How do you actually read an echocardiogram report? Gradients, the official meaning of mild, and why normal does not mean nothing is wrong

TL;DR

• On the mean gradient in aortic stenosis: a version saying "40–60 mmHg is moderate" differs from what the guideline prints. Table 3 of the ASE and EACVI focused update on the assessment of aortic valve stenosis of 2017 (Baumgartner et al.) prints a mean gradient of 20–40 mmHg as moderate and 40 mmHg or above as severe. This article sets out that one row because a reading of 45 mmHg is "moderate" under one version and "severe" under the other. The same guideline also states that the definitions of the grades are to some extent arbitrary, that any single criterion only "suggests" severe disease, and that a gradient measured while blood pressure is uncontrolled may not reflect the disease — those points matter as much as the number.
• "Normal" does not mean no heart disease. The ASE guideline of 2025 on diastolic function and the diagnosis of heart failure with preserved ejection fraction (Nagueh et al.) states that the clinical diagnosis of HFpEF requires three things together — signs and symptoms of congestive heart failure, an echocardiographic determination of normal LVEF (generally accepted to be ≥50%), and the absence of other cardiac or non-cardiac causes for the patient's symptoms — and that such patients make up half of all heart failure hospitalisations; and a normal resting study cannot exclude it either — up to 50% of HFpEF patients have normal left ventricular filling pressure at rest, and as many as 30% have normal natriuretic peptide blood results. And a resting echocardiogram is not itself a test of whether the coronary arteries are open.
• "A little leak is very common" does not apply to every valve. The original of the ASE guideline of 2017 on native valvular regurgitation: physiologic or mild degrees of tricuspid and pulmonic regurgitation are commonly noted in normal examinations, but aortic regurgitation is not. The ASE reporting standardisation guideline of 2025 narrows it further: on a structurally normal valve what may be considered normal is "trace", and mild or greater aortic or mitral valve regurgitation should be classified as abnormal.
• "Mild" has an official definition. Table 8 of the ASE reporting standardisation guideline of 2025: mild means a clearly detected observation usually of no suspected current clinical significance. The same table also states that the descriptors "mild-to-moderate" and "moderate-to-severe" do not exist in ASE guidelines tables at all, and should be used only sparingly where data are missing or discrepant.
• The "critical" tiers on a report are written for the reporting physician, not for a patient to triage themselves. The Critical tier of ASE's table 14 calls for direct verbal notification of the ordering physician within minutes, and the Urgent tier for clinical action within hours. Which is to say that a genuinely critical finding should already have produced a telephone call to a doctor before the patient sees the report.
• A pericardial effusion is not "small so it is fine". The ASE recommendations of 2013 on imaging in pericardial disease state that cardiac tamponade can be fatal regardless of the size of the effusion; and there are also low-pressure and regional tamponade, in which the typical signs are often absent.
• What this article will not do: it will not provide a table for scoring your own report cell by cell, will not tell you what your numbers mean for you, will not advise whether to take medication, have surgery or watch and wait, and will not compare institutions. It sets out what each international guideline printed, which body printed it and in which year; the rest is for a doctor to decide on your own circumstances.

#What is an echocardiogram actually doing, and what does the Hospital Authority call it?

It is an examination that images the heart with ultrasound — but in Hong Kong's public system it is not a radiology service, it is a cardiology procedure, and even its official Chinese name is not the one most people assume.

healthdirect, the Australian government-funded health information platform, describes the examination on its page on the electrocardiogram (page self-dated as last reviewed May 2025) as "an ultrasound of your heart (echocardiogram)".

The Hospital Authority has two Chinese names of its own, and neither is 超聲心動圖. Under "cardiology" in section 5.2 of annex III on diagnostic and therapeutic procedures in the Hospital Authority's list of non-subvented medical service items, the column for mobile investigations and procedures prints, in both the Chinese and English versions, seven echocardiography items across two fee categories (as implemented by the fee schedule taking effect on 1 January 2026). Category 2 (4,190 dollars each) has two and Category 3 (6,490 to 14,650 dollars each) has five, all reproduced in the original at [Note 1].

Two points go with that list. First, "starin" is as printed by the source (the correct spelling is strain), reproduced as found. Second, each category's own heading reads 「第二類，例如」 / "Category II, such as" — that is, examples, not a closed list — so "the name on my report is not on that list" does not mean it has no classification.

And the day services page of Pok Oi Hospital uses a more colloquial term: the cardiac and neurological investigation unit provides patients with various examination services including electrocardiography, echocardiography and 24-hour cardiac monitoring; and the booking procedure for that column reads that a referral from a doctor in this cluster is required [Note 2].

⚠️ That page lists six units in all, each with its own booking procedure, and the six cells carry five different formulations (all reproduced at [Note 2]). So the sentence above belongs to the cardiac and neurological investigation and endoscopy unit column, and cannot be taken as a rule for the whole hospital.

In one sentence: the formal fee schedule calls it 「超聲波心臟檢驗」, the hospital service page calls it 「心臟超聲波」, and both are the Hospital Authority's own words; 「超聲心動圖」 belongs to another set of terminology (it is what ASE's official Chinese version uses, and that version is in simplified characters), and is not the name used in any published Hospital Authority material.

Within the Hospital Authority it does not belong to radiology. The table of contents of annex II to the gazetted fee schedule lists the two separately in both languages, with echocardiography under section 5.2, cardiology. That has second and third lines of support: Pok Oi Hospital places it with electrocardiography and ambulatory electrocardiography in the cardiac and neurological investigation unit; and group four of annex II of the Hospital Authority's radiology items (ultrasonography, 490 to 7,100 dollars per examination) itemises 58 ultrasound examinations covering the abdomen, thyroid, breast, scrotum, infant brain, carotid Doppler and so on, among which not one is an echocardiogram.

⚠️ The limits of that conclusion have to be drawn: among the 58 there is indeed one entry "Radiology 3321 – Ultrasonography – Doppler – Pericardium" (in the Chinese version, 放射科 3321——超聲波——多普勒——心包), so the accurate statement is that the radiology item list contains no echocardiography item, not that radiology never images anything near the heart. That negative conclusion is drawn against a list that itself carries a great many other ultrasound items.

⚠️ If you are holding a referral letter and want to know which department this examination sits in: the Hospital Authority's fee classification places it in cardiology rather than radiology; and the Hospital Authority's own frequently asked questions on the public healthcare fee reform print which examinations each of the three tiers of "non-urgent radiology service" contains, and the ultrasound in those three tiers is 「超聲造影」 (in the English version "Ultrasonography", that is the radiology kind), with no echocardiography. So those three tiers on the fee schedule are not how this item is charged.

#What should a "standard" echocardiogram report contain?

The format of a report is not left to each laboratory: ASE published a guideline in September 2025 specifically on how a report is written, down to definitions of the report's status (draft, preliminary, final, amended) — and that last point is the most useful of all to a patient holding a printed report.

The American Society of Echocardiography (ASE) Guidelines for the Standardization of Adult Echocardiography Reporting of 2025 (published 3 September 2025) sets out that a transthoracic echocardiography (TTE) report should carry a report heading for each of the following structures [Note 3]: the left ventricle, the interventricular septum, the right ventricle, the left atrium (including the pulmonary veins), the interatrial septum, the right atrium, the aortic valve, the mitral valve, the pulmonic valve, the tricuspid valve, the aorta, the pulmonary artery, the inferior vena cava, the superior vena cava, the pericardium, and where relevant implanted devices.

That is, the standard report has 15 mandatory structural headings plus a conditional 16th (where there is an implanted device) — a different level of description from the popular account of three parts, structure, function and valves: the latter is a simplification, not what ASE printed as the standard.

The four names for a report's status, as defined in the same document (quoted in full at [Note 3]): a draft report is measurements, worksheets and findings entered or electronically generated by experienced sonographers and physicians in training for the laboratory's internal use; a draft report has not been reviewed or approved by an interpreting physician, and should therefore not be visible in the electronic record or issued to external care providers. A preliminary report is a verbal or written report generated by an appropriately trained physician, approved for clinical use but not yet finalised by the interpreting physician; a preliminary report does not include all recommended reporting components. A final report is a written complete report reviewed, signed and dated by the interpreting physician; the final report should identify and reconcile any differences with any previously issued preliminary report. An amended report is created whenever changes are made to a "final report"; it refers to the prior report by date and time and includes clear language highlighting clinically relevant revisions from it.

The same guideline separately defines three types of examination: comprehensive; limited (a focused protocol for a specific clinical question, usually a follow-up after a recent comprehensive study); and POCUS (point-of-care ultrasound), whose definition states that the term is not defined by the location of the examination, the capability of the machine, or the specialty of the operator.

⚠️ If you have received a report written differently from the last one, or marked "preliminary": ASE has printed it — a preliminary report by definition does not include all recommended components, and a final report has a duty to reconcile the differences with a preliminary one. What status the document carries is itself a piece of information.

#Why can the same heart produce two different numbers on two reports?

Because LVEF is not measured, it is calculated by subtracting two volumes that were traced — and the tracing is done by a person.

Section 2.2 of the ASE/EACVI Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults of 2015 sets out the formula: EF = (EDV − ESV) / EDV, that is end-diastolic volume minus end-systolic volume, divided by end-diastolic volume; and the two-dimensional method the committee recommends by consensus is the biplane method of discs (the modified Simpson's rule). ASE's official Chinese version (simplified, translated from the English original) prints the same passage as 「EF 由EDV 和ESV 的测值计算而来」 [Note 4].

Section 1.3 of the same document also states that all measurements should be made over more than one cardiac cycle to allow for beat-to-beat variation: an average of three beats is recommended in sinus rhythm and at least five in atrial fibrillation. The sentence immediately following matters as much — the committee itself acknowledges that implementing this recommendation is time consuming, and writes that the use of representative beats is acceptable in the clinical setting [Note 4].

That is, between the best practice the guideline prints and everyday practice there is a door the guideline itself left open.

How much variation this "traced by a person" method carries has been measured. Cole GD et al. (Int J Cardiovasc Imaging 2015) gave 35 operators 20 anonymised apical four-chamber video clips of varying image quality and left ventricular function, each operator seeing each clip twice without knowing it was a repeat, for 1,400 interpretations in all, with the following results [Note 5]: when grading left ventricular function into five categories, an operator's chance of agreeing with another operator was 50%, and of agreeing with themselves on blinded re-presentation 68%; blinded repeat eyeball estimates of LVEF by the same operator had a standard deviation of difference of 7.6 EF units, with the standard deviation across operators averaging 8.3 EF units.

The conclusion of that same study [Note 5]: individuals cannot themselves identify when poor image quality is disrupting their estimate of left ventricular function; clinicians should not assume that patients changing in grade or in visually estimated EF have had a genuine clinical change.

Variation between modalities has its own figures, but they have to be read with the population. Pellikka PA et al. (JAMA Netw Open 2018) analysed 2,032 patients in the STICH trial with coronary artery disease and LVEF ≤35%, with images interpreted by a specialist core laboratory. The paper's "Key Points" box states [Note 6] that the correlation of LVEF between modalities ranged from r = 0.493 for biplane echocardiography against cardiovascular magnetic resonance to r = 0.660 for cardiovascular magnetic resonance against gated single-photon emission computed tomography; and that there was no systematic overestimation or underestimation of LVEF for any modality. The Meaning line immediately following in the same box is the authors' own conclusion: there is substantial variability in LVEF assessment between modalities, which should be considered in trial design and clinical management.

These were patients with severe left ventricular dysfunction and coronary disease, not people told their echocardiogram was normal — the denominator and the population go with the figure. The same paper reports that correlation between methods within echocardiography itself was higher (biplane against visual estimate r = 0.898).

The guidelines say the same. Section 2.3.1 of the ACC/AHA valvular heart disease guideline of 2020: given the inherent measurement variability for these parameters, decisions are most robust when based on sequential studies [Note 7].

⚠️ If you are holding two reports from different years with different numbers and want to know whether the disease has changed: this section is not saying reports cannot be trusted, it is saying that a single number from a single study is not a stable quantity. How much difference counts as a real change is calculated once, using ASE's own printed thresholds, in the "do the arithmetic" section below.

#Can a "normal" report say you have no heart disease?

It cannot, and this is the most important passage in this article.

Section 16 of the ASE guideline of 2025 on diastolic function and HFpEF diagnosis (published 3 July 2025) states [Note 8]: HFpEF constitutes half of all heart failure hospitalisations, with a growing prevalence relative to heart failure with reduced ejection fraction; the clinical diagnosis of HFpEF is reached by establishing the presence of signs and symptoms of congestive heart failure together with an echocardiographic determination of normal LVEF (generally accepted to be ≥50%) in the absence of other cardiac or non-cardiac causes for the patient's symptoms; and although the Framingham criteria demonstrate excellent specificity for the diagnosis of heart failure, they lack sensitivity, particularly in elderly patients who may not have had acute heart failure decompensation — so a patient may have HFpEF even without satisfying specific clinical criteria for heart failure.

That is, a report of LVEF 60% not only fails to exclude heart failure, it is precisely the definitional range of half of all heart failure hospitalisations.

A normal resting study cannot exclude it either. Section 13 of the same guideline [Note 8]: left ventricular filling pressure at rest may not be sufficient to evaluate a patient whose breathlessness happens mostly on exertion; importantly, up to 50% of patients with HFpEF have normal left ventricular filling pressure at rest that increases rapidly with exercise, or even with leg raising.

Nor can a normal blood test. Section 16.C of the same guideline [Note 8]: up to 30% of patients with HFpEF can have normal natriuretic peptide levels despite signs and symptoms of heart failure, echocardiographic abnormalities and elevated left ventricular filling pressures on invasive haemodynamic testing; so although natriuretic peptide is important in evaluating HFpEF, a normal level does not necessarily rule the diagnosis out, particularly in obese patients with HFpEF.

One more thing: a resting echocardiogram is not a test of the coronary arteries. The ASE chamber quantification guideline of 2015 assigns the role of demonstrating significant coronary stenosis to stress echocardiography [Note 9]; and item 3 of the Key Points of section 16 of the ASE diastolic function guideline of 2025 lists coronary disease among the things to be separately excluded: before reaching a diagnosis of HFpEF, valvular heart disease, non-cardiac pulmonary hypertension, significant coronary artery disease, infiltrative and hypertrophic cardiomyopathy, and pericardial constriction should be excluded [Note 9]. Table 9 of the same guideline (the differential diagnosis of HFpEF) likewise lists myocardial ischaemia among its entries.

And at the patient-facing level, after describing the electrocardiogram healthdirect lists the other tests that may be needed — the echocardiogram cited above is the first item on that list, and the list does not stop there: an ultrasound of the heart, blood tests, and an angiogram (pictures of the heart's blood vessels) [Note 10].

In one sentence: on that patient-facing list, imaging the heart and imaging the heart's blood vessels are two things side by side. This article will not tell you whether you need one, or which — the only use of this passage is this: do not let a resting echocardiogram's "normal" stand in for an answer about the coronary arteries.

The converse has to be said too. healthdirect on heart valve disease (page self-dated as last reviewed February 2024): even if you do not have any symptoms, heart valve disease still needs treating [Note 10].

In one sentence: "the report is normal so nothing is wrong" and "I have no symptoms so the report does not matter" point in opposite directions, and the sources say neither holds.

ASE has another kind of examination for this situation, but it prints who it is not for alongside who it is for. Section 13.A of the same guideline puts the suitable and the unsuitable in one passage, five consecutive sentences quoted at [Note 11], and the direction is: diastolic stress testing is most valuable when resting echocardiography does not explain the symptoms of heart failure or exertional breathlessness; in general, patients with completely normal diastolic function at rest with preserved e′ velocity need not undergo stress testing; likewise, patients with abnormal findings at baseline consistent with elevated left ventricular filling pressures should not be referred; and the most appropriate group is those with grade 1 diastolic dysfunction, along with symptomatic patients whose diastolic function or filling pressure at rest is indeterminate.

