by Cat Vasko

· Appropriateness Criteria for Cardiac Ultrasound Released
· Newly Elected: ASE Elects New President
· Tech Zoom: 4D Technology Gives Echocardiographers a Surgeon’s Perspective
· Aiding Early Detection: New Recommendations Tap Ultrasound for Ovarian Cancer Diagnosis

Appropriateness Criteria for Cardiac Ultrasound Released

On June 15, the American College of Cardiology Foundation, Washington, DC, and the American Society of Echocardiography (ASE), Raleigh, NC, in partnership with several other medical professional associations, released appropriateness criteria for two of the most frequently used cardiac ultrasound techniques, transthoracic (TTE) and transesophageal (TEE) echocardiography.

“In the past, the American College of Cardiology (ACC), which we work with on a lot of initiatives, has offered many different guidelines documents,” explained Michael Picard, MD, director of clinical echocardiography at Massachusetts General Hospital, Boston; outgoing ASE president; and current leader of the Appropriateness Criteria Committee. “For echocardiography, these documents would say, if you have this disease, you should be ordering an echocardiogram, or an echocardiogram can help you diagnose or follow these conditions. It established ground rules for using the technology.”

But then the strategy changed, and the ACC and ASE shifted their focus from guidelines to appropriateness criteria. “For example, we know that if you have aortic stenosis, the guidelines say an echocardiogram is very important for diagnosing and following that condition,” Picard said. “The appropriateness criteria give you a scenario: if the patient has aortic stenosis and is doing well, do you need to provide another echocardiogram? We’ve established now that echo is helpful in a variety of conditions. Appropriateness criteria go a little deeper into the nuances of the condition to ask whether an echocardiogram is really needed.”

In keeping with this strategy, the new criteria address a broad range of clinical situations in which TTE or TEE might be used and aim to guide physicians in determining when and how often to use the tests. More often than not, the criteria recommend using the technology for initial evaluation of structure and function, but then scaling back—routine repeat testing and general screening uses for certain clinical scenarios tend to be viewed unfavorably.

“We all know the costs of health care continue to rise,” Picard said. “A component of that is the cost of medical testing, and a component of that is the various imaging tests we use, including echocardiography. The hope is that if people follow these criteria, we’ll be preventing overuse. And the criteria offer easy-to-understand guidelines—they give confidence that these tests are being used appropriately.”

Because data have shown that the majority of echocardiograms are ordered by noncardiologists, ASE plans to disseminate the criteria to medical professionals responsible for ordering them regardless of specialization. Patients are also encouraged to review the criteria.

Picard explained that the ASE wants to be a leader in stemming overutilization. “This is a simple, relatively inexpensive test that’s relatively safe,” he noted. “There’s no radiation, and there’s probably little harm in repeated testing. But sometimes when you order tests you can get false positives; there’s always the danger of overusing a test. Sometimes tests can be done to make patients feel better. This helps us make sure the tests are being used for the right reasons.”

He also stressed that when professional associations bear the brunt of responsibility for addressing utilization management, regulators have less to worry about—and that’s good for everyone involved.

“The policymakers are very concerned about this,” he said. “I’m proud we’ve developed these criteria. We’re the best experts to make these decisions. Rather than have regulators or others develop ground rules, we’ve developed these criteria on our own initiative, and I think that’s the right way.”

Newly Elected:

ASE Elects New President

The American Society of Echocardiography (ASE), Raleigh, NC, elected a new president at its June annual meeting in Toronto. Thomas Ryan, MD, MBA, director of the Ohio State University Heart Center, Columbus, will succeed outgoing president Michael Picard, MD, director of clinical echocardiography at Massachusetts General Hospital, Boston.

Thomas Ryan, MD, MBA

Ryan holds the John G. and Jeanne McCoy Chair in Cardiovascular Medicine at Ohio State and is director of the Richard Ross Heart Hospital at the OSU Medical Center; in the past he has served as heart center director and interim chief of cardiology at Duke University Medical Center, Durham, NC. He is a graduate of the Indiana University School of Medicine, Indianapolis, and his MBA is from Duke’s Fuqua School of Business.

Ryan has served as associate editor of the American Heart Journal and the Journal of the American Society of Echocardiography, and coauthored the 6th edition of Feigenbaum’s Echocardiography.

“It’s a great honor to have the opportunity to lead this outstanding group of health care professionals,” Ryan said. “ASE has always been committed to excellence in cardiovascular ultrasound and to supporting our members and promoting the health and well-being of our patients, and I’m excited to help continue that reputation.”

