1.1 INDICATED. 

• Murmur in the presence of cardiac or respiratory symptoms. 
• Murmur in an asymptomatic individual in whom clinical features or other investigation suggest structural heart disease. 

1.2 NOT INDICATED. 

• Assessment of an innocent murmur diagnosed by a competent physician. 
• Unchanged murmur in an asymptomatic individual with previous normal echocardiogram. 

2.1 INDICATED. 

• Initial assessment of aetiology and severity, ventricular size and function 
• Repeat assessment of known stenosis with change in clinical status. 
• Periodic repeat assessment of asymptomatic individual with known severe stenosis for ventricular size and function. 
• Repeat assessment of known stenosis in pregnancy. 
• Assessment for pre-procedural decision-making for valvular intervention (eg suitability for balloon valvuloplasty). 
• Periodic repeat assessment of asymptomatic individual with moderate stenosis for valve severity, ventricular size and function. 

2.2 NOT INDICATED. 

• Periodic repeat assessment of asymptomatic individual with haemodynamically-insignificant lesions, eg mitral annular calcification. 

3.1 INDICATED. 

• Initial assessment of aetiology and severity, ventricular size and function. 
• Initial assessment and risk stratification of individual with clinical signs of mitral valve prolapse. 
• Repeat assessment in known regurgitation with change in clinical status. 
• Periodic repeat assessment of asymptomatic individual with known severe regurgitation for ventricular size and function. 
• Periodic repeat assessment of asymptomatic individual with known mild or moderate regurgitation and ventricular dilatation or dysfunction. 
• Periodic repeat assessment of asymptomatic individual with moderate MR. 
• Repeat assessment of known regurgitation in pregnancy. 
• Assessment for pre-procedural decision-making for valvular intervention (eg suitability for mitral valve repair – consider TOE). 

3.2 NOT INDICATED. 

• Periodic repeat assessment of asymptomatic individuals with trivial or mild regurgitation and normal ventricular size and function. 
• Periodic repeat assessment of asymptomatic individuals with mitral valve prolapse and no or mild MR. 

4.1 INDICATED. 

• Baseline assessment of newly implanted prosthetic valve. 
• Late post-intervention re-evaluation for ventricular remodelling. 
• Repeat assessment of prosthetic valve with change in clinical status. 
• Repeat assessment of prosthetic valve with clinical findings suggestive of dysfunction. 
• Repeat assessment of prosthetic valve following exposure to clinical risk of valve thrombosis. 
• Periodic repeat assessment of asymptomatic individual with bioprosthetic valve (after 7 years for aortic bioprosthesis; after 5 years for mitral bioprosthesis) if intervention without symptoms would be undertaken. 

4.2 NOT INDICATED. 

• Periodic repeat assessment of asymptomatic individual with mechanical prosthesis. 
• Repeat assessment of patients whose clinical status precludes therapeutic intervention.

Note: In view of the possibility of both false-negative and false-positive studies, echocardiography should supplement but not replace clinical and microbiological diagnosis. 

5.1 INDICATED. 

• To characterise valvular lesions, haemodynamic consequences, and ventricular response in a patient with clinically proven or suspected endocarditis.
• Detection of high-risk complications, eg fistula, abscess, mass lesions. 
• TOE evaluation of patients with a high clinical suspicion following negative or equivocal TTE in native and prosthetic valves. 
• Persistent bacteraemia of unknown source, particularly in staphylococcal infection (consider TOE). 
• Baseline assessment of valve, ventricular size and function prior to discharge following completion of treatment for endocarditis. 

5.2 NOT INDICATED. 

• Fever with no other suggestive features. 
• Periodic repeat assessment in a clinically stable patient with prior echocardiographic evaluation to assess response to therapy. 

6.1 INDICATED. 

• Chest pain with haemodynamic instability 
• Murmur following acute or recent myocardial infarction. 
• Assessment of infarct size, presence of complications and baseline LV function following MI, if high BMI/BSA consider referral for LV contrast echocardiography. 
• Evaluation of patients with non-diagnostic ECG and indeterminate laboratory markers if performed during or immediately after cardiac chest pain. 
• Evaluation of LV function to guide further therapy or assess effect of intervention, e.g. drug therapy, ICD implantation, CRT, patients scheduled to undergo coronary artery by-pass surgery. 
• Stress echocardiography to assess reversible ischaemia, myocardial viability and risk stratification. 

6.2 NOT INDICATED. 

• Evaluation of non-cardiac chest pain. 