⚠️ Note that "indeterminate" is itself a result that can be printed on a report — which is to say that a report saying "indeterminate" is not, in the guideline's wording, a middle ground but a named group for which stress testing is appropriate. But which group you are in still depends on a grading and a clinical assessment, not on matching yourself to a word on a report — so this article states only that these groups exist, not whether you are suitable.

⚠️ If you had an echocardiogram because of breathlessness or reduced exercise tolerance, were told it was largely normal, and still have symptoms: what ASE printed is that a normal resting left ventricular filling pressure may still not exclude HFpEF — up to 50% of HFpEF patients are in that position. And separately: a resting echocardiogram is not an answer about the coronary arteries.

#What does "mild" on a report mean?

The word has an official definition, and the definition is itself the most direct answer.

The severity section of table 8, "Reporting standards terminology and definitions", of the ASE reporting standardisation guideline of 2025 is quoted in full at [Note 12]. The essentials:

• None — when a condition is clearly excluded.
• Trace — less than mild (used for valve regurgitation).
• Mild(ly) — a clearly detected observation (or degree of other abnormality) usually of no suspected current clinical significance, which may or may not be due to a structural or functional abnormality, but which is defined by reference values in ASE guidelines.
• Moderate(ly) and Severe(ly) — an obvious abnormal observation of suspected current or future clinical significance, defined by reference values in ASE guidelines.
• Mild-to-Moderate and Moderate-to-Severe — these descriptors do not exist in ASE guidelines tables, and should be used only sparingly where missing or discrepant data prohibit a "mild", "moderate" or "severe" designation; where used, they should carry an accompanying statement explaining the reasons for the mixed grade.

The same section also notes that some cardiac structures with abnormal features have not been categorised into grades (the degree of leaflet thickening, for example), and that in those cases laboratories are encouraged to develop internal standards for consistency.

There are two practical points in that passage, worth taking separately.

First, the definition of "mild" contains the phrase "usually of no suspected current clinical significance". That is a definition an international professional body has given for a word on a report; it is not a rule you can apply to your own numbers — the actual determination of severity is defined by grading tables this article does not print (see below).

Second, if your report says "mild to moderate". ASE states that this formulation does not exist in its tables, that it should be used only sparingly where data are missing or discrepant, and that where used it should carry an explanation. Which is to say that the phrase is itself a signal that data are incomplete or inconsistent, and not a grade of disease lying between two others.

#Is "a little leak" really something everyone has? — a distinction that cannot be generalised

For the tricuspid and pulmonic valves the guideline states directly that mild regurgitation is common in normal people; for the aortic valve the same guideline states that it is not.

Section II.A of the ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation of 2017 (Zoghbi et al.) states that Doppler techniques are very sensitive, so that trivial or physiologic valve regurgitation can be detected even in a structurally normal valve, and occurs frequently in right-sided valves [Note 13].

Section II.C of the same guideline, on the consensus about grading terminology (quoted in full at [Note 13]): the writing group's consensus is to classify the severity of regurgitation into mild, moderate and severe; "Trace" is used where regurgitation is barely detected, which is usually physiologic, particularly in the right heart valves and the mitral valve, and may not produce an audible murmur; since the severity of regurgitation may be influenced by haemodynamic conditions, it is essential to record the patient's blood pressure, heart rate and rhythm at the time of the study; and when following a patient with serial examinations, these factors need to be considered in comparing the severity of regurgitation, and the actual studies reviewed and compared, because of the inherent variability of the techniques and measurements.

That second half is the commonest explanation for "last time it said mild, this time moderate". The same valve examined on two different occasions with different blood pressures and heart rates can produce two grades without the disease having moved a grade — and telling those two possibilities apart takes the original images from both studies and the blood pressure and heart rate on each day, not two words on two reports.

Note another point: ASE's consensus in that section is three grades plus a "trace", not a four-tier "trivial / mild / moderate / severe". But "trivial" is not a word absent from ASE documents — it appears three times in that 2017 guideline. The difference is that ASE uses the word in running text to describe something less than mild, rather than defining it as a grade. The ASE reporting standardisation guideline of 2025 addresses this directly [Note 14]: the writing committee acknowledges that terms such as "trace", "insignificant", "trivial", "physiologic" or "minimal" have historically been used to describe regurgitation that is less than mild, and recommends the use of "trace" in place of all other "less than mild" regurgitation descriptors.

In other words, if your report says "trivial", it is not a word that does not exist, and it is not a fifth grade; it is the cell ASE recommends writing in future as "trace".

On the tricuspid and pulmonic valves the same guideline states, in four different places (⚠️ the four sentences do not come from one kind of passage; all are quoted at [Note 13]): a small degree of tricuspid regurgitation is present in the majority of normal individuals; physiologic mild tricuspid regurgitation is common in normal individuals; physiologic, mild pulmonic regurgitation is common in normal individuals; and trivial and mild pulmonic regurgitation is clinically very common, while on the other hand clinically significant pulmonic regurgitation is uncommon.

Then comes the point of this section, from section IV.C of the same guideline [Note 13]: while "physiologic" or mild degrees of tricuspid and pulmonic regurgitation are commonly noted in normal examinations, aortic regurgitation is not; when aortic regurgitation is detected, the evaluation starts with an assessment of the anatomy of the aortic valve and root to determine the aetiology of the regurgitation, followed by an assessment of left ventricular size, geometry and function.

That distinction is worth stating plainly, because putting mild mitral, mild aortic and mild tricuspid regurgitation together into one bucket of common degenerative findings needing no action is very easy to do. ASE says that of the tricuspid and pulmonic valves, and says the opposite of the aortic valve.

And the ASE reporting standardisation guideline of 2025 draws the line more sharply still, putting the mitral valve on the strict side [Note 14]: "trace" regurgitation of a structurally normal native valve or a prosthetic valve may be considered normal, whereas mild or greater aortic or mitral valve regurgitation should be classified as abnormal; however, for structurally normal native tricuspid or pulmonary valves, mild regurgitation may be regarded as a normal functional finding (physiologic).

That is, the cell that "may be considered normal" is not in the same place for all four valves:

• Aortic and mitral valves: what may be considered normal is trace. Mild or greater, ASE 2025 states, should be classified as abnormal.
• Tricuspid and pulmonic valves (with a structurally normal valve): even mild may be regarded as a normal functional finding.

⚠️ "Classified as abnormal" is not "severe", and does not mean anything must be done — ASE's definition of mild in table 8 is still "usually of no suspected current clinical significance". The two sentences have to be read together to be accurate: a mild mitral or aortic regurgitation is a finding for a doctor to assess against your overall situation, not an item to be ticked off at home; and equally, it is not itself a determination of "severe".

At population level, the threshold differs for each valve, and the rows cannot be read side by side. Singh JP et al. (Am J Cardiol 1999) used colour Doppler in 1,696 men and 1,893 women at a routine examination in the Framingham study (mean age 54 ± 10 years):

Those three figures must be read with their thresholds: the mitral and tricuspid figures are "mild or greater", excluding trace; the aortic figure is "trace or greater", including trace. So the aortic 13.0% and 8.5% were caught with a wider net and are nevertheless the smaller numbers. The abstract does not publish the trace proportions for the mitral and tricuspid valves, so the true proportion with any detectable regurgitation is higher than 19.0% and 14.8% — and that figure is not printed in the paper's abstract.

The same paper reports the determinants for each of the three valves (three sets have to be reported, not two): for mitral regurgitation, age (odds ratio 1.3 per 9.9 years, 95% confidence interval 1.2 to 1.5), hypertension (1.6; 1.2 to 2.0) and body mass index (0.8 per 4.3 kg/m²; 0.7 to 0.9); for tricuspid regurgitation, age (1.5 per 9.9 years; 1.3 to 1.7), body mass index (0.7 per 4.3 kg/m²; 0.6 to 0.8) and female sex (1.2; 1.0 to 1.6); and for aortic regurgitation, age (2.3 per 9.9 years; 2.0 to 2.7) and male sex (1.6; 1.2 to 2.1). Of the three sets, age is the only factor appearing for all three valves.

⚠️ These are figures from a United States community cohort of the 1990s, not Hong Kong figures and not 2026 figures; more sensitive modern equipment will raise detection rates.

Mitral valve prolapse is not "common in young women". Freed LA et al. (N Engl J Med 1999) examined 1,845 women and 1,646 men at the fifth examination of the Framingham Offspring cohort (mean age 54.7 ± 10.0 years), with these results [Note 15]: a total of 84 subjects (2.4%) had mitral valve prolapse, of whom 47 (1.3%) had classic prolapse and 37 (1.1%) non-classic prolapse; their age and sex distributions were similar to those of the subjects without prolapse; and in a community-based sample of the population the prevalence of mitral valve prolapse was lower than previously reported, as was the prevalence of the adverse sequelae commonly associated with it in studies of patients referred for that diagnosis.

The same paper also reports that chest pain, breathlessness and electrocardiographic abnormalities occurred with similar frequency in those with and without prolapse; and that those with prolapse had a greater degree of mitral regurgitation, but on average trace or mild.

Finally, one sentence about murmurs. healthdirect on heart valve disease: remember, having a murmur does not mean that you have heart valve disease; you can have a heart murmur and a healthy heart [Note 10].

⚠️ If your report says mild aortic or mild mitral regurgitation and you have found online that "a little leak is very common" and been reassured: ASE says the opposite about the aortic valve; and the ASE reporting standardisation guideline of 2025 states it for the aortic and mitral valves together — mild or greater should be classified as abnormal, and what may be considered normal is only trace.

#The mean gradient in aortic stenosis: the one threshold this article will print

On principle this article does not print grading tables, but the mean gradient row is an exception, and the reason can be stated: a version saying "40–60 mmHg is moderate" differs from what the guideline printed by a full grade, and a reader holding a reading of 45 mmHg needs to know what is actually on the page.

Table 3 of the ASE and EACVI Recommendations on the Echocardiographic Assessment of Aortic Valve Stenosis: A Focused Update of 2017 (Baumgartner et al., published 1 April 2017) prints, on the mean gradient row:

That is: 40 mmHg or above is, in this guideline, severe, not moderate. The table reads as printed in the original — the moderate cell says 20–40 and the severe cell says ≥40, so the two overlap at the point 40. The mean gradient for the aortic sclerosis grade is printed as a dash — that grade has no gradient cut-off at all; it is defined by a peak velocity ≤2.5 m/s. A report saying aortic sclerosis with no gradient figure has not omitted one; the original table does not have one.

But this row cannot be used to grade on its own, and the strongest reason for that is what the guideline itself says in the passages before and after table 3. The passage before table 3 [Note 16]: aortic valve disease runs a continuum from aortic sclerosis without haemodynamic consequence to very severe obstruction of flow, so that measures of disease severity must be regarded as a continuum; the definitions of the grades of aortic stenosis severity are to some extent arbitrary; any one of three criteria — a valve area <1.0 cm², a peak velocity ≥4.0 m/s, or a mean gradient ≥40 mmHg — may be taken to suggest severe aortic stenosis; and ideally the criteria should all fall in the severe range and be consistent with one another.

In one sentence: a mean gradient of ≥40 is, in the guideline's own word, a suggestion of severe disease, not a determination of it. The passage after table 3 explains why: the current cut-offs for the several parameters are not consistent with one another — to produce a mean gradient of 40 mmHg at normal flow, the valve area would need to be closer to 0.8 than 1.0 cm²; and small body size can be another reason for a small valve area with a low gradient. The original table's four other rows are not reproduced here, because those four together with the mean gradient are to be integrated in one reading, and the integrated reading is the clinician's work.

One more thing printed in the same guideline, and rarely passed on with the number: the blood pressure on the day it was measured. The Arterial Hypertension section of that document [Note 16]: assessing the severity of aortic stenosis while hypertension is uncontrolled may not accurately reflect the disease, so it is recommended that blood pressure be controlled before the echocardiographic assessment where feasible; and echocardiography reports should always include the blood pressure measurement recorded at the time of the study, for comparison with previous studies and other clinical data.

The same section also notes that hypertension mainly affects flow and gradients, and affects valve area less. In other words, a mean gradient of 45 mmHg measured on a day when blood pressure was uncontrolled is not necessarily a number about the valve at all — and telling that apart takes the blood pressure record for that day, which is exactly the item ASE and EACVI ask to have printed on the report.

A more important point, and it runs the other way. The same guideline notes that when left ventricular systolic dysfunction, reduced stroke volume and severe aortic stenosis coexist, velocities and gradients can be low despite a small valve area; heart failure can make a patient with genuinely severe stenosis present with a "seemingly moderate" peak velocity and mean gradient. In other words, a mean gradient under 40 cannot be used to exclude severe aortic stenosis.

The guideline also stresses that follow-up studies must use exactly the same method: the difference between measurements taken from different transducer positions is by itself enough to produce an apparent rise; and where flow falls at the same time, velocities and gradients can stay the same or even fall despite the stenosis in fact worsening.

⚠️ If your report says AS with a mean gradient figure and you have come across the "40–60 is moderate" formulation: what ASE/EACVI 2017 table 3 prints is ≥40 for severe. But the same guideline prints three things that change what that number means: the definitions of the grades are to some extent arbitrary, any single criterion only suggests severe disease, and a gradient measured while blood pressure is uncontrolled may not reflect the disease (which is why the report should also print the blood pressure on the day).

#Pericardial effusion: size is not the measure of risk

ASE states it plainly — cardiac tamponade can be fatal regardless of the amount of the effusion, so the inference "small, therefore fine" does not hold.

The ASE Clinical Recommendations for Multimodality Cardiovascular Imaging of Patients with Pericardial Disease of 2013 (Klein et al.) states that when tamponade is suspected, two-dimensional and Doppler echocardiography should be performed urgently; and that cardiac tamponade can be fatal regardless of the size of the effusion.

The same document records three situations that do not match the typical picture: a trivial pericardial effusion with a large pleural effusion can equally cause tamponade; patients who are hypovolaemic from traumatic bleeding, haemodialysis or ultrafiltration, poor oral intake and vomiting (in cancer patients, for instance) or over-diuresis can present with low-pressure tamponade — cardiac filling severely impeded, but with pericardial and end-diastolic cardiac pressures equalising at a level still below 10 mmHg, which is normal; and a loculated, eccentric effusion or a localised haematoma can cause regional tamponade, compressing only some chambers, often on the left. In these situations the typical clinical, haemodynamic and echocardiographic signs are often absent. The same document also notes that mild cardiac tamponade is frequently asymptomatic, and that arterial hypotension is a late sign in tamponade.

ASE does have a semiquantitative grading of effusion size, in five grades, and this article does not print it. The reason comes from the source itself: the risk is not carried by that size grade. The same document also notes that seeing a circumferentially distributed effusion from several two-dimensional transducer positions improves the predictive value of the size estimate, and that effusions in the small and the very large grades are the ones most likely to be unevenly distributed in the pericardial space and its recesses. (Reading those two sentences together — that in those two grades the size itself is less reliable — is this article's inference, not the source's own sentence.)

⚠️ If your report says small pericardial effusion and you have found online that a small one is usually asymptomatic and set it aside: what ASE printed is that lethality does not follow the size of the effusion, and that there are several forms of tamponade in which even the typical signs are absent.

#Who are the "critical" tiers on a report actually written for?

