certified in basic life support.

                           3.1.6

 

Advanced Cardiac Life Support - There must be ACLS certified personnel on site and immediately available during cardiac stress procedures.

STANDARD - Elements of Examination Performance

3.2  

Examination performance must include proper technique.

 

3.2.1  

Elements of study performance include, but are not limited to:

  1. Proper patient positioning during image acquisition. Beds with imaging drop sections are strongly recommended.
  2. Appropriate transducer selection and placement.
  3. Achievement of optimal heart rate.
  4. Optimization of the ultrasound equipment gain and display settings.
  5. Contrast is indicated for use when two contiguous segments are not visualized as it provides greater accuracy in determining left ventricular function. Contrast must be used if this is not accomplished with harmonic optimal imaging.
  6. Depth settings and view orientation must be the same at all stages for the purpose of side by side comparisons.
  7. For treadmill stress, post stress images must be obtained within 60 seconds of peak stress. If images are obtained beyond 90 seconds it should be noted in the report.
  8. For pharmacologic echo, images must be obtained within the last 60 seconds of each stage.
  9. Optimization of digitized images for side by side comparison.
  10. Utilization of artifact free ECG for digital triggering purposes.
  11. Appropriate ECG lead placement.
  12. Utilization of appropriate Doppler technique (including proper alignment) and measurements.
  13. Performance of a stress echocardiogram according to the laboratory specific and appropriate protocol that incorporates all views and imaging planes mandated by the ICAEL Standards(3.4)

 

3.2.2  

Elements of study quality include, but are not limited to:

  1. Definition of endocardium.
  2. Display of standard, on axis, imaging planes (e.g. avoidance of foreshortening).
  3. Measurements of left ventricular dimensions (when performed) obtained from standard orthogonal imaging planes.
  4. Accurate digital triggering (from ECG R wave).
  5. Appropriate side by side image display.
  6. Adherence to the laboratory specific and appropriate protocol.
  7. Avoidance of artifacts when using contrast.

STANDARD - Stress Echocardiography Laboratory Arrangement

3.3  

Stress echocardiograms must be performed in a laboratory designed to assure patient safety.

 

3.3.1  

Elements of the stress echocardiography laboratory arrangement include, but are not limited to (ICAEL Standards, Part I: Section 2, 2.1, 2.1.2 and Section 4, 4.1,4.1.1):

  1. Proper placement of emergency equipment (crash cart and oxygen) such that they are easily accessible.

STANDARD - Stress Echocardiogram Components

3.4  

Stress echocardiograms must be comprehensive and include standard components.

 

3.4.1  

Components of the examination: Separate protocols must be in place that defines the components of each type of stress echocardiograms performed in the laboratory. Indications for the performance of a pharmacologic stress echocardiogram and/or a standard exercise stress echocardiogram must be included.
Note: Alternate views may be obtained if contrast is used.

  1. Treadmill stress echo: Images must be obtained at baseline and immediately post exercise. All LV segments need to be visualized and compared side by side (baseline vs. peak exercise). The required views are parasternal long axis view, parasternal short axis view, apical four-chamber view and apical two-chamber view, or apical long axis, apical four-chamber view, apical two-chamber view and apical short-axis view.
  2. Bicycle stress echo protocols: At a minimum, images must be obtained at baseline and immediately post exercise. All LV segments need to be visualized and compared side by side. The required views are parasternal long axis view, parasternal short axis view, apical four-chamber view and apical two-chamber view or apical long axis, apical four-chamber view, apical two-chamber view and apical short-axis view.
  3. Pharmacologic stress echo: Images must be obtained at baseline and three other phases. Common protocols include digitizing rest, low-dose, pre-peak and peak, or rest, low-dose, peak and recovery. All LV segments need to be visualized and compared side by side. The required views are parasternal long axis view, parasternal short axis view, apical four-chamber view and apical two-chamber view, or apical long axis, apical four-chamber view, apical two-chamber view and apical short-axis view.
  4. Contrast is indicated for use in patients when two contiguous segments are not visualized and provides greater accuracy in determining left ventricular function. Laboratories should have a written policy for use of contrast agents for stress echocardiography.
  5. A Doppler stress echocardiogram includes interrogations of flow velocities (from the same site) before, during and/or immediately following stress. Doppler stress echocardiography may be utilized to document gradient changes that occur with stress, or to evaluate diastolic filling pattern changes that occur with stress.

