Transthoracic echocardiography – the new AWMF S2k guidelines establish uniform standards

10.1055/a-2775-3065

Dear colleagues,

Did you know that until now there have not been any clearly defined guidelines for one of the imaging methods most commonly performed in Germany? Transthoracic echocardiography (TTE) has become an indispensable tool in cardiology. Whether in a private practice, hospital ward, or emergency department: The examination provides essential information for diagnosis and treatment. In light of the growing number of cardiovascular diseases and the increasing percentage of older multimorbid patients, standardization of TTE procedures is becoming more important than ever. Uniform quality standards are essential to ensure the diagnostic significance and comparability of findings in the clinical routine. Recommendations regarding echocardiography are provided in numerous AWMF guidelines, e. g., on cardiac insufficiency, pulmonary embolism, cardiogenic shock, coronary heart disease, and stroke [1]. However, current comprehensive guidelines dedicated to echocardiography have been lacking until now. Thus, the DEGUM had a clear mandate to assume a leading role in the development of S2k guidelines on echocardiography in cooperation with the German Cardiac Society.

While echocardiography examinations are often performed by specially trained non-physician personnel in countries like Great Britain, Australia, and the USA, these examinations are traditionally performed by physicians in German-speaking countries. Echocardiography training is usually part of specialist training in internal medicine or cardiology. However, the content of the training curriculum has not been uniformly defined. Various professional societies, as well as others, offer continuing education and advanced training, but their curricula and requirements have not yet been standardized.

This heterogeneity affects the quality of examinations. Even though there are numerous international recommendations regarding examination technique, image acquisition, measurement methods, and documentation, there is often a lack of concrete minimum standards and adaptation to German care structures [2] [3].

In light of this, the development of independent guidelines by the German Society for Ultrasound in Medicine (DEGUM) and the German Cardiac Society was a logical and necessary step. Since echocardiographic examinations are used not only in cardiology practices but also in internal medicine departments, emergency departments, intensive care units, and operating rooms, it was essential to include additional professional societies, including the German Association of Cardiologists in Private Practice, German Society of Internal Medicine, Professional Association of German Internists, and the German Society of Anesthesiology and Intensive Care Medicine.

The new guidelines were created in consensus in accordance with the requirements of the AWMF by representatives of the relevant professional societies. They are intended for all physicians performing echocardiographic examinations but do not explicitly exclude non-physician medical personnel [4].

The focus is on practice-based recommendations for optimal equipment settings and standardized presentation of imaging planes, image sequences, and video documentation. The minimum requirements for routine examinations to be met in the case of unremarkable findings, i. e., the “minimum volume of data”, are defined. This is supplemented by recommendations regarding routine measurements and an example of structured reporting. Together with the German Heart Foundation, recommendations regarding patient-centered communication and an information flyer were also created.

The group developing the recommendations felt that it was particularly important to differentiate echocardiography from focused cardiac ultrasound examinations (FoCUS) as used in emergency departments, operating rooms, and emergency situations [5]. The guidelines emphasize that: FoCUS is a valuable, clinically relevant tool but cannot replace comprehensive echocardiography. Therefore, detailed recommendations on indication, implementation, and interpretation are given.

The guidelines are not intended as a textbook and do not reflect all aspects of echocardiographic diagnostic imaging. However, they do define binding standards for high-quality routine examinations and thus lay the foundation for uniform and reproducible procedures in German-speaking countries.

In the future, in light of the medical evidence, implementation and documentation of echocardiographic examinations will have to be performed in accordance with these guidelines. Deviations from the standards defined in the guidelines require a medical explanation – particularly in the context of quality assurance, medical accountability, and liability. The guidelines thus provide users not only with guidance but also with increased technical and legal security in the daily routine.

Additional guidelines on specific topics – like the evaluation of heart valve diseases or myocardial function – could follow in the future. Separate guidelines on transesophageal echocardiography would also be desirable. This method entails special safety-related aspects that have not yet been standardized – particularly with regard to sedation in patients with preexisting cardiac conditions.

Moreover, the current guidelines provide a well-founded basis for the curricular integration of echocardiography in continuing medical education. They can help to formulate binding learning objectives, to develop competence-based examination formats, and to create objective criteria for quality assurance, certification, and accreditation, for example, for training centers and ultrasound labs.

Priv.-Doz. Dr. med. Jan Knierim

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Bundesärztekammer (BÄK), Kassenärztliche Bundesvereinigung (KBV), Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF). Nationale Versorgungsleitlinie Chronische Herzinsuffizienz – Langfassung. Version 4.0. 2023. www.leitlinien.de/herzinsuffizienz
• 2 Mitchell C, Rahko PS, Blauwet LA. et al. Guidelines for Performing a Comprehensive Transthoracic Echocardiographic Examination in Adults: Recommendations from the American Society of Echocardiography. Journal of the American Society of Echocardiography 2019; 32: 1-64
• 3 Robinson S, Rana B, Oxborough D. et al. A practical guideline for performing a comprehensive transthoracic echocardiogram in adults: the British Society of Echocardiography minimum dataset. Echo Res Pract 2020; 7: G59-G93
• 4 Knierim J, ten Freyhaus H, Magunia H. et al. Transthorakale Echokardiographie. Leitlinie der DEGUM, DGK, DGAI, DGIM, BDI, BNK (S2k Leitlinie AWMF Registernummer 085-004). https://register.awmf.org/de/leitlinien/detail/085-004
• 5 Via G, Hussain A, Wells M. et al. International evidence-based recommendations for focused cardiac ultrasound. J Am Soc Echocardiogr 2014; 27: 683.e1-683.e33

Publication History

Article published online:
19 February 2026