The 2003 Guideline for the Clinical Application of Echocardiography, jointly published by the American College of Cardiology, the American Heart Association, and the American Society of Echocardiography, revises recommendations written in 1997 with new information on use of the technique during stress or exercise testing and on use in patients with heart failure or those who are critically ill.

"In the guidelines published in 1997, there was relatively minimal information about the usefulness of stress in detecting ischemia, in prognosticating what was going to happen to the patient with ischemia, and in detecting myocardial infarct," said Melvin D. Cheitlin, MD, Chair Writing Committee. "Since that time, there has been a great deal of evidence collected that shows the value of echo stress testing."

"The updated guidelines on echocardiography add to the growing body of evidence about its important applications in the diagnosis and treatment of patients with cardiovascular disease," said Sidney C. Smith Jr., MD, former president of the American Heart Association. "Especially important are the recommendations concerning the use of stress echo in the evaluation of ischemic heart disease. These guidelines define valuable concepts which will contribute to identification of patients who might benefit from medical versus surgical therapies."

In addition to new recommendations on echocardiography and ischemic heart disease, other noteworthy changes include new information on use of transesophageal echocardiography during cardiac surgery, new guidelines for use of echocardiography in children, and significant updates to sections on use in heart failure and in the setting of critical illness.

"Echocardiography is exceedingly important. Without question, as far as noninvasive techniques are concerned, it's the most important advance in diagnostic technology in the last 50 years," said Cheitlin. "With the development of Doppler, it has been possible to measure a lot of the parameters of cardiac physiology and function which, before echocardiography, required cardiac catheterization."

The revised guidelines still consider the patient's history and physical examination the most important part of the evaluation. Douglas remarked that the committee was sensitive to general criticisms of guidelines that focus on recommendations for testing while saying relatively little about when it may be best not to test: “Guidelines tend to give positive guidelines, but not negative guidelines: 'You should use this test in these kinds of patients,' as opposed to, 'You shouldn't use this test in these other kinds of patients.' We tried to be balanced about it and to give the practicing physician information on both when they should use the test and the times when they really don't need it."

The committee did not make recommendations about technical aspects of echocardiography or about applications that are not yet ready for regular clinical practice. For example, the report does not make recommendations about 3-dimensional echocardiography.

A summary report on the new guidelines will be published in the September 3rd issue of the Journal of the American College of Cardiology and in the September 2nd issue of Circulation. The full text of the updated guidelines is currently available electronically at http://www.acc.org/clinical/guidelines/echo/index.pdf