Comparably to almost every scientific discipline or field of study, medicine has also drastically revolutionized its methods and diagnostics throughout the last centuries. One of the most important milestones in the field of cardiology was the development of cardiological diagnostic test and procedures. The conceptualization of transthoracic echocardiography (TTE) was brought forward already 65 years ago when Edler and Hertz noted down movements of the heart walls “in the normal and in the diseased heart” by using 2,5MHz transducer in vivo connected to the cathode-ray-tube screen. (1) The penetration of TTE method has significantly changed the course of cardiology in the XX and XXI century, due to the vast amount of data gathered through non-invasive and non-harmful applicability used for creating a diagnostic and therapeutic impact. Nowadays, TTE and its use have been framed through a standard protocol (2), indications (3) and guidelines (4) published on a constant basis by different professional societies (Table 1). In the upcoming years, alongside the increase of the volume, the development of TTE will be further stimulated by: a) growing demand for handheld or portable echocardiography devices, b) increased use of automated function imaging and c) emergence of 5D imaging technology.

Current research shows that there is still room for improvement regarding the optimal use of TTE when it comes to patients with acute myocardial infarction, heart failure, arrhythmias, stroke, sepsis or in critically ill patients. This could be partially regarded to the fact that 35-50% of patients will repeat their TTE within one to three years from the first examination but this will yield any significant change in the outcome of patients only in less than a third of cases. (5) Even though the TTE is a low-risk, the consequences of over-use could be false positive tests, downstream utilization of resources, and an increase in overall costs. There are a few methods of addressing over-testing: a) clinical practice guidelines (available in both hard copy form and on the Internet; Table 1), b) appropriate use criteria (6-8) (the nomenclature for appropriate use categorization: appropriate, may be appropriate, and rarely appropriate procedures; Table 2), c) changes in financial incentives, d) education and training, e) national campaigns and public awareness, f) change in assessment of the value of diagnostic testing, etc. Recently in order to improve all aspects of the overall health care service, British Society of Echocardiography has published The Echocardiography Quality Framework (9). Alongside, the quality of echocardiography these methods also include reproducibility and consistency, education and training, and customer feedback.

In March 2019, Nucleus of the Working Group on Echocardiography and Cardiac Imaging Modalities of the Croatian Cardiac Society has investigated the frequency of the echocardiography follow-ups in different clinical case scenarios. The anonymous online questionnaire was distributed by e-mail to subscribers of the kardio.hr newsletter, who were voluntarily requested to answer on 10 questions. The questionnaire was comprised of two parts – routine procedures in the echocardiography laboratory (first five questions) and the perceived frequency of the need for repeating TTE follow-ups (second five questions). The routine procedures have been analyzed with the length of the echocardiography experience, order for procedures, indications for the first and the control examination and the frequency of follow-ups as explanatory variables. Moreover, the perceived frequency of the need for repeating the TTE check-ups has been investigated through several possible clinical scenarios such as patients with arterial hypertension, mitral valve prolapse, after an acute myocardial infarction as well as patients with the aortic stenosis or implanted aortic valve.