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
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)
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
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
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
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 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.
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.
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
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
