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Indications

Echocardiography Types

  • Bicycle Stress Echo
  • Dobutamine Stress Echo
  • Transthoracic Echo (TTE)
  • Transesophageal Echo (TEE)

Echocardiography Indications

  • Class I (Useful)
    • Murmurs Table 23
      • Murmurs with cardiorespiratory symptoms
      • A murmur in an asymptomatic patient if the clinical features indicate at least a moderate probability that the murmur is reflective of structural heart disease
    • Valvular Stenosis Table 24
      • To define the primary lesion and its etiology and judge its severity
      • Define hemodynamic severity
        • Detect coexisting abnormalities
        • Detect secondary lesions
        • Evaluate size and function
        • Establish reference point
      • Reevaluation after intervention or with changing signs and symptoms
      • Assessment of changes in severity and ventricular compensation in patient with known valvular stenosis during pregnancy
      • Reevaluation of asymptomatic patients with severe stenosis
    • Native Valvular Regurgitation Table 25
      • Same as Valvular Stenosis
      • Reevaluation of patients with mild-moderate regurgitation with ventricular dilation without clinical symptoms (eg, virulent organism, severe hemodynamic lesion, aortic valve involvement, persistent fever or bacteremia, clinical change, or symptomatic deterioration)
    • Mitral Valve Prolapse Table 26
      • Assess Severity, leaflet morphology, ventricular compensation
    • Infective Endocarditis Table 28
      • Detection of valvular lesions
      • Detection of associated abnormalities
      • Reevaluation studies in complex endocarditis
    • Valvular Heart Disease and Prosthetic Valves Table 29
      • Timing of intervention
      • Selection of therapies
      • Postintervention for valve function (early) and ventricular remodeling (late)
    • Chest Pain Table 30
      • Diagnose underlying cardiac disease in patients with chest pain and clinical evidence of valvular, pericardial, or primary myocardial disease
      • Evaluation of chest pain in patients with suspected acute myocardial ischemia, when baseline ECG is non-diagnostic and when study can be obtained during pain or soon after its abatement (see section IV)
        • The presence of regional systolic wall motion abnormalities in a patient without known CAD is a moderately accurate indicator of an increased likelihood of acute myocardial ischemia or infarction by pooled data with a positive predictive accuracy of about 50%
      • The absence of regional wall motion abnormalities identifies a subset of patients unlikely to have an acute infarction1 with a pooled negative predictive accuracy of about 95%2
      • Evaluation of suspected aortic dissection
      • Evaluation with severe hemodynamic instability
    • ACS Table 31-32
      • Diagnosis of suspected acute ischemia or infarction not evident by standard means
      • Measurement of baseline LV function
      • Patients with inferior myocardial infarction and bedside evidence suggesting possible RV infarction.
      • Assessment of mechanical complications and mural thrombus
      • Assessment of infarct size and/or extent of jeopardized myocardium
      • In-hospital assessment of ventricular function when the results are used to guide therapy
      • In-hospital or early postdischarge assessment of the presence/extent of inducible ischemia whenever baseline abnormalities are expected to compromise electrocardiographic interpretation
    • Chronic Stable Ischemic Heart Disease Table 33-34
      • Diagnosis of myocardial ischemia in symptomatic individuals (Exercise TTE)
      • Assessment of global ventricular function at rest
      • Assessment of myocardial viability (hibernating myocardium) for planning revascularization (Dobutamine Stress)
      • Assessment of functional significance of coronary lesions (if not already known) in planning percutaneous transluminal coronary angioplasty
      • Assessment of LV function when needed to guide institution and modification of drug therapy in patients with known or suspected LV dysfunction
      • Assessment for restenosis after revascularization in patients with atypical recurrent symptoms (Exercise TTE)
    • Dyspnea/Edema/Cardiomyopathy Table 35
      • Assessment of LV size and function in patients with suspected cardiomyopathy or clinical diagnosis of heart failure
      • Edema with clinical signs of elevated central venous pressure when a potential cardiac etiology is suspected or when central venous pressure cannot be estimated with confidence and clinical suspicion of heart disease is high
      • Dyspnea with clinical signs of heart disease
      • Patients with unexplained hypotension, especially in the intensive care unit
      • Patients exposed to cardiotoxic agents, to determine the advisability of additional or increased dosages
      • Reevaluation of LV function in patients with established cardiomyopathy when there has been a documented change in clinical status or to guide medical therapy
    • Pericardial Disease Table 36
      • Patients with suspected pericardial disease, including effusion, constriction, or effusive-constrictive process
      • To follow resolution
    • Echocardiography in Thoracic Disease
    • Pulmonary Disease Table 39
      • Suspected pulmonary hypertension
      • Pulmonary emboli and suspected clots in the right atrium or ventricle or main pulmonary artery branches
      • For distinguishing cardiac versus non-cardiac etiology of dyspnea in patients in whom all clinical and laboratory clues are ambiguous
      • Follow-up of pulmonary artery pressures in patients with pulmonary hypertension to evaluate response to treatment
      • Lung disease with clinical suspicion of cardiac involvement (suspected cor pulmonale)
    • Hypertension Table 40
      • When assessment of resting LV function, hypertrophy, or concentric remodeling is important in clinical decision making (see LV function)
      • Detection and assessment of functional significance of concomitant coronary artery disease (see coronary disease)
      • Follow-up assessment of LV size and function in patients with LV dysfunction when there has been a documented change in clinical status or to guide medical therapy
    • Vascular/Neurologic Events
      • Patients of any age with abrupt occlusion of a major peripheral or visceral artery
      • Younger patients (typically <45 years) with cerebrovascular events
      • Older patients (typically >45 years) with neurological events without evidence of cerebrovascular disease or other obvious cause
      • Patients for whom a clinical therapeutic decision (anticoagulation, etc) will depend on the results of echocardiography
    • Arrhythmias and Palpitations Table 41
      • Arrhythmias with clinical suspicion of structural heart disease
      • Arrhythmia in a patient with a family history of a genetically transmitted cardiac lesion associated with arrhythmia such as tuberous sclerosis, rhabdomyoma, or hypertrophic cardiomyopathy.
      • Evaluation of patients as a component of the workup before electrophysiological ablative procedures.
    • Syncope Table 44
      • Syncope in a patient with clinically suspected heart disease
      • Periexertional syncope
    • CVD Screening Table 45
      • Patients with a family history of genetically transmitted cardiovascular disease
      • Potential donors for cardiac transplantation
      • Patients with phenotypic features of Marfan syndrome or related connective tissue diseases
      • Baseline and reevaluations of patients undergoing chemotherapy with cardiotoxic agents
  • Class III (Not useful)
    • However, many murmurs in asymptomatic people are innocent and of no functional significance. Such murmurs are defined as having the following characteristics: a systolic murmur of short duration, grade 1 or 2 intensity at the left sternal border, a systolic ejection pattern, a normal S2, no other abnormal sounds or murmurs, no evidence of ventricular hypertrophy or dilation, no thrills, and the absence of an increase in intensity with the Valsalva maneuver. Such murmurs are especially common in high-output states such as pregnancy.
    • Syncope Table 44
      • Classic neurogenic syncope
      • Syncope in a patient for whom there is no clinical suspicion of heart disease
      • Recurrent syncope in a patient in whom previous echocardiographic or other testing demonstrated a cause of syncope

