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Introduction Transthoracic echocardiography (TTE) is a cornerstone diagnostic tool, valued for its non-invasive nature and real time imaging capabilities. Requests for TTE submitted internally were retrospectively reviewed to evaluate their appropriateness.Methods Internal requests for TTE submitted between September 2023 and January 2024 were reviewed retrospectively. Clinical indications provided on request forms were evaluated against the British Society of Echocardiography (BSE) guidelines and categorized as either indicated or not indicated. Reviewers were blinded to TTE outcomes during assessment, with ambiguous cases adjudicated by two independent investigators. Associations between categorical variables were analyzed using the Pearson Chi-Square test.Results There were 314 patients included. The mean age was 64 ± 17 years, and 45% were female. 62 patients (19.7%) were referred for assessment of arrhythmias, palpitations and syncope, 59 (18.1%) for cardiomyopathy, and 29 (9.2%) for ischaemic heart disease. 26 patients (8.3%) were referred for indications not listed in the BSE guidelines ( figure 1). A total of 220 (70%) were considered appropriate and 94 (30%) were considered inappropriate. 18 (21%) of the inappropriate referrals were made for pre-operative echo without a change in biomarker or functional status (table 1). Of the 40 TTEs performed with inappropriate indication, 20 (50%) were normal and 13 (32.5%) had new significant findings. 1 had apical hypertrophic cardiomyopathy, 1 had new dilated cardiomyopathy, 3 (7.5%) had new evidence of pulmonary hypertension and 5 (12.5%) had moderate - severe valvular pathology. After consideration of the 27 (8.6%) referrals for indications not formally listed, 16 (59.2%) were considered appropriate (table 2). In the group of appropriate referrals, there was a significantly higher proportion of TTEs with significant findings 56, 47% (p 0.005) (figure 2).Conclusion The findings suggest that the utility of the transthoracic echocardiography (TTE) in Beaumont Hospital can be further streamlined. Enhancing referrer education and further improving an electronic ordering system that aligns requests with BSE guidelines may improve the appropriateness of TTE referrals.Abstract 87 Figure 1Abstract 87 Table 1Transthoracic echocardiography indications and appropriateness BSE Indication Appropriate Inappropriate Murmur 6 2 Native valvular stenosis 6 1 Native valvular regurgitation 4 1 Prosthetic valve assessment 9 4 Infective endocarditis 6 7 Ischaemic heart disease 23 6 Cardiomyopathy 46 13 Pericardial disease 9 1 Cardiac Masses 1 0 Pulmonary Disease 20 3 Neurological disease 13 9 Arrhythmia, Palpitations and Syncope 46 14 Hypertension 6 3 Aortic and major arterial disease 5 0 Pre-operative echo for elective and semi-urgent surgery 3 18 Not mentioned in BSE 16 11 Post cardiac procedure 1 0 Assessment of complex fluid balance 0 1 TOTAL 220 94 Abstract 87 Table 2Indications not mentioned in the transthoracic echocardiography BSE guidelines Indication Number of patients Screening ◊ To enrol & retain on the renal transplant list 4 ◊ Long term dopamine agonist therapy 3 Cardiac ◊ Angina 1 ◊ Previous ASD repair/Cor triatriatum resection 1 ◊ LV thrombus resolution 1 Respiratory ◊ Dyspnoea with no cardiac involvement (normal BNP, no evidence or arrhythmia or clinical/radiographic evidence of overload) 4 Neurological ◊ Undifferentiated collapse 2