7.1 INDICATED. 

• Clinical cardiomegaly. 
• Clinical or radiographic signs of heart failure.
• Unexplained shortness of breath in the absence of clinical signs of heart failure if ECG/CXR abnormal.
• Persistent hypotension of unknown cause.
• Suspected cardiomyopathy based on abnormal examination, ECG, or family history in first degree relative. 
• Baseline LV function and periodic review when using cardiotoxic drugs, eg Herceptin.
• Repeat assessment in documented cardiomyopathy with change in clinical status. 
• Repeat assessment in documented cardiomyopathy where result may change management or following procedures affecting function, eg cardiac resynchronisation, septal ablation. 

7.2 NOT INDICATED. 

• Minor radiographic cardiomegaly in the absence of symptoms or signs of heart failure. 
• Routine repeat assessment in clinically stable patients in whom no change in management is contemplated. 
• Assessment of patients with oedema, normal venous pressure and no evidence of cardiac disease. 

8.1 INDICATED. 

• Suspected pericarditis, pericardial effusion, tamponade or constriction. 
• Suspected pericardial effusion or bleeding (post-surgery or trauma). 
• Periodic repeat assessment of moderate or large pericardial effusion. 
• Repeat assessment of small pericardial effusion with change in clinical status. 
• Echo-guided pericardiocentesis. 

8.2 NOT INDICATED. 

• Repeat assessment of small pericardial effusion without clinical change. 
• Pericardial friction rub following uncomplicated MI.
• Follow-up studies in patients with terminal illness whose management would not be affected by echocardiographic abnormalities.

9.1 INDICATED. 

• Embolic peripheral or neurological events suggesting intracardiac mass.
• Haemodynamic or auscultatory findings suggesting intracardiac mass.
• Periodic repeat assessment following removal of cardiac mass/tumour, eg myxoma.
• Known primary malignancies where echocardiographic surveillance for cardiac involvement forms part of the normal staging process, eg renal hypernephroma. 

9.2 NOT INDICATED. 

• Patients with terminal illness whose management would not be affected by echocardiographic abnormalities. 

10.1 INDICATED. 

• Lung disease with clinical suspicion of cardiac involvement (cor pulmonale).
• Suspected or established pulmonary hypertension.
• Suspected or established pulmonary embolism to inform a decision regarding thrombolysis. 
• Evaluation for surgical procedures for advanced lung disease including transplantation.
• Repeat assessment of pulmonary artery pressure to evaluate response to treatment for pulmonary hypertension (consider saline contrast enhancement).
• To distinguish cardiac from non-cardiac causes of dyspnoea when the results of clinical and other diagnostic testing are ambiguous.
• Patients with known chronic lung disease and unexplained desaturation (consider saline contrast echocardiography).

10.2 NOT INDICATED. 

• Lung disease with no clinical suspicion of cardiac involvement. 

11.1 INDICATED. 

• Acute interruption of blood flow to major peripheral or visceral artery. 
• Unexplained stroke or TIA without evidence of prior cerebrovascular disease or without significant risk factors for other cause (consider saline contrast echocardiography by TTE or TOE). The importance of a PFO if found when performing contrast studies may depend on the patient's age and may therefore only be appropriate in those under 55. 
• Patients for whom a therapeutic decision will depend on outcome of echocardiography, eg anticoagulation.
• Assessment of neuromuscular diseases associated with cardiac manifestations, eg muscular dystrophies, mitochondrial myopathies and periodic paralyses.
• Hemiplegic migraine (saline contrast study). 

11.2 NOT INDICATED. 

• Patients in whom echocardiography will not affect decision to commence anticoagulation (eg patients in AF with cerebrovascular event and no suspicion of structural heart disease).

12.1 INDICATED. 

• Clinical suspicion of structural heart disease in proven arrhythmia.
• Assessment of ventricular function for primary prevention of sudden cardiac death (SCD) post-MI. 
• Assessment of ventricular function for secondary prevention of SCD in VT. 
• Evaluation of LV function prior to anti-arrhythmic medication.
• Syncope in a patient with clinically suspected heart disease.
• Exertional syncope. 
• Syncope in a patient with high-risk occupation, eg pilot, bus driver. 
• Assessment of patients without clinical suspicion of structural heart disease who have an arrhythmia commonly associated with structural heart disease. 
• Guidance of catheter placement during radiofrequency ablation (consider TOE or intracardiac echo).
• Post-operative evaluation of patients following RF ablation and surgical procedures in the absence of complications.

