What is the recommended approach for a complete echocardiogram (echo) in patients with suspected cardiac disease?

Recommended Approach for a Complete Echocardiogram in Suspected Cardiac Disease

A complete echocardiogram should include assessment of left ventricular systolic and diastolic function, valvular structure and function, regional wall motion abnormalities, chamber size measurements, and evaluation for potential sources of embolism, guided by the specific clinical presentation. 1

Components of a Complete Echocardiogram

Essential Structural Assessment

• Left ventricular size and wall thickness
• Right ventricular size and function
• Left and right atrial dimensions
• Valvular anatomy and function (mitral, aortic, tricuspid, pulmonary)
• Pericardium (thickness, presence of effusion)
• Aortic root and proximal ascending aorta

Functional Assessment

• Left ventricular systolic function with ejection fraction quantification
• Regional wall motion abnormalities
• Diastolic function parameters
• Valvular function (stenosis, regurgitation)
• Estimated pulmonary artery pressures
• Assessment of intracardiac shunts

Clinical Indications for Echocardiography

Chest Pain

• Recommended for patients with:

  • Suspected myocardial ischemia with non-diagnostic ECG and cardiac biomarkers 2
  • Underlying cardiac disease (valvular, pericardial, or primary myocardial) 2
  • Hemodynamic instability unresponsive to simple measures 2
  • Suspected acute aortic syndromes, myocarditis, pericarditis, or pulmonary embolism 2

• Not recommended for:

  • Patients with apparent non-cardiac etiology of chest pain 2
  • Ongoing chest pain in patients with confirmed myocardial infarction 2

Heart Murmurs

• Echocardiography serves multiple purposes in evaluating heart murmurs:
  • Define the primary lesion and assess severity
  • Detect coexisting abnormalities
  • Identify secondary lesions
  • Evaluate cardiac function
  • Establish baseline for future comparison 2

Dyspnea

• Recommended for patients with:

  • Clinical findings suggestive of significant coronary, valvular, or hypertensive heart disease 2
  • Suspected heart failure to assess systolic and diastolic function 1

• Not recommended for:

  • Dyspnea without clinical evidence of heart disease, pulmonary hypertension, or significant lung disease 2
  • Hyperventilation syndrome 2

Arrhythmias and Palpitations

• Echocardiography can detect underlying cardiac disorders in approximately:
  • 10% of patients with atrial fibrillation who have no clinically suspected cardiac disease
  • 60% of those with equivocal evidence of heart disease 2

Special Considerations

Transesophageal Echocardiography (TEE)

• Should be considered when transthoracic studies are non-diagnostic 2
• Particularly valuable for:
  • Left atrial thrombi detection
  • Atrial septal abnormalities
  • Aortic atheroma evaluation
  • Valvular vegetations in suspected endocarditis
  • Prosthetic valve assessment

Stress Echocardiography

• Valuable for:
  • Evaluation of coronary artery disease
  • Assessment of valvular function with exercise
  • Determination of myocardial viability

Common Pitfalls to Avoid

1. Failing to tailor the echocardiographic examination to the specific clinical question
2. Overlooking the need for TEE when transthoracic images are suboptimal
3. Not considering stress echocardiography for patients with atypical chest pain and normal resting studies
4. Relying solely on physical examination to rule out valvular heart disease 1
5. Ordering echocardiography for all patients with peripheral edema without other cardiac findings, leading to low diagnostic yield 1

Conclusion

A complete echocardiogram should be comprehensive but focused on answering the clinical question at hand. The examination should include standard views and measurements while paying particular attention to the cardiac structures most relevant to the patient's presentation. Following a systematic approach ensures that all important cardiac structures and functions are evaluated properly.