Do I need an echocardiogram (echo)?

When Do You Need an Echocardiogram?

An echocardiogram is indicated if you have symptoms or clinical findings suggestive of heart disease, such as heart murmurs, cardiorespiratory symptoms, arrhythmias with hemodynamic compromise, or if you are under 45 years old with a cerebrovascular event. 1

Specific Indications for Echocardiography

Class I Indications (Definitely Needed)

• Heart murmur with features suggesting organic heart disease 1
• Murmur in a patient with cardiorespiratory symptoms 1
• Chest pain with clinical evidence of valvular or pericardial disease 1
• Patients with cerebral embolism and clinical evidence of heart disease 1
• Patients under 45 years of age with a cerebrovascular event 1
• Peripheral emboli involving major arteries (regardless of clinical findings) 1
• Edema with other evidence of cardiac disease 1
• Suspected cardiac trauma with hypotension and tachycardia 1

Class II Indications (May Be Needed)

• Murmur in an asymptomatic patient with low probability of heart disease but where diagnosis cannot be excluded by standard evaluation 1
• Known or suspected coronary artery disease 1
• Patients without clinical evidence of heart disease and normal findings on evaluation for non-cardiac causes of syncope 1
• Patients over 45 years of age with suspicion of cardiogenic brain embolism but without clinical evidence of heart disease 1
• Edema without evidence of cardiac disease 1

Class III Indications (Not Needed)

• Typically innocent murmur in an asymptomatic patient without other reasons to suspect heart disease 1
• Patients with known non-cardiac causes of syncope 1
• Non-cardiac chest pain 1
• Edema of known non-cardiac origin 1
• Minor chest injuries without tachycardia, hypotension, respiratory difficulty, or chest pain 1

Clinical Decision Algorithm

1. Assess for Class I indications:

   • Do you have a heart murmur with concerning features?
   • Do you have chest pain with signs of valvular or pericardial disease?
   • Have you had a stroke under age 45?
   • Do you have peripheral emboli?
   • Do you have edema with other cardiac signs?

2. If no Class I indications, assess for Class II indications:

   • Do you have known or suspected coronary disease?
   • Do you have unexplained syncope?
   • Do you have edema without clear cause?

3. If neither Class I nor Class II indications are present, an echocardiogram is likely unnecessary.

Value and Limitations of Echocardiography

• Echocardiography has replaced cardiac catheterization as the definitive study for many types of valvular and congenital heart disease 1, 2
• It provides essential information about cardiac structure and function that complements other cardiac tests 2
• For heart failure evaluation, echo assesses ejection fraction and structural abnormalities 2, 3
• In coronary artery disease, echo can identify wall motion abnormalities 4

Important Caveats

• The basic cardiovascular examination remains the most appropriate method to screen for cardiac disease - echocardiography should not replace a thorough clinical evaluation 1, 2
• Despite its utility, only 27.5% of physicians in one study reported that echocardiograms significantly affected patient care 5
• Echocardiography is more expensive than other cardiac tests and should not be used as a routine screening test for the general population 2
• Technical limitations such as body habitus can affect echo quality and interpretation 2

Remember that the decision to obtain an echocardiogram should be based on clinical findings that suggest potential cardiac disease, not as a routine screening test in the absence of symptoms or clinical indications.