For the physician issuing the report, and they carry deadlines: the Critical tier calls for direct verbal notification of the ordering physician within minutes, and the Urgent tier for clinical action within hours.

The framework itself is a useful piece of information for a reader: by this standard, a genuinely critical finding should already have produced a telephone call to a doctor before you had the report in your hand.

Table 14 of the ASE reporting standardisation guideline of 2025 is reproduced in full at [Note 17] (the table's own title says "Examples of" — examples, not a closed list). The definitions of the three tiers and a summary of their items:

• Critical findings — findings that constitute a life-threatening condition requiring immediate clinical action; direct verbal notification of the ordering physician is recommended as soon as the finding is identified (communication measured in minutes). Items include: suspected cardiac tamponade; suspected aortic dissection or acute aortic syndrome; complications of myocardial infarction; thrombus in transit; acute right ventricular dysfunction and suspected acute pulmonary embolism; complications of a left ventricular assist device or extracorporeal membrane oxygenation; and severe obstruction or stenosis of a prosthetic or native valve, particularly acute or new.
• Urgent findings — findings that constitute a significant abnormality or a change from a prior study, potentially requiring clinical action in the short term; direct personal notification of the ordering physician is recommended (communication measured in hours). Items include: a new large pericardial effusion without tamponade; new severe left or right ventricular dysfunction; a newly suspected vegetation, intracardiac mass or thrombus; an orthotopic heart transplant with signs of acute rejection; suspected cardiogenic shock; new left ventricular outflow tract obstruction (a resting gradient >30 mmHg before Valsalva); and high-risk findings on stress echocardiography.
• Significant findings — significant findings that may require consultation and additional or follow-up testing. Items include: a significant decline in left ventricular systolic or diastolic function; a significant change in right ventricular systolic function; significant aortic dilation; findings suggestive of a specific cardiomyopathy; a change in the size of a pericardial effusion; and a known valve stenosis or regurgitation progressing to severe.

The asterisked footnote at the end of the table states that the interpreting physician should consider the indication for the study, the patient's history and the acuity of the finding, and apply clinical judgment, in deciding the urgency of these findings and the manner of communication.

Three things have to be said with that table.

1. It is examples, not a complete list. The title says "Examples of", and the footnote hands the final judgment back to the interpreting physician's clinical judgment. "Not on this table" does not mean "not important".
2. It is written for clinicians, not for a patient to triage themselves. Elsewhere the same guideline separately defines the acuity of findings (Routine, Significant, Urgent, Critical), all of it about how quickly and by what means the laboratory should notify the ordering physician.
3. There are two published sentences in this article's material addressed directly to patients, and neither turns on a number on a report. The first turns on symptoms — section 2.3.2 of the ACC/AHA valvular heart disease guideline of 2020 [Note 7]: patients with valvular heart disease should be instructed to report promptly any change in symptom status; the onset of symptoms or a change on physical examination should raise concern about the heart's response to the valve lesion, requiring a repeat transthoracic echocardiogram. healthdirect says the same to a general reader: if you think you have any symptoms of heart valve disease, or if you are worried about your health, you should see a doctor [Note 10].

And the sentence immediately after it is the second trigger — it turns on age, not symptoms [Note 10]: if you are 45 or over (35 for Aboriginal and/or Torres Strait Islander people), you should see a doctor every two years for a "Heart Health Check"; the 20-minute check calculates your risk of a heart attack or stroke.

⚠️ The scope of that sentence has to be stated: healthdirect is an Australian government-funded platform, the "Heart Health Check" is an Australian service, and both age thresholds are Australian settings. There is no corresponding age-based trigger recommendation in the Hong Kong official material cited in this article. So the use of that sentence in Hong Kong is as a reminder that symptoms are not the only way a follow-up gets triggered — not as a schedule that applies here.

⚠️ If you are holding a report and looking for a list of "go straight to A&E if you see this": the guidelines and patient-information pages cited here have never published a patient version of such a list, and this article will not assemble one either. Every published urgency tier is addressed to a doctor; and of the two sentences addressed directly to patients, one is triggered by a change in symptoms and one by age (in Australia) — neither by a number on a report.

#The twelve tools this article will not print, and why

This section is itself the answer: these questions cannot be answered at home.

The twelve below are all verbatim, sourced, on point, and quotable clinical tools. Every one of them is made for a doctor who has the images, the measurements, the history and a physical examination in hand. This article states only that they exist, who issued them, and what has to be in hand before they can be used — it will not print their cut-offs and grades. The reason sits in each cell, and every one of them is the source's own.

The exclusions on the diastolic function algorithm are worth reading verbatim once, as the most concrete example there is of "this tool is not made for you". The legend to figure 3 of the ASE guideline of 2025 [Note 18]: an algorithm for the estimation of mean left atrial pressure, applicable to patients in sinus rhythm without severe primary mitral regurgitation, without mitral stenosis of any degree, and without moderate or severe mitral annular calcification; the algorithm should also not be applied in patients with atrial fibrillation, heart transplant recipients, non-cardiac pulmonary hypertension, constrictive pericarditis or a left ventricular assist device, nor in patients who have had mitral valve repair, mitral valve replacement or transcatheter edge-to-edge mitral repair.

While we are here, one common formulation needs correcting: in the ASE guideline of 2025 the grades of diastolic function are labelled by left atrial pressure (grade 2 is labelled as a mild-to-moderate elevation of left atrial pressure and grade 3 as a marked elevation), not by "mild or severe disease". The same section also states that where the interpreting physician cannot determine the grade, the report should instead state whether left ventricular filling pressure is normal or elevated.

⚠️ If you want to score your own report against a table: all twelve tools exist and can all be found in the originals, and this article chooses not to reproduce their numbers; not reproducing them is itself the answer — these judgments need material you do not have in hand.

#Doing the arithmetic once: is an LVEF falling from 60% to 52% a deterioration?

What this section calculates is not "is something wrong with you" but "how much can two numbers on their own answer". The answer is: very little.

⚠️ First, what this table is. The title of table 15 of the ASE reporting standardisation guideline of 2025 reads, verbatim, "Examples of echocardiography findings that are new or significant and may warrant consultation and/or follow-up testing". Like table 14, it is examples, not a closed list; and it is addressed to the physician issuing the report, not to the patient. Using it to calculate below is only a demonstration of how many readings one gap between two numbers can have.

The first yardstick: the left ventricle cell of table 15. That cell prints three examples of a significant change, not one [Note 19]: a significant decline in LVEF (a fall of more than 10 percentage points from any cause, and to below 53%); a significant change in left ventricular diastolic function such that filling pressure rises; and a worsening of left ventricular global longitudinal strain to below the lower limit of normal for the equipment and software the laboratory uses, or a relative change in GLS of more than 15% from baseline.

Take the first: 60 − 52 = 8 percentage points. The threshold ASE printed is "more than 10 percentage points" and below 53%. This example meets the second half (52 < 53) but not the first (8 is not more than 10). The two conditions are joined by "and", so as that item is written this example does not reach the threshold it gives.

But this is where the arithmetic stops. The second and third items — whether diastolic function has changed significantly, and whether GLS has fallen below the lower limit of normal or fallen by more than 15% relatively — are two independent thresholds, and neither of them is settled by the numbers 60 and 52. A report carrying an EF alone simply does not supply what those two items need. So the accurate statement is: this example does not reach the first item's threshold, and this article cannot answer the second and the third. "Does not reach the first item" is not "reaches none of the three", still less "there has been no significant change".

The second yardstick: the measured variation in Cole 2015. The same operator making blinded repeat eyeball estimates of the same clip had a standard deviation of difference of 7.6 EF units; across operators the average was 8.3 EF units. Calculate: 8 ÷ 7.6 ≈ 1.05, and 8 ÷ 8.3 ≈ 0.96. That is, this gap of 8 percentage points is about one standard deviation of the typical difference produced by the same person re-reading the same clip, or by another person reading it.

Third, ASE lists in the same table a menu of "possible causes" for the interpreting physician to choose among [Note 19]: a true worsening of left ventricular systolic function; or not a true worsening, but possibly a difference in imaging or measurement technique; a change in image quality; left ventricular foreshortening; a change in rhythm or heart rate; a change in blood pressure; a change in treatment (an inotrope or an intra-aortic balloon pump, for instance); or an operation in the interval.

Fourth, something entirely separate from "has there been a significant change", and easily buried by the subtraction above: where the number 52% itself sits in the normal range ASE printed. Tables 2 and 4 of the ASE chamber quantification guideline of 2015 print the normal range for biplane LVEF as 52–72% in men and 54–74% in women; and the recommendations box in section 2.2 of the same guideline states that below 52% in men and below 54% in women suggests abnormal left ventricular systolic function. Which is to say:

• for a woman reader, 52% is already below the tabulated normal range (54–74%);
• for a man reader, 52% is exactly in the bottom cell of the tabulated range (52–72%).

⚠️ "This change does not reach the threshold of the first item of table 15" and "this number is within the normal range" are two entirely different questions, and the subtraction above answers only the first.

In one sentence: in ASE's own tables, "the number has fallen" and "the disease has worsened" are two things to be kept apart, and it lists a menu of non-clinical causes for the first. But the other direction has to be said just as plainly — "does not reach a given threshold" is not "nothing is wrong" either: table 15 is itself a list of examples, its left ventricle cell has three items and this article has calculated only one; and whether the number is inside the normal range is a separate question.

⚠️ If you are holding two reports, alarmed that the number has fallen — or relieved that it "does not reach the threshold": neither footing is stable. Repeated measurement carries a noise band that can be calculated, so the gap may not be real; but that ASE threshold is one of three examples, and 52% is already below the normal range ASE printed for women.

#What are the normal reference ranges? — including the passage where the guideline contradicts itself

ASE publishes normal ranges by sex, and the same document gives two different normal ranges for LVEF within two pages of each other — which is itself the most forceful demonstration there is of why not to fix on a single number.

In the ASE/EACVI chamber quantification guideline of 2015, table 2 (normal values for left ventricular size and function by sex) and table 4 (normal ranges and severity cut-offs for LVEF and left atrial volume by two-dimensional echocardiography) print the same set of figures; and the Recommendations box in section 2.2 prints only the lower bound, with no upper bound — below 52% in men and below 54% in women suggests abnormal left ventricular systolic function. The Chinese of that box (ASE's official simplified-Chinese version; the layout and typographical error are as printed in the source, in which "3ED" is the source's own slip), rendered in English here:

"Recommendation. EF calculated by 2DE or 3ED should be listed as a routine measure of LV function. Below 52% in men and below 54% in women suggests abnormal LV systolic function." (our translation from the Chinese original)

Chinese original:

「推荐.2DE 或3ED 计算的EF 应列为常规LV 功能的测量指标。男性<52%，女性<54%提示LV 收缩功能异常。」

But the main text of section 2.4, Normal Reference Values, in the same document gives another set of numbers: EF bears no significant relation to sex, age or body surface area, and normal EF measured by the biplane method of discs is 63 ± 5%, so that in people over 20 an EF between 53% and 73% should be classified as normal [Note 20].

The inconsistency is real, and this article will not pick one side of it for the guideline. The by-sex figures appear in two tables plus a recommendations box; the figure of 53–73% appears in a passage of main text. Both stand within the same document of 2015. Any statement citing "the normal EF" ought to say which part of the document it is citing.

Several points from this that do bear on a reader:

• The normal ranges are by sex. A figure of 53% sits in a different place in the tabulated range for a man and for a woman.
• The left atrium is measured by volume indexed to body surface area, not by diameter. Table 4 of ASE 2015 prints a volume indexed to body surface area of 16–34 mL/m², and it has a lower bound; the ASE reporting guideline of 2025 likewise requires left atrial size and shape to be described and indexed to body surface area.
• Wall thickness is measured in centimetres; the grading recommended in the main text uses indexed myocardial mass, but there is also a table in the appendix grading it in millimetres. Table 6 of ASE prints the normal range for the septum and the posterior wall as 0.6–0.9 cm in women and 0.6–1.0 cm in men; and the recommendation on left ventricular mass is to report it indexed to body surface area, with the upper limit of normal by the linear method at 95 g/m² in women and 115 g/m² in men. ⚠️ A common formulation needs correcting: it is not the case that ASE has never published a grading of wall thickness itself. Supplemental Table 3 in the appendix to that same guideline of 2015 (PDF page 47) prints, by sex, four-grade cut-offs — normal, mildly, moderately and severely abnormal — for septal and posterior wall thickness. This article does not reproduce those numbers — but "does not exist" and "exists and is not printed here" are two different things and should not be run together.
• The guideline states of itself that these figures are affected by body size and ethnicity. ASE 2015 notes that left ventricular mass values vary with sex, age, body size, obesity and world region, which makes a unified reference value difficult to set; and the right ventricle section of the same document states that most of the values it proposes are not adjusted for sex, body surface area or height, so that people at the extremes of height or body surface area may be misclassified as outside the reference range, as may patients with congenital heart disease and endurance athletes, for whom there are no dedicated reference values at all.
• ⚠️ None of the sources cited in this article contains echocardiographic reference values for a Hong Kong or southern Chinese population. ASE 2015 lists the seven databases it drew on, none of them a Chinese or Hong Kong cohort; the only Asian data in table 3 (three-dimensional normal values) are Japanese and South Asian Indian populations, and when that study split its cohort 51% European white and 49% Asian Indian, the ranges for end-diastolic volume index differed between the two groups (in men, white 49 (31, 67) against Indian 41 (23, 59) mL/m²), while EF was essentially the same.

⚠️ If your number is just at the edge of "normal" and you want to know whether a percentage point either way matters: the main text and the tables of the same guideline disagree on this, and it says of itself that these figures are affected by body size and ethnicity — with no dedicated reference values for a Hong Kong population at all.

#How long until the next study? — the published intervals, and who they apply to

The ACC/AHA valvular heart disease guideline of 2020 has a published table of follow-up frequencies, but its scope covers two stages only: patients a doctor has already determined to have progressive (stage B) or severe asymptomatic (stage C1) valvular heart disease — not an ordinary report saying trace TR.

Section 2.3.3 of the guideline states [Note 21]: after the initial evaluation of an asymptomatic patient with valvular heart disease, the clinician should continue follow-up with periodic examination and transthoracic echocardiography; at minimum, an annual history and physical examination are required; the follow-up interval may be lengthened for patients with mild regurgitation that has not changed over 10 to 15 years; and beyond routine periodic imaging, the onset of symptoms or a change on physical examination requires a repeat transthoracic echocardiogram.

Table 5 of the same guideline has four columns: aortic stenosis, aortic regurgitation, mitral stenosis and mitral regurgitation. Read cell by cell, it is not as tidy as "mild every 3 to 5 years, moderate every 1 to 2 years" (the original as printed is at [Note 21]):

• Progressive (stage B). Aortic stenosis every 3 to 5 years (mild; peak velocity 2.0–2.9 m/s); aortic regurgitation and mitral regurgitation every 3 to 5 years (mild). The mitral stenosis cell is not defined by "mild" but by valve area: every 3 to 5 years (valve area >1.5 cm²). The moderate row of the same stage: aortic stenosis every 1 to 2 years (peak velocity 3.0–3.9 m/s), aortic regurgitation and mitral regurgitation every 1 to 2 years — and mitral stenosis has no "moderate" cell at all.
• Severe asymptomatic (stage C1). Aortic stenosis every 6 to 12 months (peak velocity ≥4 m/s); aortic regurgitation every 6 to 12 months; mitral regurgitation every 6 to 12 months; mitral stenosis every 1 to 2 years (valve area 1.0–1.5 cm²). One further cell on the same row: aortic regurgitation and mitral regurgitation more frequently where the left ventricle is dilating; mitral stenosis annually (valve area <1.0 cm²).

