Where to Send a Patient for Transthoracic Echocardiography (TTE)
Send the patient to the hospital's echocardiography laboratory or cardiology department where trained sonographers and interpreting physicians are available, with the specific location depending on clinical urgency—emergency department or bedside for acute presentations, and outpatient echocardiography lab for non-urgent evaluations. 1
Location Based on Clinical Urgency
Emergency/Acute Settings
Bedside TTE in the Emergency Department is the appropriate location for intermediate-risk patients with acute chest pain, as it serves as a rapid bedside test to establish baseline ventricular and valvular function, evaluate for wall motion abnormalities, and assess for pericardial effusion 1
Intensive Care Units (ICU) and Coronary Care Units (CCU) should have TTE routinely available and performed by trained physicians for patients with hemodynamic instability of suspected cardiac origin 1
Point-of-care echocardiography performed at the bedside by properly trained clinicians and technicians is particularly useful for rapid assessment during symptomatic episodes 1
Emergency room or chest pain unit settings should have TTE routinely available for all patients during hospitalization for suspected acute coronary syndromes 1
Non-Urgent/Outpatient Settings
Outpatient echocardiography laboratory within the hospital or cardiology department is appropriate for stable patients requiring diagnostic evaluation 1, 2
University hospital echocardiography laboratories or accredited imaging centers can perform scheduled TTEs with appropriate documentation of clinical indications 2
Key Considerations for Referral Location
Availability of Trained Personnel
The facility must have trained physicians capable of performing and interpreting TTE studies, as restriction to standard imaging planes only may miss important pathological findings, especially in emergency situations 1
Sonographers and echocardiographers should be able to obtain both standard and non-standard imaging techniques to avoid inaccurate reports 1
Equipment and Technology Requirements
Modern echocardiographic systems with high-resolution probes and harmonic imaging are essential for optimal diagnostic accuracy 3
Facilities should have capability for contrast echocardiography when endocardial visualization needs enhancement, particularly for assessment of global and regional systolic performance 1
Three-dimensional echocardiography capabilities may be beneficial, though currently have limited role in emergency settings 1
Clinical Context Determines Urgency
Immediate bedside TTE is indicated for: hemodynamic instability, suspected acute major cardiovascular events, respiratory failure with suspected cardiac etiology, and suspected acute pulmonary embolism requiring urgent therapy decisions 1, 4, 5
Same-day outpatient TTE is appropriate for: suspected heart failure with dyspnea, valvular heart disease with symptoms, abnormal cardiac examination findings, or new cardiac murmurs 1, 6
Scheduled outpatient TTE is suitable for: routine surveillance (e.g., Marfan syndrome annual imaging), follow-up of known conditions, or evaluation of stable symptoms 1
Common Pitfalls to Avoid
Do not delay TTE in acute settings by sending patients to off-site facilities when bedside capability exists—this is particularly critical for suspected acute aortic syndrome, acute valvular regurgitation, or hemodynamic instability 1
Avoid sending patients for TTE when clinical examination reveals stable vital signs, no murmurs, and no signs of heart failure without other compelling indications, as this may represent inappropriate utilization 6
Do not assume all facilities are equivalent—ensure the receiving location has adequate image quality capabilities, as studies with suboptimal imaging may require repeat testing or escalation to transesophageal echocardiography 3, 5
Consider relative contraindications to alternative testing (such as transesophageal echocardiography) when determining if TTE location has adequate capabilities, as 15% of shock cases may have contraindications to more invasive testing 5