Handheld ultrasound could provide sufficient information to satisfy the clinical questions underlying 'rarely appropriate' echo requests, but there are limited data about its use as a gatekeeper to standard echocardiography. We sought to determine whether the use of handheld ultrasound could improve the appropriate use of echocardiography.A prospective study comparing handheld ultrasound strategy to standard echocardiography for studies deemed rarely appropriate, using a questionnaire based on appropriate use criteria was conducted across two hospitals, from October 2017 to April 2018.Groups undergoing Handheld ultrasound ( = 76, 58 (46.5-72.5) years, 53 males, 78% outpatients) and standard echocardiography ( = 72, 61 (49.0-71.5) years, 42 males, 76% outpatients) were comparable. There was a significant decrease in the time to scan from just over 1 month in standard group to a median of 12 days in handheld ultrasound group ( < 0.001). This difference was small for inpatients (from 1 day to a median of 10 min in handheld ultrasound,  = 0.014), but prominent in outpatients (from 1.5 months in the standard group to median of 2 weeks in the handheld ultrasound group,  < 0.001). There was no increase in the need for follow-up scan within 6 months and no significant differences in length of hospital stay for inpatients.nHandheld ultrasound can be an effective gatekeeper to standard echocardiography for requests deemed rarely appropriate, reducing time to echocardiography significantly and potentially decreasing the need for standard echocardiography by up to 20%.