⚠️ That distinction bears directly on a reader: "3 to 5 years" is the interval in the progressive-mild cell, not the interval of the whole table. The same table prints every 6 to 12 months for severe asymptomatic aortic stenosis. Someone holding a report of severe AS who remembers only "3 to 5 years" has misremembered the entire table.

There are two notes under the table, and both change how it reads [Note 21]: the asterisk on the aortic stenosis column reads "assuming a normal stroke volume"; and the table note reads that patients with mixed valve disease may require serial evaluations at intervals earlier than those recommended for single valve lesions, and that these intervals apply to most patients with each valve lesion and do not take account of the aetiology of the valve disease.

Four limits go with this table.

1. It is arranged by an established valve-disease stage, not by a word on a report. Physiologic or trace regurgitation on a structurally normal valve is not a valvular heart disease stage at all, and does not appear in this table.
2. Patients in stages C2 and D are not in the table, because the guideline treats them as candidates for consideration of intervention. But to be clear: only C2 and D are excluded — severe asymptomatic stage C1 is in the table.
3. It has two notes, not one: mixed valve disease needs earlier follow-up, and the aortic stenosis column assumes a normal stroke volume — that is, the low-flow situation described above (severe stenosis presenting as "seemingly moderate") is outside the scope of that column.
4. This guideline of 2020 has more than one erratum. The publisher's article page states that the paper has several errata, listing four dates: 1 February 2021, 21 August 2023, 13 November 2023 and 16 September 2024. Every cell above and every passage quoted in this section has been checked cell by cell against the full text of the guideline of 2020; but of the errata themselves, only one has been checked: the one of August 2023 changes the wording of a surgical risk box and does not touch table 5, while the two of November 2023 and September 2024 are unobtainable (the publisher's site returns HTTP 403 to non-subscribers and to automated retrieval alike, and neither PubMed Central nor Europe PMC carries the full text of the errata). Those two errata not having been checked, any cell that differs from an erratum is governed by the erratum.

The guideline also makes one recommendation about where the study is done: since echocardiography remains the mainstay of the initial evaluation of every patient with valvular heart disease, it recommends that the laboratory be a programme accredited by the Intersocietal Accreditation Commission (IAC).

⚠️ If your report says mild something and you want to know when to have the next scan: table 5 prints every 3 to 5 years for progressive (stage B), mild. But remember one thing: that "3 to 5 years" is one cell among many — the same table prints every 6 to 12 months for severe asymptomatic (stage C1), and the whole mitral stenosis column is arranged by valve area rather than by mild or moderate. The premise common to every cell is that a doctor has already staged your valve disease.

#Hong Kong in practice: who does it, what it costs, how long the wait is, and whether you can get the report

Everything in this section is published administrative material, with no clinical judgment in it. Several of the answers emerge only from reading two published documents against each other, and for several the honest answer is that the publications do not print one.

Fees. In the eligible-persons column of the Hospital Authority's public healthcare service fees (taking effect on 1 January 2026), a specialist clinic is 250 dollars per attendance and 20 dollars per drug item. The same table separately lists three tiers of "non-urgent radiology service": basic items free, intermediate items 250 dollars per service and advanced items 500 dollars per service; and three tiers of pathology testing service at free, 50 dollars and 200 dollars.

Which examinations each of those three tiers contains, the Hospital Authority has printed itself [Note 22]: basic items — X-ray (free); intermediate items — fluoroscopy, ultrasonography and mammography (250 dollars); advanced items — computed tomography, magnetic resonance imaging, breast interventional radiology, angiography and vascular interventional radiology, non-vascular interventional radiology, nuclear medicine and positron emission tomography (500 dollars). The English version of the same page prints the 250-dollar tier as "Intermediate Item: Fluoroscopy, Ultrasonography and Mammography" — that is, the ultrasound in that tier is the radiology kind.

⚠️ The question that comes before those three prices marks out which situations the three tiers apply to — and that sentence matters as much as the three figures [Note 22]: the fees apply to non-urgent radiology services arranged as a follow-up from an outpatient clinic or an accident and emergency department, and for day patients or inpatients after discharge; urgent radiology services for inpatients and accident and emergency patients remain free.

In other words, the figures of 250 dollars and 500 dollars are printed for non-urgent radiology services; a reader who was scanned in an emergency department or during an inpatient stay should not use those three tiers to work out what they will pay.

Which is to say: the published list for the three tiers of "non-urgent radiology service" contains no echocardiography. Together with the point already established above — that the Hospital Authority classifies echocardiography under section 5.2, cardiology, of annex II rather than under section 4, radiology — this item does not belong to those three fee tiers.

⚠️ But how much weight that "not on the list" can carry has to be marked out. These tier lists are illustrative, not closed: on the same page the intermediate and advanced pathology tiers are printed as 「包括非常見的血液檢驗項目」 and 「包括複雜的基因血液檢驗項目」 — "including" is open-ended wording; and each category heading in annex II of the gazette says 「例如」 / "such as" in itself. ⚠️ But the basic tier in the same passage cannot be used to support that reading: the full sentence printed there is 「涵蓋最常見的血液病理學檢驗及所有非血液病理學檢驗」 — that "all" is exhaustive wording, pointing the opposite way from "illustrative", so this article does not cite that sentence. So "not visible on the list" does not by itself mean "certainly not in that tier" — the conclusion here that it does not belong to those three tiers rests mainly not on an absence from a list but on the Hospital Authority's own classification.

Does the 250-dollar attendance fee cover this item? The structure of the fee schedule is written this way. Clause 1.3(A) of appendix I to the gazetted fee schedule, verbatim [Note 23]: the fee for consultation (including telemedicine) includes prescribed drugs (other than prescribed drugs for attendance at specialist clinics and family medicine clinics), pathology testing (likewise other than testing for attendance at those two kinds of clinic), urgent radiology services and other investigations.

In other words: the attendance fee says of itself that it includes "other investigations"; and in this public fee schedule the items charged separately are three only — prescribed drugs under clause 1.3(B), pathology testing under clause 1.3(C), and non-urgent radiology services under clause 1.6. An echocardiogram is not a drug, is not a pathology test, and is not on the published list of the three non-urgent radiology tiers.

⚠️ This is a reading of the structure of a published document, not a price the Hospital Authority has quoted. The Hospital Authority has not put any amount against echocardiography in the public fee schedule, so this article will not write "an echocardiogram costs X dollars". The actual charge is whatever the hospital's bill says. Note also that the two parenthesised exceptions in clause 1.3(A) cover, besides specialist clinics, family medicine clinics (including general outpatient clinics) — a point easily missed when reading the clause.

⚠️ Two more things to be clear about:

1. The word "Echocardiogram" appears nowhere in appendix I (the public fees), in either language.
2. The 4,190 dollars (Category 2) and 6,490 to 14,650 dollars (Category 3) in annex III are the fees for "non-subvented medical service items" — that is, private patient charges, not what an eligible person pays. They cannot be cited as public prices.

Waiting. The Hospital Authority's "Specialist Outpatient Waiting Time" is published by specialty and by cluster, not by examination. Taking medicine for the data period from 1 July 2025 to 30 June 2026 as an example: 164,462 new case bookings territory-wide, of which 124,072 were in the "stable" category; the median wait for a "stable" new case ran across the seven clusters from 27 weeks (Hong Kong West) to 65 weeks (Kowloon Central), and the longest wait (the 90th percentile) from 50 weeks (Hong Kong West) to 98 weeks (Kowloon Central).

⚠️ That set of figures is not the whole of it. The same data also prints the numbers for the triage of new medicine cases into urgent, semi-urgent and stable, and the median waits of the three are not in the same order of magnitude at all — read the "stable" row alone and a reader triaged as urgent or semi-urgent would think they too faced a year:

• Urgent new cases, 9,694 (6%): the median wait across the seven clusters is 1 week, and less than 1 week in Hong Kong West.
• Semi-urgent new cases, 28,898 (18%): a median of 4 weeks in Hong Kong West, 5 weeks in Kowloon East, and 6 weeks in the other five clusters.
• "Stable" new cases, 124,072 (75%): the set of figures above, 27 to 65 weeks.

⚠️ Those three categories do not add up to the 164,462 above. 9,694 + 28,898 + 124,072 = 162,664, short of the total by 1,798 cases (about 1.1%); the percentage column bears this out too, at 6% + 18% + 75% = 99%. All four figures are printed verbatim in the source document and have been checked as consistent against the Hospital Authority's open-data JSON version; they are not transcription errors. But the source document does not explain where the shortfall of 1,798 comes from, so the three categories above should be read as three independent published category figures.

⚠️ Three notes are printed under the table on that page, and two of them change directly how the figures above should be read [Note 24]: note (2) — "excluding other cases pending triage", which is to say that 164,462 is not the total number of referrals medicine received but the number of new case bookings already triaged; note (3) — the information on the page is divided by the former hospital cluster boundaries, the Hong Kong East and Hong Kong West clusters having formally merged into the Hong Kong Island cluster with effect from 1 April 2026; and note (1) explains how "longest" is calculated.

⚠️ Note also that this set of figures is the wait for the medicine specialist outpatient clinic — the door through which you see a cardiologist — not the wait for an echocardiogram itself.

The waiting time for echocardiography itself is not published. The Hospital Authority publishes waiting times by specialty and cluster, not by examination. Among published Legislative Council documents, what relates to echocardiography is a service volume pledge rather than a waiting figure: the Secretary for Food and Health's briefing on the 2016 Policy Address (18 January 2016) states 「就心臟科服務提高心臟超聲波檢查的服務量」 — to increase the service volume of echocardiography examinations in cardiac services. ⚠️ That is a document of 2016 and does not describe the position in 2026.

Who performs it, who signs it. Hong Kong has no statutory registration system for cardiac sonographers. The Supplementary Medical Professions Council's own description lists five boards — medical laboratory technologists, occupational therapists, optometrists, physiotherapists and radiographers [Note 25]. Five boards, five professions, and not one of them is cardiac sonography.

As for radiographers, appendix I to the Code of Practice for Radiographers (revised December 2025), "Prohibited acts applicable to all radiographers", item 2 under A, Diagnostic Radiology, prohibits: issuing reports on organ imaging examinations performed using radiation, fluoroscopy, ultrasound and other methods including computed tomography, magnetic resonance and radioisotopes [Note 25].

⚠️ That code binds radiographers only. Echocardiography in Hong Kong is usually performed in a cardiac and neurological investigation unit by a cardiac technician or a nurse, who is not a radiographer and is not on any statutory register — so this code establishes where radiographers stand; it is not a general rule about who may sign an echocardiogram report.

The shift to "performed by a technician, reported by a doctor" is on the record in Hong Kong, but the document is a very old one: Legislative Council paper CB(2) 1308/99-00(11), Long Working Hours of Doctors in Public Hospitals (discussed 10 March 2000), records a finding of the Hospital Authority's internal audit: 「審計結果認為醫院有移交工作的例子，例如由技師進行以往由醫生負責的心臟超聲波檢查」 — that the audit found instances of work being transferred at hospitals, such as echocardiography examinations previously carried out by doctors now being performed by technicians. ⚠️ That is a document of 2000 and cannot be taken as the position in 2026.

The name of the specialty. The list of specialties in the Medical Council of Hong Kong's Specialist Register (page self-dated August 2026) prints: 「12 內科 Internal Medicine S12」, 「13 心臟科 Cardiology S13」, 「66 兒童心臟科 Paediatric Cardiology S68」 and 「25 放射科 Radiology S25」. Which is to say that cardiology is its own specialty category on the register, and is not registered as a subspecialty of internal medicine.

Getting your own report back. The Hospital Authority's personal data privacy policy statement provides that data subjects will be permitted to make data access and correction requests, and that because it has many hospitals under it 「各醫院已委出一名資料控制員」 — each hospital has appointed a data controller. The Hospital Authority has no central data access request form; each hospital issues its own. Take the form used by Tuen Mun Hospital (version 01/26) as an example.

The figure of 40 days is not a hard deadline — the first page of the same form writes the exception in itself [Note 26]: the Personal Data (Privacy) Ordinance requires a data user to comply with a data access request within 40 days of receiving it; where it is unable to comply within 40 days, it must notify the requester in writing of its inability and the reasons, comply to the extent it is able within that same 40-day period, and thereafter comply as soon as practicable or in full.

In other words: when the 40 days are up, what you should have received is a reply, not necessarily the complete record. That sentence matters as much as the "40 days", because it settles whether not having the whole record after 40 days is something having gone wrong.

Charges. The notes page of that form prints the charges applying from 1 January 2026: a handling fee of 100 Hong Kong dollars per request (which covers the first 10 pages of copying and the postage), and 1.5 Hong Kong dollars per page from page 11 onwards; on the imaging side, 300 Hong Kong dollars per imaging modality or per disc and 300 Hong Kong dollars per film (⚠️ the Chinese and English versions print different item lists in the same cell; this article uses the Hospital Authority's own Chinese word 「底片」, film). Two attached conditions are printed on the same page, and both affect when you actually receive anything [Note 26]: unless the hospital is unable to supply the information requested, the handling fee is not refundable; and if the total fee payable exceeds 100 Hong Kong dollars, the hospital will notify the applicant to pay, and the copies will be released once the balance is settled.

Doing the arithmetic once (an example): a paper record of 14 pages in all — a handling fee of 100 dollars (covering the first 10 pages), plus pages 11 to 14, that is 4 pages at 1.5 dollars = 6 dollars, making 106 dollars in total. ⚠️ But under the second condition above, the 6 dollars over the 100 has to be paid separately, and the copies are released only once that 6 dollars is settled — which is to say that a case of this kind carries one extra round of notify, pay the difference, collect.

⚠️ A detail worth mentioning: the "type of data" tick-box column of that form has a separate "report" box for X-ray, computed tomography, magnetic resonance imaging and positron emission tomography, but no box for echocardiography — an echocardiogram report has to go under "other" or under "specialist outpatient records". That confirms from a third direction that echocardiography is not filed under imaging within the Hospital Authority.

Is it visible on eHealth? Put the two published lists together and the answer is that it is not among the nine categories a patient can look up themselves.

The first list: the eHealth "Sharable Data" page lists eleven categories of sharable data, among them two separate categories — "Laboratory and Radiology Reports" and "Other Investigation Reports". ⚠️ That list is the scope of sharing between healthcare providers, not the scope of what a patient sees in the app.

The second list: the Health Bureau's press release of 3 April 2025, eHealth App Adds Radiology Report Viewing Function, states [Note 27] that eHealth users can currently view nine categories of electronic health record — personal particulars, allergies and adverse drug reactions, admission, encounter and appointment information, immunisation records, medication records, laboratory and radiology reports, medical referral information, observations and lifestyle records, and medical certificates. The same release also sets out the list to be extended in future, and it likewise contains no echocardiography.

Line the two lists up and the difference becomes visible. The nine categories a patient can look up include "Laboratory and Radiology Reports" but not "Other Investigation Reports". And this article has already established from three directions that the Hospital Authority does not classify echocardiography as radiology. Three directions point at the same place: an echocardiogram report falls in the "Other Investigation Reports" cell.

⚠️ The limits of that conclusion have to be drawn. eHealth has published no item-by-item list saying which examination goes in which category, so the above is the result of reading two published lists against each other, not a sentence eHealth has said. But on the published material, the published route to obtaining an echocardiogram report in the public system remains a data access request to the hospital concerned.

