What is the next step for a patient with multivessel disease identified on an echocardiogram (echo), should I refer for a transesophageal echocardiogram (TEE), heart catheterization (heart cath), or consultation with a structural heart disease doctor?

Management of Multivessel Disease Identified on Echocardiogram

For patients with multivessel disease identified on echocardiogram, cardiac catheterization is the recommended next step to guide appropriate revascularization strategy, as it provides definitive assessment of coronary anatomy and allows for immediate intervention if needed. 1

Initial Assessment of Multivessel Disease

When multivessel disease is identified on echocardiogram, the following considerations should guide your next steps:

• Wall motion abnormalities: Segmental wall motion abnormalities on echo strongly correlate with specific coronary artery distribution and pathology 1
• Compensatory function: Lack of expected compensatory hyperkinesia in non-infarcted segments suggests multivessel disease and is associated with worse prognosis 1
• Left ventricular function: Patients with multivessel disease and LV dysfunction (LVEF <0.40) are at high risk and may derive survival benefit from CABG 1

Diagnostic Pathway

1. Cardiac catheterization: This is the definitive next step for patients with multivessel disease identified on echocardiogram 1

   • Allows identification of patients with no significant coronary stenoses (10-20%)
   • Identifies patients with 3-vessel disease with LV dysfunction or left main CAD (approximately 20%)
   • Enables immediate PCI of culprit lesions if appropriate

2. Transesophageal echocardiography (TEE) is generally NOT the next step unless:

   • There is suspicion of valvular complications (acute mitral regurgitation, ventricular septal rupture) 1
   • Assessment of prosthetic valve function is needed 1
   • TTE images are inadequate for assessment of cardiac structures 1

Referral to Structural Heart Disease Specialist

Referral to a structural heart disease specialist should be considered in specific scenarios:

• Presence of significant valvular disease accompanying multivessel CAD 1
• Complex congenital heart disease requiring specialized management 1
• Mechanical complications of myocardial infarction (ventricular septal rupture, papillary muscle rupture) 1

Revascularization Strategy

The choice between PCI and CABG should be based on:

• Coronary anatomy: Left main disease or complex multivessel disease may favor CABG 2
• LV function: Patients with reduced LVEF and multivessel disease often benefit more from CABG 1
• Comorbidities: Age, frailty, and other medical conditions may influence the decision 1

Important Considerations

• Multivessel disease is present in approximately 50% of patients with acute coronary syndrome and is associated with higher risk of ischemic events and worse prognosis 2, 3
• Patients with multivessel disease and LV dysfunction on echo should be prioritized for early catheterization as they may derive survival benefit from CABG 1
• The GRACE risk score can help identify patients likely to benefit from early, aggressive therapy including coronary revascularization 1

Pitfalls to Avoid

• Don't delay catheterization in patients with multivessel disease and LV dysfunction, as early intervention may improve outcomes 1
• Don't assume all wall motion abnormalities represent infarction - they may also indicate ischemia, stunning, or hibernating myocardium 1
• Don't overlook valvular complications that may accompany multivessel disease, especially in the setting of myocardial infarction 1

By following this approach, you can ensure appropriate and timely management of patients with multivessel disease identified on echocardiogram, potentially improving morbidity, mortality, and quality of life outcomes.