Tech Zoom:

4D Technology Gives Echocardiographers a Surgeon’s Perspective

Short of open-heart surgery, access to a 3D view of a heart in real time was unheard of until recently. But as 4D technology continues to evolve, more echocardiographers incorporate systems like the Vivid 7 Dimension cardiovascular ultrasound system from GE Healthcare, Waukesha, Wis, into their daily diagnostic routines.

With 4D imaging, echocardiographers can observe the pumping action of the heart, which allows them to determine the left ventricular function or even observe the valve structure. This complements their reading of the traditional 2D images of the heart. “Really, what it helps customers do is build their confidence in what they’re seeing in a 2D image,” says Al Lojewski, global marketing manager for cardiovascular ultrasound for GE Healthcare.

The 4D image also helps echocardiographers communicate more effectively with physicians and cardiologists, who might feel more at home with images that show the heart beating in real time. With the Vivid 7 Dimension system, echocardiographers can crop, rotate, or reorient the image so that they can see a particular valve or outflow track—a helpful tool when communicating with surgeons as well. “With 4D imaging, you can give them the surgeon’s view so that they understand the anatomy in a way that they’re used to seeing it every day,” Lojewski says.

As transducer technologies and system capabilities evolve, Lojewski expects that systems will eventually have the ability to show the entire heart. Today’s echocardiographers rely on ECG gating to get a complete picture. “Over time, both the spatial and temporal resolution will increase, and you’ll be able to see more information,” he says. Better temporal resolution also will allow systems to support high frame rates and more advanced quantitative features.

As the technology continues to improve, Lojewski says that 4D systems will likely become the norm and eventually replace 2D systems. “Many customers try to incorporate this examination into their daily routine,” he says. “It’s the natural evolution of where echocardiography is going—into 4D ultrasound.”

—Ann H. Carlson

Aiding Early Detection:

New Recommendations Tap Ultrasound for Ovarian Cancer Diagnosis

A new set of recommendations regarding the early diagnosis of ovarian cancer has been released. Developed by several groups working in coordination—the Gynecologic Cancer Foundation, Chicago; the Society of Gynecologic Oncologists, Chicago; and the American Cancer Society, Atlanta—the recommendations list a set of symptoms to be monitored closely, including bloating, pelvic or abdominal pain, difficulty eating or feeling full quickly, and a frequent or urgent need to urinate. A woman who displays any of these symptoms nearly every day for more than 2 weeks is advised to see a gynecologist immediately.

Barbara Goff, MD

Barbara Goff, MD, is director of gynecologic oncology at the University of Washington, Seattle; she is also the author of several studies that were used to identify symptoms common to women with early-stage ovarian cancer. “We know that 57% of women with early-stage cancer will present with these symptoms,” she said. “If there’s a concern that there may be some ovarian pathology, we’d say transvaginal ultrasound should be the next step.”

Early diagnosis is particularly important when it comes to ovarian cancer because of the high survival rate when the cancer is found and surgically removed before metastasizing outside the ovary. Of patients who catch the cancer early, 93% are still alive 5 years later. But only 19% of cases are found that early, and the survival rate 5 years out is only 45%.

The major obstacle to early diagnosis is doctors not taking their female patients seriously and failing to administer the best diagnostic test: transvaginal ultrasound. “Women often get blown off,” Goff said. “I did a study back in 2000 where we found that women who had ovarian cancer were told they had irritable bowel syndrome 15% of the time; 12% were told it was stress, and 9% were told there was nothing wrong with them. It’s a pretty big problem. Misdiagnosis is common among women with ovarian cancer.”

The recommendations clearly mandate follow-up when bloating, pelvic or abdominal pain, difficulty eating, or urinary symptoms are present over an extended length of time. “Women who have these symptoms almost daily for more than a few weeks should see their doctors, preferably a gynecologist who will perform a skillful pelvic exam. If a physician believes there is a reasonable concern that ovarian cancer may be present, further evaluation should be performed, including possibly a CA125 and/or pelvic ultrasound.”

The recommendations continue, “There is little to be lost and much to be potentially gained by increasing awareness of ovarian cancer symptoms that might lead to early medical evaluation and intervention. Although population screening with CA125 and ultrasound has the potential to lead to many false-positive results, their use in the evaluation of a symptomatic woman represents appropriate medical care.”

Concurred Goff, “Ultrasound is pretty important when you’re doing the initial workup. If people come in with symptoms, the first thing to do is an exam; the next step is proceeding with transvaginal ultrasound. It’s a good diagnostic test.”