The Hospital Authority's patient information platform has no page on echocardiography. The index of disease and examination information on the Hospital Authority's Smart Patient website (retrieved 3 August 2026) has no dedicated page on echocardiography or cardiac ultrasound, even though myocardial infarction, coronary heart disease, arrhythmia, cardiac muscle biopsy, endoscopic ultrasonography, X-ray examination and adult magnetic resonance imaging examination all have their own pages. ⚠️ That negative has a boundary: it is about that one index on the Smart Patient website, not a claim that there is no Chinese-language patient information anywhere in Hong Kong.

#What to do next

Each of the following is a direct extension of material already cited above, not this article's advice on your own circumstances.

1. Look first at the status of the report. ASE defines four — draft, preliminary, final and amended; a preliminary report by definition does not contain all the recommended components, and a final report has a duty to reconcile the differences with a preliminary one. A report marked "preliminary" carries information in its status alone.
2. Read the report together with the symptoms, in both directions. The ASE guideline of 2025: a normal resting left ventricular filling pressure may still not exclude HFpEF (up to 50% of HFpEF patients are in that position); healthdirect: heart valve disease with no symptoms still needs treating. The two sentences point in opposite directions, and both hold.
3. Do not let a resting echocardiogram stand in for an answer about the coronary arteries. ASE 2015 assigns the role of demonstrating significant coronary stenosis to stress echocardiography; ASE 2025 goes further and lists significant coronary artery disease among the things to be excluded before diagnosing HFpEF.
4. Keep your reports from year to year. Section 2.3.1 of the ACC/AHA guideline of 2020 states that, given the inherent measurement variability for these parameters, decisions are most robust when based on sequential studies. As for the requirement that follow-up use exactly the same method, that comes from a different document — the Follow-up Assessment section of the ASE/EACVI aortic stenosis update of 2017.
5. If there is a mean gradient figure on the report, look while you are there for whether the report prints the blood pressure on the day. ASE and EACVI require in terms that an echocardiography report always include the blood pressure recorded at the time of the study — because a gradient measured while blood pressure is uncontrolled may not reflect the disease.
6. There are two published triggers addressed to patients, and neither is a number on a report. One turns on symptoms (ACC/AHA 2020, section 2.3.2: patients with valvular heart disease should be instructed to report promptly any change in symptom status); the other turns on age, and is Australian (healthdirect: a "Heart Health Check" every two years from 45).
7. If you want a paper copy, the route in the public system is a data access request to the hospital concerned — a reply within 40 days, from 100 dollars; ⚠️ the form itself states that where it cannot be met, what follows is a written notification and delivery in parts, not necessarily the complete record on the 40th day.
8. The technical terms on the report have published sources. Every figure's original document and its publication date are listed one by one at the end of this article, and can be taken to a follow-up appointment to go through with a doctor.

#Frequently asked questions

My report says "mild MR" — is that serious?

Two sentences have to be given together, because either alone misleads. The first: the definition table 8 of the ASE reporting standardisation guideline of 2025 gives for "mild" is a clearly detected observation (or degree of other abnormality) usually of no suspected current clinical significance. The second: the same guideline of 2025 also states that what may be considered normal on a structurally normal valve is "trace", and that mild or greater aortic or mitral valve regurgitation should be classified as abnormal; as for mild being treatable as a normal functional finding, the source says that only of a structurally normal tricuspid or pulmonary valve, and not of the mitral valve. So "mild MR" is not "severe", but neither is it in the normal range ASE describes — the actual determination is defined by grading tables this article does not print, and that table states of itself that all the parameters have limitations and must be read integratively.

What does "mild to moderate" on my report mean?

Table 8 of ASE 2025 states that the descriptors "mild-to-moderate" and "moderate-to-severe" do not exist in the tables of ASE guidelines, that they should be used only sparingly where missing or discrepant data prohibit a single designation, and that where used they should carry an accompanying statement explaining the reasons. Which is to say that the phrase points at the state of the data, not at a grade of disease lying between two others.

The report says normal, but I get breathless walking quickly — why?

The ASE diastolic function and HFpEF guideline of 2025 states that the clinical diagnosis of HFpEF requires three things together — signs and symptoms of congestive heart failure, an echocardiographic determination of normal LVEF (generally accepted to be ≥50%), and the absence of other cardiac or non-cardiac causes for the patient's symptoms — and that such patients make up half of all heart failure hospitalisations; that up to 50% of HFpEF patients have normal left ventricular filling pressure at rest that rises rapidly on exercise or even on leg raising; and that as many as 30% have normal natriuretic peptide blood results as well. The same guideline notes that diastolic stress echocardiography is most valuable where a resting study does not explain the symptoms — but the same section also states which two groups need not have it or should not be referred, and names two groups for which it is appropriate. One further thing has to be made clear: a resting echocardiogram is not itself a test of the coronary arteries. Which examination you need, and whether you need one, is for a doctor to decide.

It was 60% last time and 52% this time — has it got worse?

This question cannot be answered, and why it cannot is itself the answer. The title of table 15 of ASE 2025 describes itself as "Examples of… may warrant" — examples, not a closed list, and addressed to the physician issuing the report. The left ventricle cell of that table prints three examples: a fall in LVEF of more than 10 percentage points and to below 53%; a significant change in diastolic function such that filling pressure rises; and GLS falling below the lower limit of normal or changing by more than 15% relative to baseline. A fall from 60 to 52 is 8 percentage points, which does not meet the first half of the first item; and the second and third items are not settled by those two numbers. ⚠️ And it has to be kept separate: 52% is itself below the normal range ASE printed for women (54–74%) and in the bottom cell of the range for men (52–72%) — "does not reach the threshold of the first item of table 15" and "this number is in the normal range" are two different things. On the other side, the same operator re-reading the same clip blind has a standard deviation of difference of 7.6 EF units, so the gap may not be real either.

What does an echocardiogram cost in a Hong Kong public hospital?

The Hospital Authority's public fee schedule puts no amount against this item ("echocardiogram" appears nowhere in appendix I in either language). But taken together the published material does have a structure: the Hospital Authority classifies the item under section 5.2, cardiology, of annex II rather than under section 4, radiology; the Hospital Authority's Public Healthcare Fee Reform — Frequently Asked Questions prints which examinations each of the three tiers of "non-urgent radiology service" contains, and the ultrasound in the 250-dollar tier is 「超聲造影」 (Ultrasonography in the English version), with no echocardiography (⚠️ that three-tier list is illustrative rather than closed, and the three tiers themselves apply only to non-urgent radiology services — the same page states that urgent radiology services for inpatients and accident and emergency patients remain free); and clause 1.3(A) of appendix I states that the consultation fee includes "other investigations", the fee schedule charging separately for three classes only — prescribed drugs, pathology testing and non-urgent radiology services. ⚠️ This is a reading of the structure of published documents, not a price the Hospital Authority has quoted; the actual charge is whatever the hospital's bill says. Separately, the non-subvented (private patient) fees are 4,190 dollars (Category 2) and 6,490 to 14,650 dollars (Category 3), and cannot be cited as public prices.

Can I get my report back?

The route in the public system is a data access request to the hospital concerned; on the Tuen Mun Hospital form (version 01/26), a reply within 40 days, a handling fee of 100 dollars per request (covering the first 10 pages) and 1.5 dollars per page from page 11 onwards. ⚠️ The form also states that where the hospital cannot meet the 40-day period, it must notify in writing, give reasons, first supply the part it can, and complete as soon as possible thereafter; and that where the total payable exceeds 100 dollars, the copies are released only once the balance is settled. As for eHealth: the Health Bureau's release of 3 April 2025 lists the nine categories of electronic health record a patient can look up, which include "Laboratory and Radiology Reports" but not "Other Investigation Reports"; and the Hospital Authority does not classify echocardiography as radiology. So on the published lists, an echocardiogram report is not among those nine categories.

#Notes: the official originals

[Note 1] The Hospital Authority's List of Non-subvented Medical Service Items, annex III, section 5.2 "Cardiology", under "Mobile investigations/procedures". Category 2 (4,190 dollars each): 「Echocardiogram (超聲波心臟檢驗)」「Advanced speckle starin/ tissue Doppler Echocardiography (斑點追蹤多普勒超聲波心臟檢驗)」. Category 3 (6,490 to 14,650 dollars each): 「3D Transthoracic Echocardiography(TTE) (經胸壁超聲波三維心臟檢驗(TTE))」「Contrast Echocardiography (造影劑超聲波心臟檢驗)」「Real-time 3D Transesophageal Echocardiography(TEE) (實時經食道超聲波三維心臟檢驗(TEE))」「Stress echocardiogram (超聲波心臟負荷檢驗)」「Trans-oesophageal echocardiogram (經食道超聲波心臟檢驗)」. ("starin" is as printed in the source; the correct spelling is strain, reproduced as found.) The table of contents of annex II to the gazetted fee schedule reads: 「3. 病理科服務收費 / 4. 放射科服務收費 / 5. 診斷∕治療程序收費 / 5.1 小型檢驗∕程序 / 5.2 心臟科 / 5.3 呼吸系統醫學 …」

[Note 2] The Pok Oi Hospital "Day Services" page. The cardiac and neurological investigation unit entry reads:

"The cardiac and neurological investigation unit provides patients with a range of examination services, including electrocardiography, echocardiography, twenty-four-hour cardiac monitoring, treadmill exercise electrocardiography, electroencephalography, lung function testing and nerve conduction study services." (our translation from the Chinese original)

Chinese original:

「心腦電檢部為病人提供各種檢查服務，包括心電圖、心臟超聲波、二十四小時心臟監測檢查、運動踏板心電圖檢查、腦電圖、肺功能檢查和神經傳導檢查服務。」

The "booking procedure" for each of the six units, in the original: 日間泌尿外科中心「預約需經門診或病房轉介。」；心腦電檢部及內視鏡部「須由本聯網醫生轉介。」；慧妍雅集日間婦科中心「所有預約婦科檢查必須要經專科門診轉介。」；日間病房及 3 中術前檢查服務「經各專科轉介及須預約。」；風濕病評估及治療中心「經本聯網專科門診轉介。」

[Note 3] ASE 2025, Guidelines for the Standardization of Adult Echocardiography Reporting: 「In addition to established measurement parameters (Table 6), a TTE report should include report headings for each of the following cardiac structures: left ventricle (LV), interventricular septum (IVS), right ventricle (RV), left atrium (LA, including pulmonary veins), interatrial septum (IAS), right atrium (RA), aortic valve (AoV), mitral valve (MV), pulmonic valve (PV), tricuspid valve (TV), aorta, pulmonary artery (PA), inferior vena cava (IVC), superior vena cava (SVC), pericardium, and when relevant implanted devices (e.g., MCS).」 The four definitions of report status: 「Draft report — Measurements, worksheets, and findings that may be entered in writing or electronically generated by experienced sonographers and physicians-in-training for laboratory internal use. A draft report is one that has not been reviewed or approved by an interpreting physician. Therefore, a draft report should not be visible in the electronic record or otherwise issued to external care providers. A draft report can only be provided to the interpreting physician for subsequent editing and approval.」「Preliminary report — A verbal or written report generated by an appropriately trained physician, that is approved for clinical use but has not yet been finalized by the interpreting physician. A preliminary report does not include all recommended reporting components …」「Final report — A written complete report that has been reviewed, signed, and dated manually or electronically by the interpreting physician. The final report should identify and reconcile any differences with any previously issued preliminary report(s).」「Amended report — Whenever changes are made to a previously "final report," an amended report is created. The amended report will refer to the prior reference report by date and time and include clear language that highlights clinically relevant revisions from the prior report.」

[Note 4] ASE/EACVI 2015, Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults, section 2.2, the formula EF = (EDV − ESV) / EDV; the same passage in ASE's official simplified-Chinese version: 「EF 由EDV 和ESV 的测值计算而来」. Section 1.3: 「Because the committee acknowledges that the implementation of this recommendation is time consuming, the use of representative beats is acceptable in the clinical setting.」

[Note 5] Cole GD et al., Int J Cardiovasc Imaging 2015: 「When grading LV function into five categories, an operator's chance of agreement with another operator was 50 % and with themself on blinded re-presentation was 68 %. Blinded eyeball LVEF re-estimates by the same operator had standard deviation (SD) of difference of 7.6 EF units, with the SD across operators averaging 8.3 EF units.」 Conclusion: 「…individuals cannot themselves identify when poor image quality is disrupting their LV function estimate. Clinicians should not assume that patients changing in grade or in visually estimated EF have had a genuine clinical change.」

[Note 6] Pellikka PA et al., JAMA Netw Open 2018, Key Points, Findings: 「…correlation of LVEF between modalities ranged from r = 0.493 (for biplane echocardiography and cardiovascular magnetic resonance) to r = 0.660 (for cardiovascular magnetic resonance and gated single-photon emission computed tomography). There was no systematic overestimation or underestimation of LVEF for any modality.」 Meaning: 「There is substantial variability in LVEF assessment between modalities, which should be considered in trial design and clinical management.」

[Note 7] The ACC/AHA valvular heart disease guideline of 2020, section 2.3.1: 「…decisions are most robust when based on sequential studies, given the inherent measurement variability for these parameters.」 Section 2.3.2: 「Patients with VHD should be instructed to promptly report any change in symptom status. The onset of symptoms or a change in the physical examination should raise concern about the cardiac response to the valve lesion, necessitating a repeat TTE.」

[Note 8] ASE 2025, Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography and for Heart Failure With Preserved Ejection Fraction Diagnosis, section 16: 「HFpEF constitutes half of all HF hospitalizations, with a growing prevalence relative to HF with reduced EF. … The clinical diagnosis of HFpEF is reached by establishing the presence of signs and symptoms of congestive HF as well as an echocardiographic determination of normal LVEF (generally accepted to be ≥50%) in the absence of other cardiac or noncardiac causes for the patient's symptoms. … Although the Framingham criteria demonstrate excellent specificity for the diagnosis of HF, they lack sensitivity, particularly in elderly patients who may have not had acute HF decompensation. Therefore, a patient may have HFpEF even in the absence of satisfying specific clinical criteria for HF.」 Section 13: 「LV filling pressure at rest may not be sufficient to evaluate a patient with dyspnea that happens mostly with exertion. Importantly, up to 50% of patients with HFpEF have normal LV filling pressure at rest that increases rapidly with exercise or even leg raising.」 Section 16.C: 「…up to 30% of patients with HFpEF can have normal NP [natriuretic peptide] levels despite signs and symptoms of HF, echocardiographic abnormalities, and elevated LV filling pressures on invasive hemodynamic testing. Therefore, although important in the evaluation of HFpEF, a normal NP level does not necessarily rule out a diagnosis of HFpEF, particularly in obese patients with HFpEF.」

[Note 9] The ASE chamber quantification guideline of 2015: 「Depending on regional coronary flow reserve, stress echocardiography can demonstrate significant coronary stenosis by inducing wall motion abnormalities.」 The ASE diastolic function guideline of 2025, section 16, Key Points, item 3: 「Before reaching a diagnosis of HFpEF, valvular heart disease, noncardiac PH, significant coronary artery disease, infiltrative and HCM, and pericardial constriction should be excluded.」

[Note 10] healthdirect, "Electrocardiogram - ECG or EKG" (last reviewed May 2025): 「an ultrasound of your heart (echocardiogram)」「Sometimes you may need other tests, like: an ultrasound of your heart (echocardiogram) · blood tests · an angiogram (pictures of the heart's blood vessels)」. healthdirect, "Heart valve disease" (last reviewed February 2024): 「Even if you do not have any symptoms, heart valve disease still needs treating.」「You should see your doctor if you feel you are having any symptoms of heart valve disease or if you are worried about your health.」「If you are aged 45 years or more (or 35 years old for Aboriginal and/ or Torres Strait Islander people) you should visit your doctor for a 'Heart Health Check' every 2 years. This 20-minute check-up will calculate your risk of having a heart attack or stroke.」「Remember, having a murmur does not mean that you have heart valve disease. You can have a heart murmur and a healthy heart.」

