GP Guidance

This page provides quick-reference guidance for summary statements on transthoracic echo reports for adult patients.

The objective is to help primary care physicians find the correct guidance quickly and without additional steps.

Where findings are complex and/or not covered by the headings below – Cardiology Advice & Guidance is still recommended.

(The information on this page has been produced by a cross-site working group including UHBW and NBT cardiology consultants, echocardiographers and GPs)

▶Impaired Left Ventricular Systolic or Diastolic Function

For full up-to-date guidance, please see the following two resources:

Remedy - Heart Failure page: Click Here

BNSSG Primary Care Heart Failure Treatment Guideline: Click Here

▶Suspected Heart Failure

For patients with clinical signs of heart failure and elevated NT-proBNP (>400pg/ml).

▶"...impaired left ventricular systolic function" (EF <50%)

This suggests a diagnosis of Heart Failure with Reduced Ejection Fraction.
(HFrEF where EF <40%, HFmrEF where EF 41-49%)

In all cases:
Optimal medical management (“four pillars”)
+/- Referral to appropriate heart failure service

Remedy - Heart Failure page: Click Here
(scroll down to advice based on NT-proBNP level)

BNSSG Primary Care Heart Failure Treatment Guideline: Click Here
(Page 2: "Treatment Algorithm for LV Systolic Dysfunction")

▶"...impaired left ventricular systolic function" (EF >50%)

This suggests a diagnosis of Heart Failure with Preserved Ejection Fraction.

In all cases:
Optimal medical management (“four pillars”)
+/- Referral to appropriate heart failure service

Remedy - Heart Failure page: Click Here
(scroll down to advice based on NT-proBNP level)

Primary Care Heart Failure Treatment Guideline: Click Here
(Page 3: "Treatment Algorithm for Preserved Ejection Fraction")

▶"Impaired diastolic function" (EF >55%)

This suggests a diagnosis of Heart Failure with Preserved Ejection Fraction.

In all cases:
Optimal medical management (“four pillars”)
+/- Referral to appropriate heart failure service

Remedy - Heart Failure page: Click Here
(scroll down to advice based on NT-proBNP level

BNSSG Primary Care Heart Failure Treatment Guideline: Click Here
(Page 3: "Treatment Algorithm for Preserved Ejection Fraction")

▶Normal systolic and diastolic function

This suggests the cause of symptoms and BNP is not due to Heart Failure – other diagnoses should be considered.

▶Known Heart Failure

After commencing optimal medical therapy for new diagnosis of heart failure, it is reasonable to repeat echo after 3-4 months to assess improvement in EF.

Further routine imaging is not recommended.

There may be instances where an echo has been performed for other reasons and there is a change in reported EF. In which case:

No significant change in clinical status:
No action required.
(changes in EF are of secondary importance to clinical status)
Significant change in clinical status despite optimal medical therapy:
Refer to the appropriate heart failure service.

Remedy - Heart Failure page: Click Here
(scroll down to “Patients with known heart failure”)

▶Incidental New Finding

Where echo has been performed for another reason and there is incidental finding of left ventricular systolic and/or diastolic dysfunction.

Severe left ventricular systolic impairment (new finding):
Urgent cardiology referral.
In most other cases:
Routine cardiology referral.
For unclear cases, cardiology advice and guidance would likely be appropriate

▶Probability of Pulmonary Hypertension

For full up-to-date guidance, please see the Remedy - Pulmonary Hypertension page: Click Here

In the most basic terms, elevated pulmonary artery pressures come about as a result of:
• Restriction of blood flow within the lungs (varied pathologies), or
• Restriction of blood flow out of the lungs (left-sided heart disease)

Estimates of the probability of pulmonary hypertension by transthoracic echo correlate poorly to gold standard measures of pulmonary pressures, so should always be considered alongside the clinical picture.

▶Low Probability of Pulmonary Hypertension

In all cases:
No action required.

