How soon after a myocardial infarction (MI) should an echocardiogram (echo) be checked?

Timing of Echocardiography After Myocardial Infarction

Echocardiography should be performed within 24-48 hours after a myocardial infarction to assess left ventricular function, detect mechanical complications, and guide further management. 1

Initial Echocardiographic Assessment

• Transthoracic echocardiography (TTE) should be performed within the first 24-48 hours after MI to establish baseline left ventricular function, which is one of the strongest predictors of survival in STEMI patients 1
• Early echocardiography helps identify:
  • Wall motion abnormalities and extent of myocardial damage 2
  • Left ventricular ejection fraction (LVEF) 1
  • Mechanical complications (ventricular septal defect, mitral regurgitation, free wall rupture) 1
  • Presence of mural thrombus 1

Specific Timing Recommendations

• For uncomplicated MI cases: Perform echocardiography on day 2 or 3 of hospitalization 1
• For patients with clinical high-risk features (heart failure, shock, new murmur): Perform echocardiography immediately upon presentation 1
• For patients undergoing primary PCI: Echocardiography should be performed within 24-48 hours after the procedure 1

Follow-up Echocardiography

• In patients with initially reduced LVEF who may be candidates for ICD therapy, a follow-up echocardiogram should be performed ≥40 days after discharge to reassess LV function 1
• This follow-up is critical because of the dynamic nature of LV functional recovery after STEMI 1

Special Considerations

• Stress echocardiography may be considered before discharge in selected patients to:

  • Evaluate residual myocardial viability and ischemia 1
  • Guide post-discharge exercise prescription 1
  • Assess the functional significance of non-infarct artery stenosis 1

• For patients who have undergone successful PCI of the infarct artery with an uncomplicated course but have non-infarct artery disease, stress imaging within 3-6 weeks after discharge is reasonable 1

Prognostic Value of Echocardiography

• Standard echocardiographic parameters that provide important prognostic information include:

  • Left ventricular ejection fraction 2
  • Wall motion score index 2
  • Diastolic measurements (E velocity deceleration time and E/e' ratio) 2

• Advanced echocardiographic parameters that provide additional prognostic value:

  • Speckle-tracking-derived longitudinal strain 2
  • Coronary flow velocity reserve 2
  • Myocardial contrast echocardiography (contrast defect index) 3

Common Pitfalls to Avoid

• Delaying echocardiography beyond 48 hours may miss early mechanical complications 1
• Relying solely on initial echocardiography without follow-up assessment (especially in patients with LV dysfunction) 1
• Failing to consider that ECG evidence of septal infarction does not always correlate with echocardiographic abnormalities 4

Algorithm for Echocardiographic Assessment After MI

1. Initial assessment (within 24-48 hours):

   • Evaluate LVEF, wall motion abnormalities, and mechanical complications 1
   • Assess for mural thrombus 1

2. Before discharge:

   • Reassess LV function if initial assessment showed abnormalities 1
   • Consider stress echocardiography for selected patients 1

3. Post-discharge follow-up:

   • Reassess LVEF at ≥40 days in patients with initially reduced LVEF 1
   • Consider stress imaging at 3-6 weeks for patients with non-infarct artery disease who underwent successful PCI 1