[Note 11] The ASE diastolic function guideline of 2025, section 13.A (five consecutive sentences of the original): 「Diastolic stress testing is most valuable when resting echocardiography does not explain the symptoms of HF or exertional dyspnea. In general, patients with completely normal diastolic function at rest with preserved e′ velocity need not undergo stress testing as it is highly unlikely that they will develop elevated filling pressures with exercise. Likewise, patients with abnormal findings at baseline consistent with elevated LV filling pressures should not be referred for stress testing as the cardiac etiology for dyspnea is already established and their filling pressures will almost certainly increase further with exercise. The most appropriate patient population for diastolic exercise testing is the group of patients with grade 1 diastolic dysfunction, which indicates the presence of delayed myocardial relaxation and normal mean LAP at rest. The diagnostic evaluation of symptomatic patients with indeterminate diastolic function or filling pressure at rest can also benefit from diastolic stress testing.」

[Note 12] The ASE reporting standardisation guideline of 2025, table 8 "Reporting standards terminology and definitions", severity section: 「Severity — None, Trace, Mild(ly), Moderate(ly), and Severe(ly): ASE guidelines-based descriptions for abnormalities of function (regurgitation or stenosis) and size (volume or thickness) based on quantitative and semi-quantitative measures. Note: some cardiac structures with abnormal features have not been categorized into grades (e.g., degree of leaflet thickening) and in these cases, labs are encouraged to develop internal standards for consistency.」「None — When condition clearly excluded」「Trace — Less than mild (for valve regurgitation)」「Mild(ly) — A clearly detected observation (or degree of other abnormality) usually of no suspected current clinical significance that may or may not be due to a structural or functional abnormality, but it is defined by reference values in ASE guidelines.」「Moderate(ly) — An obvious abnormal observation of suspected current or future clinical significance and defined by reference values in ASE guidelines.」「Severe(ly) — An obvious abnormal observation of suspected current or future clinical significance and defined by reference values in ASE guidelines.」「Massive and Torrential — May describe subgroups of severe tricuspid regurgitation.」「Mild-to-Moderate and Moderate-to-Severe — These descriptors do not exist in ASE guidelines tables. They should be used only sparingly when missing or discrepant data prohibits a "mild", "moderate" or "severe" designation. If used, they should have an accompanying statement explaining the reasons for this mixed grade category. Numerical grading systems for valvular regurgitations may be considered when appropriately measured and associated with validated clinical outcomes.」

[Note 13] ASE 2017, Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (Zoghbi et al.), section II.A: 「Doppler techniques are very sensitive, and thus trivial or physiologic valve regurgitation, even in a structurally normal valve, can be detected and occurs frequently in right-sided valves.」 Section II.C: 「The consensus of the writing group is to classify grading of severity of regurgitation into mild, moderate, and severe. "Trace" regurgitation is used in the event that regurgitation is barely detected. Usually this is physiologic, particularly in right heart valves and MV, and may not produce an audible murmur. Since the severity of regurgitation may be influenced by hemodynamic conditions, it is essential to record the patient's blood pressure, heart rate, and rhythm at the time of the study and note the patient's medications whenever possible. When following a patient with serial examinations, these factors need to be considered in comparing the severity of regurgitation and its hemodynamic consequences and actual studies reviewed and compared because of inherent variability of techniques and measurements.」 The sources of the four sentences separately: 「A small degree of TR is present in the majority of normal individuals.」 (the opening sentence of the main text of section V); 「Physiologic mild TR is common in normal individuals.」 (Key Points); 「Physiologic, mild PR is common in normal individuals.」 (Key Points); 「Trivial and mild PR is clinically very common and easily diagnosed. On the other hand, clinically significant PR is uncommon and is usually secondary to pulmonary hypertension and congenital heart disease.」 (the main text of section VI.F). Section IV.C: 「While "physiologic" or mild degrees of tricuspid and PR are commonly noted in normal exams, AR is not. When AR is detected, the evaluation starts with an assessment of the anatomy of the aortic valve and root to determine the etiology of the regurgitation followed by an assessment of LV size, geometry, and function.」

[Note 14] The ASE reporting standardisation guideline of 2025: 「The writing committee acknowledges that terms such as "trace," "insignificant," "trivial," "physiologic," or "minimal" have been historically used to describe the presence of "less than mild" regurgitation. These jets often exhibit incomplete spectral Doppler displays. We recommend the use of "trace" in place of all other "less than mild" regurgitation descriptors.」「"Trace" regurgitation of a structurally normal native valve or a prosthetic valve may be considered normal, whereas mild or greater aortic or mitral valve regurgitation should be classified as abnormal. However, for structurally normal native tricuspid or pulmonary valves, mild regurgitation may be regarded as a normal functional finding (physiologic). A statement such as "mild tricuspid regurgitation is present, which may be within normal limits", can be used in the report.」

[Note 15] Freed LA et al., N Engl J Med 1999: 「A total of 84 subjects (2.4 percent) had mitral-valve prolapse: 47 (1.3 percent) had classic prolapse, and 37 (1.1 percent) had nonclassic prolapse. Their age and sex distributions were similar to those of the subjects without prolapse.」「In a community based sample of the population, the prevalence of mitral-valve prolapse was lower than previously reported. The prevalence of adverse sequelae commonly associated with mitral-valve prolapse in studies of patients referred for that diagnosis was also low.」

[Note 16] The ASE/EACVI aortic stenosis update of 2017 (Baumgartner et al.), the passage before table 3: 「There is a continuous spectrum of aortic valve disease from aortic sclerosis without haemodynamic consequences to very severe flow obstruction. The measures of disease severity need therefore to be viewed as a continuum. Definitions of grades of severity of AS are to some extent arbitrary. … Any one of the three criteria: a valve area <1.0 cm2, a peak velocity ≥4.0 m/s, or a mean gradient ≥40 mmHg can be considered to suggest severe AS. Ideally, there should be concordance with all criteria in the severe range.」 The Arterial Hypertension section: 「Nevertheless, evaluation of AS severity with uncontrolled hypertension may not accurately reflect disease severity. Thus, control of blood pressure is recommended before echocardiographic evaluation, whenever possible. The echocardiographic report should always include a blood pressure measurement recorded at the time of the examination, to allow comparison between serial echocardiographic studies and with other clinical data.」

[Note 17] The ASE reporting standardisation guideline of 2025, table 14: 「Table 14 Examples of critical or urgent consultation findings in echocardiography reports*」「Critical findings: Findings that represent a threat to life and require immediate clinical action. A direct verbal notification to the ordering provider or clinician immediately after the finding is identified is recommended (communication in minutes).」「- Suspected cardiac tamponade - Suspected aortic dissection or acute aortic syndrome - Complications of myocardial infarction, including ventricular septal rupture, ventricular or papillary muscle rupture, or pseudoaneurysm - Thrombus in transit - Acute RV dysfunction and suspected acute pulmonary embolism - Left ventricular assist device or VA-ECMO complications - Severe valve obstruction/stenosis in prosthetic or native valves, especially if acute or new」「Urgent findings: Findings that represent a significant abnormality or change from prior testing and may require clinical action in the short term. Direct personal notification to the ordering provider or clinician is recommended, either verbally or utilizing other means of communication at the discretion of the interpreting physician (communication in hours).」「- New large pericardial effusion without tamponade - New severe left or right ventricular dysfunction - New suspected vegetation, intracardiac mass or thrombus - Orthotopic heart transplant with signs of acute rejection, including newly depressed LVEF - Suspected cardiogenic shock, low cardiac output in hypotensive patients - New LV outflow tract obstruction (pre-Valsalva resting gradient >30 mm Hg) - High-risk findings on a stress echocardiogram」「Significant findings: Significant findings in the echocardiogram that may warrant consultation and additional or follow-up testing (in addition to critical and urgent findings detailed above).」「- Significant reduction in the LV systolic or diastolic function - Significant change in RV systolic function - Significant aortic dilatation - Findings suggesting specific cardiomyopathies (e.g., hypertrophic cardiomyopathy, infiltrative cardiomyopathy, cardiac amyloidosis) - Change in the size of a pericardial effusion - Known valve stenosis or regurgitation in prosthetic or native valves that is progressing to severe」「*The reporting physician should consider the indication, patient history, acuity of a finding, and exert clinical judgment when determining the urgency and method for communication of these findings.」

[Note 18] The ASE diastolic function guideline of 2025, legend to figure 3: 「Algorithm for estimation of mean LAP for patients in sinus rhythm and who do not have severe primary MR, any degree of mitral stenosis (MS), or moderate or severe MAC. The algorithm should also not be applied to patients in atrial fibrillation, heart transplant (HTX) recipients, noncardiac PH, pericardial constriction or LV assist device (LVAD). … The algorithm should also not be applied to patients with mitral valve repair, mitral valve replacement, or mitral-transcatheter edge-to-edge repair.」

[Note 19] The ASE reporting standardisation guideline of 2025, table 15, title: 「Table 15 Examples of echocardiography findings that are new or significant and may warrant consultation and/or follow-up testing」. The three items in the left ventricle cell: 「Significant reduction in the LVEF (more than 10-point reduction for any reason and <53%)」「Significant change in LV diastolic function, leading to increased filling pressures」「(Worsening in LV global longitudinal strain below lower limits of normal for equipment and software utilized in the echocardiography lab or a relative change in GLS >15% from baseline)」. The menu of causes: 「"The reported change in LV systolic function might be due to:" (consider selecting from the following: an actual worsening in the LV systolic function; or may not be an actual worsening in the LV systolic function but is likely due to a difference in imaging or measurement technique; change in imaging quality; LV foreshortening; change in rhythm or heart rate; change in BP; change in therapy such as inotropes or IABP; interval surgery)」

[Note 20] The recommendations box in section 2.2 of the ASE chamber quantification guideline of 2015, in ASE's official simplified-Chinese version: 「推荐.2DE 或3ED 计算的EF 应列为常规LV 功能的测量指标。男性<52%，女性<54%提示LV 收缩功能异常。」 ("3ED" is the source's own slip, reproduced as found.) Section 1.3: 「Any description of the degree of deviation from normality in the echocardiographic report should remain at the discretion of the individual laboratory, and the writing group does not recommend specific partition values.」 and 「…suggested partition values for additional parameters of LV size and mass are listed in the Appendix」

[Note 21] The ACC/AHA guideline of 2020, section 2.3.3: 「After initial evaluation of an asymptomatic patient with VHD, the clinician should continue regular follow-up with periodic examinations and TTE. The purpose of follow-up is to prevent the irreversible consequences of severe VHD, primarily affecting the status of the ventricles and pulmonary circulation, which may occur in the absence of symptoms. At a minimum, a yearly history and physical examination are necessary. … The follow-up interval may be extended in patients with mild regurgitation who show no change over a 10- to 15-year period. In addition to routine periodic imaging, the onset of symptoms or a change in the physical examination should raise concern about the cardiac response to the valve lesion, necessitating a repeat TTE.」 The asterisk on the aortic stenosis column of table 5: 「With normal stroke volume.」 The table note: 「Patients with mixed valve disease may require serial evaluations at intervals earlier than recommended for single-valve lesions. These intervals apply to most patients with each valve lesion and do not take into consideration the etiology of the valve disease.」

[Note 22] The Hospital Authority's Public Healthcare Fee Reform — Frequently Asked Questions, Q3, in the original: 「符合資格人士非緊急放射科服務分級收費如下：」「基礎項目：X光（免費）」「進階項目：螢光透視、超聲造影和乳腺造影（乳腺X光造影）（250元）」「高端項目：電腦掃描造影、磁力共振掃描造影、乳腺介入放射、血管造影及血管介入放射、非血管介入放射、核子醫學和正電子電腦斷層掃描（500元）」. The same tier in the English version: 「Intermediate Item: Fluoroscopy, Ultrasonography and Mammography ($250)」. Q2, in the original: 「收費適用於由門診或急症室安排覆診，以及日間或住院病人出院後的非緊急放射科服務。住院和急症室病人的緊急放射科服務維持免費。」 The English version: 「Urgent radiology services for inpatients and A&E patients remain free of charge.」 (The page prints 「那一類」, reproduced as found; the standard form is 「哪一類」.)

[Note 23] Clause 1.3(A) of appendix I to the gazetted fee schedule, in the original: 「診治(包括遙距醫療)費用包括處方藥物(在專科診所(包括綜合診所及專職醫療診所)及家庭醫學診所(包括綜合診所)求診的處方藥物除外)、病理學檢驗(在專科診所(包括綜合診所及專職醫療診所)及家庭醫學診所(包括綜合診所) 求診的檢驗除外)、緊急放射科服務及其他檢驗。」

[Note 24] The three notes under the table on the Hospital Authority's "Specialist Outpatient Waiting Time" page. Note (1), rendered here:

"The longest (90th percentile) waiting time means that 90% of new cases can be seen within a waiting time shorter than that shown." (our translation from the Chinese original)

Chinese original:

「最長(第90個百分位數)輪候時間，是指有90%的新症可以在早於顯示的輪候時間內就診。」

Note (2): 「不包括有待分流的其他個案。」 — excluding other cases pending triage. Note (3), rendered here:

"The information on this page is divided by the former hospital cluster boundaries. The Hong Kong East Cluster and the Hong Kong West Cluster were formally merged into the Hong Kong Island Cluster with effect from 1 April 2026, and the relevant information will be updated in due course." (our translation from the Chinese original)

Chinese original:

「本頁資料按舊有醫院聯網界線劃分。港島東醫院聯網和港島西醫院聯網已於2026年4月1日起，正式合併為香港島醫院聯網，相關資料將於稍後作出更新。」

[Note 25] The Supplementary Medical Professions Council's description (the original inserts a space between every character, reproduced as found): 「專 職 醫 療 業 管 理 局 轄 下 的 5 個 管 理 委 員 會 包 括 醫 務 化 驗 師 管 理 委 員 會 、 職 業 治 療 師 管 理 委 員 會 、 視 光 師 管 理 委 員 會 、 物 理 治 療 師 管 理 委 員 會 及 放 射 技 師 管 理 委 員 會 。 各 管 理 委 員 會 負 責 有 關 專 業 的 事 宜 。」 The Code of Practice for Radiographers (revised December 2025), appendix I, A, Diagnostic Radiology, item 2, prohibits: 「就使用放射、螢光透視、超聲波及其他包括電腦斷層掃描、磁力共振、放射性同位素方法進行的器官造影檢查發出報告。」 Legislative Council paper CB(2) 1308/99-00(11): 「審計結果認為醫院有移交工作的例子，例如由技師進行以往由醫生負責的心臟超聲波檢查。」

[Note 26] The Tuen Mun Hospital data access request form (version 01/26): 「A data user is required by the Personal Data (Privacy) Ordinance to comply with a DAR within 40 days after receiving the same. If a data user is unable to comply with the DAR within the 40-day period, it must inform the requestor by notice in writing that it is so unable and the reasons, and comply with the DAR to the extent it is able to within the same 40-day period and thereafter comply or fully comply with it as soon as practicable.」「The Processing Fee is non-refundable unless the hospital is unable to provide the Requested Data.」「If the total charge payable exceeds the processing fee of HK $100, our hospital will notify the applicant to settle the charge/estimated charge. The data copy will be released after the residual cost is settled.」 The imaging charges cell in the English version: 「Reproduction charge for ECG, EEG, X-ray Film/disc or photo etc.」; the same cell in the Chinese version: 「光片、光碟、電腦掃描片、腦電圖等」, at 「每種造影 / 每張光碟港幣 300 元」 and 「每張底片港幣 300 元」.