▶Intermediate Probability of Pulmonary Hypertension

Known left-sided heart pathology:
Optimal treatment of heart disease.
Known pulmonary pathology:
Optimal treatment of pulmonary disease.
For patients with unexplained dyspnoea and normal left heart findings:
Further investigation +/- referral to appropriate clinical specialty
Please refer to Remedy - Pulmonary Hypertension page: Click Here

▶High Probability of Pulmonary Hypertension

Known left-sided heart pathology:
Optimal treatment of heart disease.
Known pulmonary pathology:
Optimal treatment of pulmonary disease.
For patients with unexplained dyspnoea and normal left heart findings:
Further investigation +/- referral to appropriate clinical specialty

Please refer to Remedy - Pulmonary Hypertension page: Click Here

▶Dilated Aorta
Please refer to the Remedy - Aortopathy page for full up-to-date guidance: Click Here
▶New Finding of Dilated Aorta

▶Absolute diameter <40mm (root or proximal ascending aorta)

Asymptomatic patients with any of the following:
- Family history of aortic or vessel aneurysm/dissection.
- Bicuspid aortic valve.
- Age <60 with strong suspicion of underlying disease.

Cardiology referral

(please see guidance on Remedy - Aortopathy page: Click Here)
Asymptomatic patients with none of the above features:
No routine follow-up

▶Absolute diameter >40mm (root or proximal ascending aorta)

In all cases:
Cardiology referral

(please see guidance on Remedy - Aortopathy page: Click Here)

▶Follow-up for Known Aortopathy

Follow-up for known aortopathy should be cardiologist-led in all cases.

▶Valve Disease
This guidance largely follows the 2025 ESC/EACTS Guidelines for the Management of Valvular Heart Disease, with some local policy modifications.
▶Aortic Valve
▶Sclerotic Aortic Valve
No routine follow-up

This describes an aortic valve with thickened and/or slightly restricted leaflets, but without any significant restriction to blood flow.
▶Aortic Stenosis
If valve intervention would not improve prognosis or quality of life (e.g. terminal illness, significant frailty etc) then referral for specialist care is not indicated.

Mild aortic stenosis:
Trileaflet valve, non-dilated aorta: Repeat echo in 3 years
No cardiology referral required.

Trileaflet valve, aorta >40mm: Routine valve clinic referral
Please see Aortopathy section for referral urgency.

Bicuspid valve: Valve clinic referral
For referral urgency - please see Bicuspid Aortic Valve section.

Moderate aortic stenosis:
In all cases: Routine valve clinic referral

Severe aortic stenosis:
In most cases: Routine valve clinic referral

If any of the following features: Urgent valve clinic referral
- Symptoms (syncope, chest pain, breathlessness, paroxysmal nocturnal dyspnoea, oedema)
- New left ventricular systolic function (EF <55%) with no other cause and/or reducing ejection fraction on subsequent scans

Low-flow/Low-gradient aortic stenosis:
See Severe aortic stenosis (above)

This describes a valve which has either Moderate or Severe aortic stenosis, but it is not possible to differentiate between grades on resting echo due to low stroke volume and resulting low flow rates across the valve. Further testing will be required to determine severity.
▶Aortic Regurgitation
If valve intervention would not improve prognosis or quality of life (e.g. terminal illness, significant frailty etc) then referral for specialist care is not indicated.

Mild aortic regurgitation:
Trileaflet valve, non-dilated aorta: Repeat echo in 5 years
No cardiology referral required.

Trileaflet valve, aorta >40mm: Routine valve clinic referral
Please see Aortopathy section for referral urgency.

Bicuspid valve: Routine valve clinic referral
For referral urgency - please see Bicuspid Aortic Valve section.

Moderate aortic regurgitation:
In all cases: Routine valve clinic referral

Severe aortic regurgitation:
In most cases: Routine valve clinic referral

If any of the following features: Urgent valve clinic referral
- Symptoms (syncope, chest pain, breathlessness, paroxysmal nocturnal dyspnoea, oedema)
- Aortic root and/or proximal ascending aorta >40mm (by absolute values)
- Dilated LV and/or reducing ejection fraction on subsequent scans
▶Bicuspid Aortic Valve
In most cases: Routine valve clinic referral

If any of the following features: Urgent valve clinic referral
- Severe aortic stenosis or regurgitation
- Aortic root and/or proximal ascending aorta >45mm (by absolute values)

First degree relatives should be offered transthoracic echo for screening due to autosomal dominant inheritance.
▶Mitral Valve
▶Mitral Stenosis
If valve intervention would not improve prognosis or quality of life (e.g. terminal illness, significant frailty etc) then referral for specialist care is not indicated.