Indications for TEE after TTE

  • Left atrial thrombus
  • Left atrial spontaneous contrast
  • Atrial Septal Aneurysm
  • Patient foramen ovale
  • Aortic Atheroma

Indications in the Critically Ill

  • The critically ill patient in the emergency department or intensive care unit is often managed by intubation and mechanical ventilation frequently utilizing positive end-expiratory pressure (PEEP)
    • Up to one half of such patients cannot be adequately imaged by TTE, especially those requiring >10 cm PEEP
  • Indications for TEE Table 46
    • The hemodynamically unstable patient with suboptimal TTE images.
    • The hemodynamically unstable patient on a ventilator.
    • Major trauma or postoperative patients (unable to be positioned for adequate TTE).
    • Suspected aortic dissection.
    • Suspected aortic injury.
    • Other conditions in which TEE is superior (see section on valvular disease).
  • Indications for TTE Table 47
    • The hemodynamically unstable patient
    • Suspected aortic dissection (TEE)
    • Serious blunt or penetrating chest trauma (suspected pericardial effusion or tamponade)
    • Mechanically ventilated multiple-trauma or chest trauma patient
    • Suspected preexisting valvular or myocardial disease in the trauma patient
    • The hemodynamically unstable multiple-injury patient without obvious chest trauma but with a mechanism of injury suggesting potential cardiac or aortic injury (deceleration or crush)
    • Widening of the mediastinum, postinjury suspected aortic injury (TEE)
    • Potential catheter, guidewire, pacer electrode, or pericardiocentesis needle injury with or without signs of tamponade