[Note 27] The Health Bureau's press release of 3 April 2025, eHealth App Adds Radiology Report Viewing Function, in the original: 「現時，醫健通用戶可查閱九類電子健康紀錄，分別是個人資料、敏感及藥物不良反應、住院、到診及預約資料、防疫接種紀錄、藥物紀錄、化驗及放射報告、醫療轉介資料、觀察及生活方式紀錄，以及醫療證明書。」 The same release also states that the records to be extended in future 「包括放射影像、中藥處方紀錄，以及口腔檢查紀錄及牙齒狀況等」 — radiology images, Chinese medicine prescription records, and oral examination records and dental condition. The eHealth "Sharable Data" page lists the sharable data categories as: personal particulars; allergies and adverse drug reactions; diagnosis, procedures and other medical procedures, medication; admission, encounter and appointment information; clinical summaries; birth and immunisation records; laboratory and radiology reports; other investigation reports; medical referral information; observations and lifestyle records; and medical certificates.

#What this article does not state

Each of the following is either unsupported by the sources cited in this article or one of the clinical tools this article deliberately does not print.

Numerically at odds with the sources, and therefore not used here:

• "Normal LVEF is 55%–70%" — tables 2 and 4 of ASE 2015 print 52–72% for men and 54–74% for women (by sex), and the main text of section 2.4 of the same document prints 53–73%. Neither set is 55–70%.
• A "low normal range (50–54%)" for LVEF — table 4 of ASE has four bands only (normal, mildly, moderately and severely abnormal); there is no "low normal" grade. That grade does not exist in the sources cited here.
• "An aortic valve mean gradient of 40–60 mmHg is moderate and >60 is severe" — ASE/EACVI 2017 table 3 prints 20–40 for moderate and ≥40 for severe. This is the largest correction in this article.
• "Septum and posterior wall normal 6–11 mm; 12–13 mm mild hypertrophy; ≥14 mm moderate to severe hypertrophy" — this set of figures is not used, but the reason is not that ASE has never published such a thing. Supplemental Table 3 in the appendix to the ASE chamber quantification guideline of 2015 does print four-grade cut-offs for septal and posterior wall thickness, and does so by sex. The circulating version fails to match it in two places: first, it is not by sex, whereas the upper limit of normal ASE prints is 0.9 cm for women and 1.0 cm for men (table 6 agrees); second, it puts the lower bound of "mild hypertrophy" at 12 mm, above the 1.1 cm for men and 1.0 cm for women that ASE prints. ⚠ This article does not reproduce the numbers in Supplemental Table 3 (see the twelfth item of the "named but not printed" section), but "this article does not print it" and "it does not exist" are two different things.
• "Normal left atrial diameter <40 mm" — that diameter figure is not to be found in the sources cited here; ASE 2015 and ASE 2025 both require the left atrium to be reported as a volume indexed to body surface area (16–34 mL/m², with a lower bound).
• Right ventricular systolic pressure (RVSP) at ">35–40 mild / >50 moderate / >60 severe" — at odds with the bands in the ASE right heart guideline of 2025. ⚠ The table in that guideline printing band values is table 1 (Summary of reference limits for recommended measures of right heart structure and function); table 2 is the image acquisition method table and carries no severity bands at all. Nor will this article print the correct bands (see the "named but not printed" section): ASE states that healthy physiological ageing and an increase in body surface area can by themselves raise RVSP without necessarily indicating pulmonary hypertension, and that right heart catheterisation remains necessary for the diagnosis and classification of pulmonary hypertension.
• "A mild finding usually means repeating the echocardiogram every 1–3 years" — ACC/AHA 2020 table 5 prints every 3 to 5 years for progressive (stage B) mild, and every 1 to 2 years for moderate. The interval 1–3 years matches no cell. ⚠ But it has to be said in the same breath: the same table also prints every 6 to 12 months for severe asymptomatic (stage C1), and the mitral stenosis column is arranged by valve area rather than by mild or moderate and has no "moderate" cell at all; "3 to 5 years" is not the interval of the whole table. That guideline has several errata, of which the one of September 2024 was unobtainable and has not been checked here.
• "Mild mitral valve prolapse is fairly common in young women" — the overall prevalence in Framingham (NEJM 1999) is 2.4%, and the age and sex distributions of those with prolapse were similar to those without; the paper's own conclusion is that the prevalence was lower than previously reported.
• Pericardial effusion "Small (<10 mm) is usually asymptomatic", and treating only "large" as a red flag — ASE 2013 states that cardiac tamponade can be fatal regardless of the size of the effusion, and describes low-pressure and regional tamponade (in which the typical signs are often absent). Separately, dividing pericardial effusion into three size grades is incomplete: ASE prints five.
• The example "an LVEF falling from 60% to 52% is more concerning than a one-off 50%" — the principle (sequential studies being more robust than a single one) is supported by section 2.3.1 of ACC/AHA 2020, but this particular example does not reach the threshold of the first item of the left ventricle cell of ASE table 15 (a fall of more than 10 percentage points and to <53%), and is roughly only one standard deviation of repeat interpretation (7.6 EF units). ⚠ That cannot be read backwards as "so nothing is wrong": the same cell has two further items (diastolic function and GLS) that two EF numbers cannot answer; and 52% is itself below the normal range ASE printed for women (54–74%).
• "Echocardiographic reference ranges are the central 95% of a healthy population, so 5% of healthy people are flagged as abnormal" — that account applies to some parameters only. Section 1.3 of ASE 2015 confines the ±1.96 standard deviation approach to parameters other than left ventricular size, function and mass and left atrial volume; the cut-offs for LVEF and left atrial volume are stated by the guideline to be empirically based expert consensus, not ±2 standard deviations. So that calculation of 5% does not apply to the two main figures this article discusses. ⚠ There is a further sentence in the same passage, pointing the same way as this article's "named but not printed" section, worth quoting in the original: 「Any description of the degree of deviation from normality in the echocardiographic report should remain at the discretion of the individual laboratory, and the writing group does not recommend specific partition values.」
• "Cardiology (a subspecialty of internal medicine)" — the Medical Council of Hong Kong's Specialist Register (August 2026) lists cardiology as item 13, code S13, registered separately from internal medicine (item 12, S12).

Deliberately not printed here (see the "named but not printed" section, twelve items in all): the ASE regurgitation grading table 8; the other four rows of ASE/EACVI aortic stenosis table 3; the ASE LVEF severity cut-offs; the diastolic function grade 1, 2 and 3 grading and the left atrial pressure estimation algorithm; the H2FPEF score; the HFA-PEFF workflow; the RVSP and tricuspid regurgitation velocity bands (table 1 of the ASE right heart guideline of 2025); the ACC/AHA stages A to D; the pericardial effusion size grading; the wall motion score index; the atrial fibrillation left atrial pressure algorithm; and the four-grade cut-offs by sex for septal and posterior wall thickness (ASE 2015 Supplemental Table 3).

Unsupported by any source, and therefore not written here:

• A patient version of a list of "see a doctor immediately if the report says this" — none of the sources cited here has ever published such a patient list. Every published urgency tier (ASE tables 14 and 15, both of whose titles describe themselves as "Examples of") is addressed to the physician issuing the report; and of the instructions addressed directly to patients, there are two sentences in this article's material, one triggered by a change in symptoms (ACC/AHA 2020, section 2.3.2) and one by age (healthdirect's Australian "Heart Health Check" recommendation), neither of them a number on a report. A list of six red flags with a "follow up within 1–2 weeks" deadline matches no published document, and this article therefore does not supply one.
• A list of indications for echocardiography — not published by the sources cited here. ASE has two appropriate use criteria documents, which this article has not cited.
• The examination taking 30–45 minutes, and transoesophageal studies requiring sedation — none of the sources cited here gives a duration for the examination.
• "No radiation, non-invasive, can be done on the spot" — none of the sources cited here has printed that sentence.
• "A normal echocardiogram does not exclude a rhythm problem" — reasonable in direction, but none of the sources cited here says it, so this article does not write it.
• Private echocardiography prices in Hong Kong (HK$1,500–3,500, HK$880, or HK$3,000–8,000 with a consultation, for instance) — there is no echocardiography price list from any Hong Kong private provider in the material cited here; the private fee material that does exist is for cardiology consultations, not for the examination.
• Echocardiographic reference values for a Hong Kong or southern Chinese population — not present in the sources cited here. None of the seven source databases of ASE 2015 is a Chinese or Hong Kong cohort, and its only Asian data are Japanese and South Asian Indian populations.
• A price for echocardiography under the Hospital Authority's public fee schedule — "echocardiogram" appears nowhere in appendix I in either language, the Hospital Authority has put no amount against this item, and this article will therefore not write "one costs X dollars". ⚠ But one easily mistaken thing has to be made clear: it is not the case that the Hospital Authority has published nothing about which examinations are basic, intermediate or advanced items — the Hospital Authority's Public Healthcare Fee Reform — Frequently Asked Questions prints the item lists for non-urgent radiology services and pathology testing tier by tier (see the "Hong Kong in practice" section). On that, together with the structure of clauses 1.3(A), 1.3(B), 1.3(C) and 1.6 of the gazette, this article has set out a reading of the published documents — but that reading is not a price the Hospital Authority has quoted.
• The public waiting time for echocardiography — the Hospital Authority publishes waiting times by specialty and cluster, not by examination.
• A direct one-sentence answer to "can a patient open their own echocardiogram report in the eHealth app" — eHealth has published no item-by-item list saying which examination falls in which data category, so there is no official original for such a sentence. ⚠ But the point is not beyond judgment: the Health Bureau's release of 3 April 2025 lists the nine categories of record a patient can look up, among them "Laboratory and Radiology Reports" and not "Other Investigation Reports", and the Hospital Authority does not classify echocardiography as radiology — so on the published lists, an echocardiogram report is not among those nine (the derivation is in the "Hong Kong in practice" section).
• The contents of the November 2023 and September 2024 errata to the ACC/AHA valvular heart disease guideline of 2020 (the latter being Circulation 2024;150(12):e267) — the full text of those two errata is not publicly obtainable (the publisher's site returns HTTP 403 to non-subscribers and to automated retrieval alike, neither PubMed Central nor Europe PMC carries them, and web archives hold no readable snapshot). Every passage of that guideline cited here and every cell of table 5 has been checked cell by cell against the full text of the guideline of 2020, but without reference to those two errata; any discrepancy is governed by the erratum.

A domain easily mistaken, recorded here:

• hkcc.org is not the Hong Kong College of Cardiology — that domain belongs to the Hong Kong Cricket Club, and is not a cardiology professional body. The Hong Kong College of Cardiology is at hkcchk.com. The College is also not one of the fifteen colleges under the Hong Kong Academy of Medicine (the Academy's page states that fifteen colleges were accredited between 1992 and 1997, among them the Hong Kong College of Physicians and the Hong Kong College of Radiologists, with no college of cardiology), so it should not be described as an Academy college. This article has not cited that College's material, because within the scope of this article it has no publication on echocardiography.