Mild mitral stenosis:
In all cases: Repeat echo in 3 years
No cardiology referral required.

Moderate mitral stenosis:
In all cases: Routine valve clinic referral
If new onset atrial fibrillation – please consider commencing Vitamin K Antagonist instead of DOAC (if no contraindications).

Severe mitral stenosis:
In all cases: Urgent valve clinic referral
▶Mitral Regurgitation
If valve intervention would not improve prognosis or quality of life (e.g. terminal illness, significant frailty etc) then referral for specialist care is not indicated.

Mild mitral regurgitation:
In most cases: No routine follow-up

Rheumatic valve/post-inflammatory process: Repeat echo in 3 years

Other anatomical abnormality: Routine valve clinic referral
(i.e. Mitral annular disjunction, mitral valve prolapse, carcinoid)

Moderate mitral regurgitation:
In all cases: Routine valve clinic referral

Severe mitral regurgitation:
In most cases: Routine valve clinic referral

If any of the following features: Urgent valve clinic referral
- Symptoms (syncope, chest pain, breathlessness, paroxysmal nocturnal dyspnoea, oedema)
- New atrial fibrillation
- Dilated LV and/or ejection fraction <60%
- Estimated pulmonary artery systolic pressure >50mmHg and/or right ventricular impairment
- Indexed LA volume >60ml/m2 (by BSA)
▶Mitral Annular Dysjunction
This describes an abnormality of the mitral annulus which can result in arrythmia.
It is associated with mitral valve prolapse and mitral regurgitation.

In all cases cardiology review is required.

Please see Mitral Regurgitation section for referral urgency.
▶Tricuspid Valve
▶Tricuspid Stenosis
Vanishingly rare!

In all cases:
Routine valve clinic referral
▶Tricuspid Regurgitation
If valve intervention would not improve prognosis or quality of life (e.g. terminal illness, significant frailty etc) then referral for specialist care is not indicated.

Mild tricuspid regurgitation:
In most cases: No routine follow-up

Anatomical abnormality: Routine valve clinic referral
(i.e. Tricuspid valve prolapse, carcinoid, previous vegetation)

Moderate tricuspid regurgitation:
In most cases: No routine follow-up

Anatomical abnormality: Routine valve clinic referral
(i.e. Tricuspid valve prolapse, carcinoid, previous vegetation, pacing lead)

Severe tricuspid regurgitation:
In most cases: Routine valve clinic referral

If any of the following features: Urgent valve clinic referral
- Symptoms (syncope, chest pain, breathlessness, paroxysmal nocturnal dyspnoea, oedema)
- Estimated pulmonary artery systolic pressure >50mmHg and/or right ventricular impairment
▶Pulmonary Valve
▶Pulmonary Stenosis
If valve intervention would not improve prognosis or quality of life (e.g. terminal illness, significant frailty etc) then referral for specialist care is not indicated.

Generally due to known congenital abnormality - followed up by the Adult Congenital Heart Disease (ACHD) team.

In most cases:
Routine cardiology referral

If severe stenosis and any of the following features: Urgent cardiology referral
- Symptoms (syncope, chest pain, breathlessness, paroxysmal nocturnal dyspnoea, oedema)
- Dilated and/or impaired right ventricle
- Estimated pulmonary artery systolic pressure >50mmHg
▶Pulmonary Regurgitation
If valve intervention would not improve prognosis or quality of life (e.g. terminal illness, significant frailty etc) then referral for specialist care is not indicated.

Mild pulmonary regurgitation:
In most cases: No routine follow-up

Anatomical abnormality: Routine valve clinic referral
(i.e. Carcinoid, previous vegetation, previous valvuloplasty, pulmonary artery dilatation)

Moderate pulmonary regurgitation:
In most cases: Repeat echo in 2 years

Anatomical abnormality: Routine valve clinic referral
(i.e. Carcinoid, previous vegetation, previous valvuloplasty, pulmonary artery dilatation)

Severe pulmonary regurgitation:
In most cases: Routine valve clinic referral

If any of the following features: Urgent valve clinic referral
- Symptoms (syncope, chest pain, breathlessness, paroxysmal nocturnal dyspnoea, oedema)
- Dilated and/or impaired right ventricle
- Estimated pulmonary artery systolic pressure >50mmHg