12.2 NOT INDICATED. 

• Palpitations without proof of arrhythmia or clinical suspicion of structural heart disease.
• Isolated premature ventricular contractions in absence of clinical suspicion of structural heart disease. 
• Classic neurocardiogenic syncope.

13.1 INDICATED. 

• Guidance for decision to attempt cardioversion, eg LV function, MV disease. 
• Patients requiring cardioversion with AF >48hours duration not adequately anticoagulated (TOE).
• Repeat assessment of documented appendage thrombus (TOE).
• Repeat assessment following embolic event at previous cardioversion (TOE). 
• Patients with AF less than 48hrs duration and clinical suspicion of structural heart disease not adequately anticoagulated (consider TOE). 
• Patients undergoing cardioversion for atrial flutter. 

13.2 NOT INDICATED. 

• Patients requiring emergency cardioversion. 
• Patients on long-term anti-coagulation at therapeutic level with no clinical suspicion of structural heart disease.
• Patients on long-term anti-coagulation at therapeutic level with structural heart disease but no recent clinical change.

14.1 INDICATED. 

• Suspected LV dysfunction.
• Evaluation of LVH and LV remodelling where this will alter management. 
• Evaluation of clinically suspected aortic coarctation. 

14.2 NOT INDICATED. 

• Routine assessment. 
• Repeat assessment of LV function in asymptomatic patients. 
• Repeat assessment for LV mass regression.

15.1 INDICATED. 

• Suspected aortic dissection: diagnosis, location, extent (TOE). 
• Assessment of aortic aneurysm and aortic dilatation: diagnosis, location, extent (consider TOE). 
• Suspected aortic rupture and intramural haematoma. 
• Periodic repeat assessment of aortic root and ascending aortic dilatation. 
• Assessment of suspected or proven connective tissue disorder in which aortic pathology may be a feature, eg Marfans. 
• Repeat assessment of prior surgical repair of aorta. 

15.2 NOT INDICATED. 

• None relevant 

16.1 INDICATED. 

• Documented ischaemic heart disease with reduced functional capacity (<4 METS). 
• Unexplained shortness of breath in the absence of clinical signs of heart failure if ECG and/or CXR abnormal. 
• Murmur in the presence of cardiac or respiratory symptoms. 
• Murmur in an asymptomatic individual in whom clinical features or other investigation suggest severe structural heart disease. 

16.2 NOT INDICATED. 

• Repeat assessment of previous echocardiogram with no intervening change in clinical status. 
• Routine pre-operative echocardiography

• To establish the link between palpitations and abnormal heart rhythms
• To diagnose the cause of syncope or near syncope
• To evaluate transient episodes of cardiac arrhythmias
• Patients with neurologic events when transient atrial fibrillation or flutter is suspected 
• To monitor the efficacy and safety of pharmacological or nonpharmacological therapies
• To detect proarrhythmic responses to antiarrhythmic therapy in patients at high risk
• To analyse the function of pacemakers or other implantable devices
• To evaluate prognosis
• To stratify the risk of sudden cardiac death

• If it delays urgent treatment, hospitalization or a procedure. For example, it should not be part of the initial investigation for angina, where a stress test would be more appropriate.
• The monitor is also contraindicated in patients who have syncope and high-risk factors at which time inpatient management is mandatory.
• Patients with symptoms such as syncope, near-syncope, episodic dizziness, or palpitation in whom other clear causes have been identified by history, physical examination, or laboratory tests.
• The AHA guidelines discouraged the use of ambulatory ECG for either arrhythmia detection or analysis of heart rhythm variability for risk assessment in patients without symptoms of arrhythmia, even if they had cardiovascular conditions such as left ventricular hypertrophy, or valvular heart disease.
• A patient who refuses to undergo further therapy once arrhythmia is established.
• • Routine screening of asymptomatic patients.

• Borderline hypertension
• Variable clinic blood pressure
• Suspected white coat hypertension
• Suspected white coat effect
• Resistant hypertension
• Hypertension in pregnancy
• Hypertension in elderly patients
• Evaluation of symptoms suggesting postural hypotension
• Evaluation of symptoms suggesting drug induced hypotension
• Blood pressure evaluation in patients with the suspected or confirmed autonomic dysfunction
• As an overall guide to hypertension treatment
• As a prognostic cardiovascular tool

• If it delays urgent treatment, hospitalization or a procedure. For example, it should not be part of the initial investigation for angina, where a stress test would be more appropriate.
• The monitor is also contraindicated in patients who have syncope and high-risk factors at which time inpatient management is mandatory.
• A patient who refuses to undergo further therapy once hypertension is established.
• Routine screening of normotensive patients.