When should I order an echocardiogram (echo)?

Indications for Ordering an Echocardiogram

Echocardiography should be ordered when there are ECG abnormalities, signs or symptoms of left ventricular dysfunction, or when detection of hypertension-mediated organ damage may influence treatment decisions. 1

Primary Indications for Echocardiography

Cardiovascular Disease Assessment

• Suspected or known valvular heart disease

  • Patients with heart murmurs suggestive of significant valvular disease or obstructive cardiomyopathy 1
  • Evaluation of valvular structure and function in patients with abnormal auscultatory findings

• Cardiac function evaluation

  • Assessment of left ventricular systolic and diastolic function
  • Evaluation of regional wall motion abnormalities
  • Quantification of ejection fraction in patients with suspected heart failure

• Hypertension management

  • Detection of left ventricular hypertrophy (LVH) when it may influence treatment decisions 1
  • Assessment of hypertension-mediated organ damage (HMOD)

Acute Cardiovascular Conditions

• Chest pain evaluation

  • Patients with suspected myocardial ischemia with non-diagnostic ECG and cardiac biomarkers 1
  • Patients with chest pain and underlying cardiac disease (valvular, pericardial, or primary myocardial)
  • Evaluation of chest pain with hemodynamic instability unresponsive to simple measures

• Suspected cardiac trauma

  • Immediate focused cardiac ultrasound in patients with chest trauma, hypotension, and tachycardia 1
  • Assessment for pericardial tamponade, valvular injuries, or myocardial contusion

• Arrhythmia evaluation

  • Assessment of underlying cardiac disorders in patients with arrhythmias 1
  • Quantification of left atrial size in patients with atrial fibrillation before cardioversion

Other Important Indications

• Suspected embolic events

  • Evaluation for cardiac source of embolism in patients with documented peripheral emboli 1
  • Assessment for endocarditis in patients with fever and peripheral arterial emboli

• Pericardial disease

  • Evaluation for pericardial effusion or tamponade
  • Assessment of constrictive pericarditis in patients with unexplained edema and elevated central venous pressure

When Not to Order Echocardiography

• Patients with chest pain for which a non-cardiac etiology is apparent 1
• Patients with minor chest injuries without tachycardia, hypotension, or other concerning symptoms 1
• Patients with edema of clearly non-cardiac origin 1
• Patients with known noncardiac causes of syncope 1

Special Considerations

Type of Echocardiography

• Transthoracic echocardiography (TTE) is typically the first-line imaging method
• Transesophageal echocardiography (TOE/TEE) should be considered when:
  • TTE studies are non-diagnostic 1
  • Better visualization of cardiac structures is needed
  • Assessment of left atrial appendage thrombi is required

Advanced Echocardiographic Techniques

• Stress echocardiography for evaluation of:

  • Coronary artery disease
  • Valvular heart disease severity
  • Pulmonary hypertension 2

• 3D echocardiography and speckle tracking for:

  • More accurate assessment of ventricular volumes and function
  • Detection of subclinical myocardial dysfunction

Clinical Decision Algorithm

1. For patients with hypertension:

   • Order echo if ECG shows abnormalities or if there are signs/symptoms of LV dysfunction
   • Consider echo to detect LVH when it may influence treatment decisions 1

2. For patients with chest pain:

   • Order echo if non-diagnostic ECG and cardiac biomarkers when pain is present
   • Order echo if underlying cardiac disease is suspected
   • Order echo if hemodynamic instability is present 1

3. For patients with arrhythmias:

   • Order echo to assess for underlying structural heart disease
   • Order echo to guide antiarrhythmic therapy selection 1

4. For patients with suspected embolic events:

   • Order echo regardless of clinical findings as heart is likely source of large emboli 1

5. For patients with edema:

   • Order echo if there is evidence of elevated central venous pressure or clinical findings of heart disease 1

Common Pitfalls to Avoid

• Failing to order echo in patients with ECG abnormalities and hypertension
• Overlooking the need for echo in patients with unexplained persistent tachycardia 3
• Relying solely on physical examination to rule out valvular heart disease
• Not considering echo in patients with peripheral emboli, which may miss a cardiac source
• Ordering echo for all patients with peripheral edema without other cardiac findings, as diagnostic yield is low 1

By following these guidelines, you can appropriately utilize echocardiography to improve diagnosis, guide treatment decisions, and enhance patient outcomes in various clinical scenarios.