#Sources

• Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015;28(1):1-39 (PMID 25559473; DOI 10.1016/j.echo.2014.10.003; also Eur Heart J Cardiovasc Imaging 2015;16(3):233-70, PMID 25712077; errata EHJCI 2016;17(4):412 and 2016;17(9):969). PDF: https://www.asecho.org/wp-content/uploads/2025/04/2015_ChamberQuantificationREV.pdf (guideline published 1 January 2015; retrieved 9 August 2026) — the EF formula and the biplane method of discs; averaging over three or five beats; the normal ranges in tables 2 and 4; the internal divergence at 53–73% in section 2.4; wall thickness and left ventricular mass in table 6; the requirement to index to body surface area; differences by ethnicity and body size; the risk of misclassification from unadjusted right ventricular values; section 3.3 (stress echocardiography and coronary stenosis) and section 3.4 on wall motion; the caution about cut-offs in section 1.3 and the sentence "the use of representative beats is acceptable in the clinical setting"; the signal in section 1.3 pointing to the appendix; Supplemental Table 3 in the appendix (four-grade cut-offs by sex for septal and posterior wall thickness; named but not printed here); and the recommendations box in section 2.2 printing the lower bound only
• The same, in ASE's official Chinese (simplified) version 〈新版关于成人超声心动图心腔定量方法的建议〉: https://www.asecho.org/wp-content/uploads/2025/04/Chamber-Quantification-2015-Chinese.pdf (retrieved 3 August 2026) — the EF formula and the Chinese original of below 52% in men and below 54% in women
• Zoghbi WA, Adams D, Bonow RO, et al. Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation. J Am Soc Echocardiogr 2017;30(4):303-371 (PMID 28314623; DOI 10.1016/j.echo.2017.01.007). PDF: https://www.asecho.org/wp-content/uploads/2025/04/2017VavularRegurgitationGuideline.pdf (retrieved 9 August 2026) — the detection of physiologic regurgitation; three grades plus trace; commonness on the tricuspid and pulmonic valves and uncommonness of aortic regurgitation (the central quotation of this article's valve-asymmetry section); the four principles of integrative reading; the note to table 8; section II.C on regurgitation severity being influenced by haemodynamics and on blood pressure, heart rate and rhythm needing consideration in serial studies; and the contexts of the three occurrences of "trivial" in the document
• Baumgartner H, Hung J, Bermejo J, et al. Recommendations on the Echocardiographic Assessment of Aortic Valve Stenosis: A Focused Update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. J Am Soc Echocardiogr 2017;30(4):372-392. PDF: https://www.asecho.org/wp-content/uploads/2025/04/2017ValveStenosisGuideline.pdf (guideline published 1 April 2017; retrieved 3 August 2026) — the mean gradient grading in table 3 (<20 / 20–40 / ≥40 mmHg) and the first column, Aortic sclerosis; the passage before table 3 with "Definitions of grades of severity of AS are to some extent arbitrary" and "Any one of the three criteria… can be considered to suggest severe AS"; the inconsistency between cut-offs; the effect of small body size; low-flow, low-gradient severe stenosis; the Arterial Hypertension section (the effect of uncontrolled blood pressure, and the report carrying the blood pressure at the time of the study); and the Follow-up Assessment section with "it is essential to use exactly the same methods to avoid artificial changes"
• Taub CC, Stainback RF, et al. Guidelines for the Standardization of Adult Echocardiography Reporting: Recommendations From the American Society of Echocardiography. J Am Soc Echocardiogr 2025;38(9):735-774. PDF: https://www.asecho.org/wp-content/uploads/2025/09/PIIS0894731725002925.pdf (published 3 September 2025; retrieved 9 August 2026) — the fifteen mandatory report headings plus one conditional heading (including e.g., MCS); the severity terminology of table 8 and the definition of mild; mild-to-moderate not existing in ASE tables; the four report statuses (including the sentence that a draft report may be provided only to the interpreting physician); the types of examination (POCUS); the four tiers of finding acuity; table 14 (whose title describes itself as Examples of), all its critical, urgent and significant findings and its footnote; table 15 (whose title describes itself as Examples of… may warrant), the three examples of significant change in its left ventricle cell and the menu of causes; the passage on printed page 743 replacing "trivial" and other "less than mild" descriptors with trace, and the sentence that mild or greater aortic or mitral regurgitation should be classified as abnormal; and the requirement to index the left atrium to body surface area
• Nagueh SF, et al. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography and for Heart Failure With Preserved Ejection Fraction Diagnosis: An Update From the American Society of Echocardiography. J Am Soc Echocardiogr 2025;38:537-69. PDF: https://www.asecho.org/wp-content/uploads/2025/07/Left-Ventricular-Diastolic-Function.pdf (published 3 July 2025; retrieved 9 August 2026) — HFpEF making up half of heart failure hospitalisations; the definition at LVEF ≥50%; a patient having HFpEF without satisfying clinical criteria; 50% having normal resting filling pressure; 30% having normal natriuretic peptide; the ending of that sentence, "particularly in obese patients with HFpEF"; the exclusions in figure 3; the labelling of the diastolic function grades by left atrial pressure in section 12; the suitable and unsuitable populations for diastolic stress testing in section 13.A; section 15.H on atrial fibrillation; item 3 of the Key Points of section 16 (significant coronary artery disease and others to be excluded before diagnosing HFpEF); table 9 on differential diagnosis including myocardial ischaemia; and the source populations of H2FPEF and HFA-PEFF
• Mukherjee M, et al. Guidelines for the Echocardiographic Assessment of the Right Heart in Adults and Special Considerations in Pulmonary Hypertension. J Am Soc Echocardiogr 2025;38:141-86. PDF: https://www.asecho.org/wp-content/uploads/2025/03/PIIS0894731725000379.pdf (published 3 March 2025; retrieved 3 August 2026) — the existence of table 1 (Summary of reference limits…) and the reason this article does not print it (table 2 being the image acquisition method table, with no severity bands); ageing and body surface area raising RVSP; and right heart catheterisation remaining necessary for the diagnosis and classification of pulmonary hypertension
• Klein AL, et al. American Society of Echocardiography Clinical Recommendations for Multimodality Cardiovascular Imaging of Patients with Pericardial Disease. J Am Soc Echocardiogr 2013;26:965-1012. PDF: https://www.asecho.org/wp-content/uploads/2025/04/2013_Multimodality-CV-Imaging-for-Pericardial-Disease.pdf (published 1 September 2013; retrieved 3 August 2026) — tamponade being potentially fatal regardless of effusion size; low-pressure and regional tamponade; the typical signs often being absent; mild tamponade frequently being asymptomatic; hypotension being a late sign; the existence of the five size grades (trivial, small, moderate, large, very large); and the sentence "Small and very large effusions are most likely to be unevenly distributed in the pericardial space and its recesses"
• Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease. Circulation 2021;143(5):e72-e227 (PMID 33332150; DOI 10.1161/CIR.0000000000000923; erratum Circulation 2024;150(12):e267, DOI 10.1161/CIR.0000000000001284; the errata of November 2023 and September 2024 have not been checked here) (retrieved 9 August 2026) — section 2.3.1 on measurement variability and sequential studies; section 2.3.2 on reporting symptom changes promptly; section 2.3.3 and table 5 on follow-up intervals (progressive stage B mild every 3–5 years and moderate every 1–2 years; severe asymptomatic C1 every 6–12 months; mitral stenosis by valve area with no moderate cell) and the two notes below the table (mixed valve disease, and *with normal stroke volume); the IAC-accredited laboratory; and the existence of stages A to D. ⚠ The full text of that guideline contains no requirement that follow-up use the same method; that item comes from the ASE/EACVI aortic stenosis update of 2017
• Singh JP, Evans JC, Levy D, et al. Prevalence and clinical determinants of mitral, tricuspid, and aortic regurgitation (the Framingham Heart Study). Am J Cardiol 1999;83(6):897-902 (PMID 10190406; DOI 10.1016/s0002-9149(98)01064-9; erratum Am J Cardiol 1999;84(9):1143) (retrieved 3 August 2026) — the detection rate for each valve and each valve's own threshold; the odds ratios for the three sets of determinants for MR, TR and AR; and the limits of population and period
• Freed LA, Levy D, Levine RA, et al. Prevalence and clinical outcome of mitral-valve prolapse. N Engl J Med 1999;341(1):1-7 (PMID 10387935; DOI 10.1056/NEJM199907013410101) (retrieved 3 August 2026) — mitral valve prolapse at 2.4%; age and sex distributions similar to those without prolapse; similar symptom frequencies; regurgitation averaging trace or mild; and the two sentences of the conclusion (prevalence lower than previously reported, and a low prevalence of adverse sequelae)
• Pellikka PA, She L, Holly TA, et al. Variability in Ejection Fraction Measured By Echocardiography, Gated Single-Photon Emission Computed Tomography, and Cardiac Magnetic Resonance in Patients With Coronary Artery Disease and Left Ventricular Dysfunction. JAMA Netw Open 2018;1(4):e181456 (PMID 30646130; PMC6324278; CC-BY) (retrieved 3 August 2026) — the Findings and Meaning columns of the Key Points box; the 2,032 STICH patients; the between-modality correlations from 0.493 to 0.660; and the higher correlation between methods within echocardiography (biplane against visual estimate, r = 0.898)
• Cole GD, Dhutia NM, Shun-Shin MJ, et al. Defining the real-world reproducibility of visual grading of left ventricular function and visual estimation of left ventricular ejection fraction: impact of image quality, experience and accreditation. Int J Cardiovasc Imaging 2015;31(7):1303-1314 (PMID 26141526; PMC4572050) (retrieved 9 August 2026) — 35 operators; 1,400 interpretations; inter-operator agreement of 50% and self-agreement of 68%; standard deviations of repeat estimates of 7.6 and 8.3 EF units; and the caution against assuming a change is a clinical change
• healthdirect (Australian government-funded), "Heart valve disease": https://www.healthdirect.gov.au/heart-valve-disease (page self-dated Last reviewed: February 2024; retrieved 3 August 2026) — the four valves; a murmur not meaning valve disease; valve disease needing treatment even without symptoms; when to see a doctor (the symptom trigger); and the age-based recommendation immediately following (45, or 35 for Aboriginal and Torres Strait Islander people, for a Heart Health Check every two years; an Australian setting)
• healthdirect, "Electrocardiogram - ECG or EKG": https://www.healthdirect.gov.au/electrocardiogram-ecg (page self-dated Last reviewed: May 2025; retrieved 9 August 2026) — an echocardiogram being an ultrasound of the heart; and the list of other tests that may be needed after an ECG (echocardiogram, blood tests, angiogram)
• Hospital Authority, List of Non-subvented Medical Service Items, annex III, diagnostic and therapeutic procedures (section 5.2, Cardiology): https://www3.ha.org.hk/fnc/DiagnosticTherapeuticProcedures.aspx?lang=CHIB5 · English version https://www3.ha.org.hk/fnc/DiagnosticTherapeuticProcedures.aspx?lang=ENG (the fee schedule implemented takes effect 1 January 2026; the page carries no revision date; retrieved 9 August 2026) — the official Chinese name 「超聲波心臟檢驗」 and all seven echocardiography items in both languages (including the source's own "starin" slip); the non-subvented fees of 4,190 dollars for Category 2 (2 items) and 6,490 to 14,650 dollars for Category 3 (5 items); and each category heading describing itself as 「例如」 / "such as"
• Hospital Authority, List of Non-subvented Medical Service Items, annex II, radiology: https://www3.ha.org.hk/fnc/Radiology.aspx?lang=ENG (retrieved 3 August 2026) — group four (ultrasonography) at 490 to 7,100 dollars per examination; that group itemising 58 ultrasound examinations (Radiology 3101 to 5013), among which there is no echocardiography, though it does include Radiology 3321 – Ultrasonography – Doppler – Pericardium
• Hospital Authority gazetted fee schedule: https://www.ha.org.hk/haho/ho/cc/Gazette_tc.pdf · English version https://www.ha.org.hk/haho/ho/cc/Gazette_en.pdf (signed 31 October 2025, effective 1 January 2026; retrieved 9 August 2026) — clause 1.3(A) of appendix I and its "and other investigations"; clause 1.6 and the three tiers of non-urgent radiology fees; and the separation in the table of contents of annex II between section 4, radiology, and section 5.2, cardiology
• Hospital Authority public healthcare service fees (Chinese version): https://www.ha.org.hk/visitor/ha_view_content.asp?Content_ID=10045&Lang=CHIB5&Dimension=100&Ver=HTML · English version https://www.ha.org.hk/visitor/ha_view_content.asp?Content_ID=10045&Lang=ENG&Dimension=100&Ver=HTML (effective 1 January 2026; retrieved 3 August 2026) — 250 dollars per specialist clinic attendance, and the three tiers of non-urgent radiology and pathology testing fees
• Hospital Authority, Public Healthcare Fee Reform — Frequently Asked Questions: https://www.ha.org.hk/ho/corpcomm/fncr/index-tc.html · English version https://www.ha.org.hk/ho/corpcomm/fncr/index-en.html (the page carries no update date; the fees described take effect 1 January 2026; retrieved 9 August 2026) — the item lists for the three tiers of non-urgent radiology service in Q3 (basic: X-ray; intermediate: fluoroscopy, ultrasonography and mammography, 250 dollars; advanced: computed tomography, magnetic resonance imaging and others, 500 dollars), with the English version's corresponding Basic, Intermediate (Fluoroscopy, Ultrasonography and Mammography) and Advanced Item; the scope in Q2 (the fees applying to non-urgent radiology services arranged as a follow-up from an outpatient clinic or accident and emergency department and for day patients or inpatients after discharge, with urgent radiology services for inpatients and accident and emergency patients remaining free); the item descriptions of the three pathology testing tiers; the open-ended wording of the intermediate and advanced tiers (「包括非常見的血液檢驗項目」 / 「包括複雜的基因血液檢驗項目」); and the exhaustive wording of the basic tier (「涵蓋最常見的血液病理學檢驗及所有非血液病理學檢驗」, which this article does not cite in support of the illustrative reading)
• Hospital Authority specialist outpatient waiting time: https://www.ha.org.hk/haho/ho/sopc/dw_wait_ls.pdf (data period 1 July 2025 to 30 June 2026; next update 30 October 2026; retrieved 9 August 2026) — the new case booking figures for medicine; the number of new cases and the median waits across the seven clusters for each of the urgent, semi-urgent and stable categories; the longest wait for the "stable" category; and notes (1) on the definition of the 90th percentile, (2) "excluding other cases pending triage" and (3) on the Hong Kong East and Hong Kong West clusters merging into the Hong Kong Island cluster from 1 April 2026
• The same, open data files: https://www.ha.org.hk/opendata/sop/sop-waiting-time-tc.json · English version https://www.ha.org.hk/opendata/sop/sop-waiting-time-en.json (the same data period; retrieved 3 August 2026) — the same values; the files do not carry the three notes below the table
• Pok Oi Hospital, "Day Services", cardiac and neurological investigation unit: https://www3.ha.org.hk/poh/ch/services/02_01_asc.asp (the page carries no date; retrieved 9 August 2026) — the Hospital Authority's colloquial name 「心臟超聲波」; the departmental placement of the cardiac and neurological investigation unit; and the requirement of a referral from a doctor in the cluster
• Hospital Authority Smart Patient index of disease and examination information: https://www.smartpatient.ha.org.hk (retrieved 3 August 2026) — the index having no dedicated page on echocardiography or cardiac ultrasound (a bounded absence; the same index does carry pages on myocardial infarction, coronary heart disease, arrhythmia, structural heart disease, cardiac muscle biopsy, cardiac catheterisation and related treatment, endoscopic ultrasonography, X-ray examination and adult magnetic resonance imaging examination)
• Supplementary Medical Professions Council, "Boards": https://www.ahp-council.org.hk/smp/tc/content.php?page=abt_board · English version https://www.ahp-council.org.hk/smp/en/content.php?page=abt_board (the page carries no update date; retrieved 3 August 2026) — five boards, five professions
• Radiographers Board, Code of Practice, appendix I (prohibited acts applicable to all radiographers): https://www.ahp-council.org.hk/rg/file/pdf/CoP_for_RG_c_dec2025.pdf · English version https://www.ahp-council.org.hk/rg/file/pdf/CoP_for_RG_e_dec2025.pdf (revised December 2025; retrieved 3 August 2026) — the prohibition on issuing reports on organ imaging examinations performed with ultrasound and other methods
• Medical Council of Hong Kong, Specialist Register, list of specialties: https://www.mchk.org.hk/tc_chi/list_register/specialist_list.php · English version https://www.mchk.org.hk/english/list_register/specialist_list.php (page footer self-dated August 2026; retrieved 9 August 2026) — cardiology S13 listed separately from internal medicine S12
• Hong Kong Academy of Medicine, "Academy Colleges": https://www.hkam.org.hk/en/academy-colleges (retrieved 3 August 2026) — the list of fifteen colleges accredited between 1992 and 1997
• Tuen Mun Hospital, "Release of Patient Information" and the Data Access Request form: https://www3.ha.org.hk/tmh/ch/patients_visitors/01_07.asp · form (English version) https://www3.ha.org.hk/tmh/en/patients_visitors/records/202601/TMH_1013E.pdf · form (Chinese version) https://www3.ha.org.hk/tmh/ch/patients_visitors/records/202601/TMH_1013C.pdf (form version 01/26; fees applying from 1 January 2026; retrieved 9 August 2026) — the 40-day period and its exception (written notification where it cannot be met, delivery in parts, and full compliance as soon as practicable thereafter); the handling fee of 100 dollars (covering the first 10 pages and the postage) and its note 1 (non-refundable unless the hospital is unable to supply the data); 1.5 dollars per page from page 11 onwards; 300 dollars per film and per disc; paragraph 4 of the notes (a balance above 100 dollars to be settled before copies are released); the absence of an echocardiography box in the data type tick-box column (in both the Chinese and English versions); the field names 「專科門診病歷」 and 「其他」 at item 5.1 of the Chinese version; and 「每張底片港幣 300 元」 in the Chinese fee table
• Hospital Authority personal data privacy policy statement: https://www.ha.org.hk/haho/ho/hesd/protectpolicy-b5.htm · English version https://www.ha.org.hk/haho/ho/hesd/protectpolicy-en.htm (the page carries no date; retrieved 3 August 2026) — data access and correction requests, and each hospital having a data controller
• eHealth, "Sharable Data": https://www.ehealth.gov.hk/tc/whats-ehealth/sharable-records/index.html · English version https://www.ehealth.gov.hk/en/whats-ehealth/sharable-records/index.html (the page carries no date; retrieved 3 August 2026) — the page itemising eleven categories of sharable data (including "Laboratory and Radiology Reports" and "Other Investigation Reports"), while describing sharing between healthcare providers and not the scope visible to a patient
• Health Bureau press release, eHealth App Adds Radiology Report Viewing Function (3 April 2025): https://www.info.gov.hk/gia/general/202504/03/P2025040200721.htm (retrieved 9 August 2026) — the nine categories of electronic health record a patient can look up (including "Laboratory and Radiology Reports" and not "Other Investigation Reports"); radiology reports generally being viewable in the app 14 days after issue; and the scope of future extension (radiology images, Chinese medicine prescription records, and oral examination records and dental condition)
• Legislative Council CB(2) 1308/99-00(11), Long Working Hours of Doctors in Public Hospitals (discussed 10 March 2000): https://www.legco.gov.hk/yr99-00/chinese/panels/hs/papers/b1308c11.pdf · English version https://www.legco.gov.hk/yr99-00/english/panels/hs/papers/b1308e11.pdf — echocardiography examinations previously carried out by doctors being performed by technicians
• The Secretary for Food and Health's briefing on the 2016 Policy Address (18 January 2016): https://www.legco.gov.hk/yr15-16/chinese/panels/hs/papers/hs20160118cb2-700-1-c.pdf — increasing the service volume of echocardiography examinations

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#Further reading

• On this platform: Reading laboratory and imaging reports
• On this platform: Public hospital fees from 2026 and medical fee waivers
• On this platform: Public waiting times too long? Private and PPP alternatives
• On this platform: The GoodDoctor.hk AI document reading tool
• American Society of Echocardiography (ASE) guidelines: asecho.org