What should be evaluated on a 2-dimensional (2D) echocardiogram (echo) in a patient presenting with chest pain?

Key Elements to Evaluate on 2D Echocardiography in Patients with Chest Pain

In patients with chest pain, a 2D echocardiogram should evaluate for regional wall motion abnormalities, ventricular function, valvular abnormalities, pericardial disease, and aortic pathology to identify the underlying cardiac cause. 1

Primary Assessment Components

Regional Wall Motion Abnormalities

• Evaluate for presence and extent of regional wall motion abnormalities, which may indicate myocardial ischemia, infarction, stunning, or hibernation 1
• Assessment of wall motion is particularly valuable when ECG and cardiac biomarkers are non-diagnostic 1
• Wall motion abnormalities have high sensitivity (93%) for detecting acute myocardial infarction 1
• Note that regional wall motion abnormalities may persist even after chest pain resolves due to myocardial stunning 1

Left Ventricular Function

• Assess left ventricular size, shape, and global systolic function 1
• Evaluate left ventricular diastolic function parameters 1
• Systolic dysfunction has been shown to be an independent prognostic variable for both short and long-term cardiac events 1

Right Ventricular Assessment

• Evaluate right ventricular size and function, particularly in patients with inferior myocardial infarction to assess for RV involvement 1
• Look for signs of right ventricular pressure or volume overload 1

Valvular Assessment

• Evaluate for acute valvular regurgitation, which may be a mechanical complication of myocardial ischemia 1
• Assess prosthetic valve function in patients with valvular heart disease 1

Pericardial Evaluation

• Look for pericardial effusion, which may indicate pericarditis or cardiac rupture 1
• Assess for signs of cardiac tamponade (right atrial collapse, right ventricular diastolic collapse, respiratory variations in mitral/tricuspid inflow) 1

Aortic Assessment

• Evaluate for signs of aortic dissection, particularly in patients with appropriate clinical presentation 1
• Transoesophageal echocardiography (TEE) is indicated when transthoracic studies are non-diagnostic for suspected aortic pathology 1

Mechanical Complications of Myocardial Infarction

• Assess for ventricular septal defect, free wall rupture, or papillary muscle rupture causing acute mitral regurgitation 1
• Look for intracardiac thrombi, which may form after myocardial infarction 1

Special Considerations

Takotsubo Cardiomyopathy

• Look for characteristic regional wall motion abnormalities that do not correspond to typical coronary artery distribution 1
• Most commonly presents as LV apical akinesia, but can also affect mid-cavity, base, or right ventricle 1

Myocarditis

• Evaluate for non-specific findings such as wall motion abnormalities, ventricular dysfunction, and pericardial involvement 1
• Consider advanced techniques like speckle tracking to detect subtle abnormalities in global longitudinal strain 1

Pulmonary Embolism

• Assess for right ventricular dilatation, dysfunction, and interventricular septal flattening 1
• Evaluate tricuspid regurgitation to estimate pulmonary artery pressure 1

Clinical Pitfalls and Caveats

• Wall motion abnormalities are not specific for ischemia and can occur in other conditions such as myocarditis, left bundle branch block, or paced rhythm 1
• Normal resting echocardiography cannot definitively rule out a transient episode of ischemia, especially if the chest pain was of short duration 1
• Echocardiography alone cannot distinguish between ischemia and infarction 1
• TEE should be considered when TTE is non-diagnostic, especially for suspected aortic dissection 1
• Interpretation of emergency echocardiography requires specific training and expertise 1

By systematically evaluating these elements on 2D echocardiography, clinicians can efficiently identify the underlying cardiac cause of chest pain, guide appropriate management, and improve patient outcomes.