Echocardiography core measures — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 69-year-old woman in Australia has symptoms and signs of HF and HF is suspected. Her LVEF on transthoracic echocardiography is 56%, and an echocardiogram three years ago showed an LVEF of 60%. She is in sinus rhythm. Her LV mass index is 99 g/m², her LA volume index 37 mL/m², her E/e′ at rest 12 and her TR velocity at rest 2.6 m/s.^[1]

1. Give the ESC 2026 HF recommendation for echocardiography in suspected HF, with its class and level. (2)^[1]
2. List the three criteria that ESC 2026 HF says must all be present for HFpEF. (3)^[1]
3. Which of her four measurements meet an ESC 2026 HF Table 10 criterion? Give each threshold. (4)^[1]
4. What does ESC 2026 HF say about how the number of abnormal parameters affects the probability of HFpEF? (1)^[1]

Model answers — SAQ 1

1. A transthoracic echocardiogram is recommended in patients with suspected HF to confirm the diagnosis, differentiate between HF phenotypes and aid in identifying the underlying aetiology of HF (1 mark).^[1] ESC 2026 HF Recommendation Table 3, Class I, Level C (1 mark).^[1]
2. Current or prior symptoms and/or signs of HF (1 mark).^[1] LVEF ≥50%, which requires that LVEF has not previously been <50% (1 mark).^[1] Objective evidence of cardiac structural and/or functional abnormalities consistent with the presence of LV diastolic dysfunction/raised LV filling pressures (Table 10), supported by raised natriuretic peptides (1 mark).^[1]
3. LV mass index 99 g/m² meets the female threshold of ≥95 g/m² (1 mark).^[1] LA volume index 37 mL/m² meets the sinus-rhythm threshold of >34 mL/m² (1 mark).^[1] E/e′ 12 at rest meets the threshold of >9 at rest (1 mark).^[1] TR velocity 2.6 m/s does not meet the threshold of >2.8 m/s (or an estimated systolic PA pressure >35 mmHg) (1 mark).^[1]
4. The probability of an HFpEF diagnosis increases with the number of parameters in the pathological range (1 mark).^[1]

SAQ 2 (10 marks)

Practice scenario. A 61-year-old man is assessed for suspected pulmonary hypertension. Echocardiography shows a peak TR velocity of 3.2 m/s, flattening of the interventricular septum with an LV eccentricity index of 1.3 in systole, and an IVC of 24 mm with less than 50% collapse on sniffing.^[5][4]

1. Which echocardiographic variable does ESC/ERS 2022 use as the key variable for the probability of PH, and why not the estimated systolic PA pressure? (2)^[4]
2. Give the ESC/ERS 2022 rows on assigning an echocardiographic probability and on the TRV threshold, each with class and level. (2)^[5]
3. Assign each of his two additional signs to its ESC/ERS 2022 Table 10 category, and state the rule for altering the probability level. (3)^[4]
4. Can echocardiography confirm PH in him? (1)^[4]
5. When does ESC/ERS 2022 Section 5.2 say a patient should be referred to a PH centre? (2)^[4]

Model answers — SAQ 2

1. The peak TR velocity is the key variable (1 mark).^[4] Because of the inaccuracies in estimating RA pressure and the amplification of measurement errors by derived variables (1 mark).^[4]
2. It is recommended to assign an echocardiographic probability of PH based on an abnormal TRV and the presence of other echocardiographic signs suggestive of PH, Class I, Level B (1 mark).^[5] It is recommended to maintain the current threshold for TRV (>2.8 m/s) for echocardiographic probability of PH according to the updated haemodynamic definition, Class I, Level C (1 mark).^[5]
3. Septal flattening with an LV eccentricity index >1.1 in systole and/or diastole is a category A sign (the ventricles) (1 mark).^[4] An IVC diameter >21 mm with decreased inspiratory collapse (<50% with a sniff or <20% with quiet inspiration) is a category C sign (inferior vena cava and RA) (1 mark).^[4] Signs from at least two categories (A/B/C) must be present to alter the level of echocardiographic probability of PH; his signs come from two categories (1 mark).^[4]
4. No: echocardiography alone is insufficient to confirm a diagnosis of PH, which requires right heart catheterisation (1 mark).^[4]
5. When an intermediate or high probability of PH is established (1 mark).^[4] In the presence of risk factors for PAH, or a history of PE (1 mark).^[4]