 

3.4.2  

Patient preparation: To adequately perform stress echocardiogram studies, appropriate safety guidelines should be in place.

  1. All stress echocardiogram procedures must be explained to the patient and/or the guardian of those unable to give informed consent. Consent must be obtained in a manner consistent with the rules and regulations outlined by the hospital or facility.
  2. Patients undergoing pharmacologic or contrast echocardiography must have a functioning intravenous access in place.
  3. A fully equipped cardiac arrest cart (crash cart) as outlined in Section 4.1.1 of the ICAEL Standards, Part I Echocardiography Laboratory Operations -Organization, with additional medications utilized for reversing the effect of the pharmacologic stress agent(s) must be readily available at all times.

 

3.4.3  

Patient monitoring:

  1. During the image acquisition phase and during the recovery phase of the examination, the vital signs of the patient must be periodically evaluated in accordance with the stress testing protocol.
  2. Cardiac monitoring with standard stress testing leads must be utilized.
  3. A list of procedural complications should be maintained.

 

3.5  

Stress echocardiogram report components

Stress echocardiography reporting must be standardized in the laboratory. All physicians interpreting echocardiograms in the laboratory must agree on uniform diagnostic criteria and a standardized report format.

Note: Stress echocardiography interpretation includes at a minimum an assessment of regional and global LV function at rest and stress. Depending on the reason for the study, the stress echocardiogram may require quantitation of valvular regurgitation, stenosis and RV systolic pressure. The electrocardiographic portion of the stress test may be interpreted as part of the stress echocardiogram or separately. 

The report must accurately reflect the content and results of the study. The report must include, but may not be limited to:

A)     Demographics:

1)       Date of the study   

2)       Name and/or identifier of the laboratory  

3)       Name and/or identifier of the patient  

4)       Date of birth and/or age of the patient   

5)       Indication for the study  

6)       Name or initials of the performing sonographer   

7)       Name of the ordering physician and/or identifier  

8)       Height 

9)       Weight 

10)    Gender

11)    Blood pressure

Comment: The information must be sufficient to allow for the identification and retrieval of previous studies on the same patient.

B)      Report text must include the following non-imaging data:

1)       Protocol used

2)       Exercise time, or maximum dose of pharmacologic agent (if used)

3)       Target heart rate

4)       Maximum heart rate achieved

5)       Whether or not target HR was achieved and/or stress adequate

6)       Blood pressure response

7)       Reason for termination

8)       Patient’s cardiac symptoms, if any, during the examination

9)       Any ECG changes during the examination

10)    Pre-exercise segmental wall motion and global systolic function 

11)    Post-exercise wall motion comparison and global systolic function 

Comment: If the electrocardiographic portion of the stress test is reported separately, the imaging report must include the items listed in 3.5 B.

Image description must include:

1)       Pre-exercise segmental wall motion and global systolic function 

2)       Post-exercise wall motion comparison and global systolic function 

C)        A summary of the results of the examination, including any pertinent positive (e.g., ischemia, viability and coronary distribution, LV cavity size and EF response) and negative findings.

Note: An accurate, succinct impression (e.g., normal, abnormal, stable). This must clearly communicate the result of the study and, when possible, answer the clinical question that was the cause for the examination. This final conclusion should resolve any inconsistencies or discrepancies (e.g., abnormal stress test with normal images) or provide guidance for further studies to do so.

D)        Any need for additional studies based on the results of the procedure being reported.

E)        The final report must be completely typewritten, including the printed name of the interpreting physician. The final report must be reviewed, signed and dated manually or electronically by the interpreting physician. Electronic signatures must be password protected and indicate they are electronically recorded. Stamped signatures or signing by non-physician staff is unacceptable.