Open access echocardiography

Because of the key role of echocardiography in assessing such patients, the concept of direct access or open access echocardiography has arisen. Francis and colleagues showed the true value of such a service.4 Among the referred patients who were already being treated for heart failure, only 36% of men and 18% of women had definitely impaired LV systolic function. In fact, the echo result led to a change in treatment for 70% of those patients who were already taking diuretics for suspected heart failure—this change was often the cessation of unnecessary treatment. However, open access echocardiography is not without its problems. These problems relate to guidelines on whom to refer, interpretation of the results, and on the maintenance of echocardiographic standards. General practitioners should ideally receive guidelines on whom to refer. In addition, echocardiography can be difficult to interpret in some cases without a fuller assessment of the individual patient. The main difficulty here is that many symptomatic patients will not have systolic dysfunction but may have "diastolic dysfunction". Whether such diastolic dysfunction seen on an echocardiogram is the cause of the patient's symptoms or not is often a difficult judgement even for an experienced cardiologist. Hence the lack of systolic dysfunction in an open access echo service could be falsely reassuring to the general practitioner. In fact it may be better referring this kind of difficult patient to a hospital consultant who can then assess the echo result as part of the whole clinical picture.

Despite this important caveat, open access echo services continue to flourish and expand. Dialogue between referring general practitioners and consultants should help to iron out dif-

Figure 10.2. Diagnosing heart failure in practice. CXR, chest x ray; BNP, B-type natriuretic peptide.

ficulties and to identify two separate groups: those patients who only need a factual echo report, and those who require further interpretation of the echo with knowledge of the whole clinical picture.

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