Is an echocardiogram (ECHO) necessary for a hemodynamically stable patient with a newly diagnosed pulmonary embolism (PE) and right heart strain on computed tomography (CT), who has distal emboli not amenable to thrombectomy?

Is an ECHO Necessary in This Clinical Scenario?

No, an echocardiogram is not necessary for diagnosis in this hemodynamically stable patient with PE and right heart strain already identified on CT. However, an ECHO should be strongly considered for prognostic risk stratification to guide treatment intensity.

Diagnostic Role: ECHO Not Recommended

Systematic use of echocardiography for diagnosis in hemodynamically stable, normotensive patients is not recommended (Class III recommendation, Level C evidence). 1

The European Society of Cardiology is clear on this point:

• ECHO has limited sensitivity (60-70%) for detecting PE and a negative study does not exclude PE 1
• The diagnosis is already confirmed by CT imaging showing pulmonary emboli 1
• ECHO does not play a major role in detecting suspected non-high-risk PE 1, 2
• Most clinicians require direct evidence of clot (which you already have from CT) before committing to anticoagulation 1

Prognostic Role: ECHO Should Be Considered

Despite not being needed for diagnosis, ECHO is valuable for risk stratification in confirmed non-high-risk PE to identify patients at intermediate risk. 2

Why Risk Stratification Matters in Your Patient

Your patient has right heart strain on CT, which places them in a higher-risk category. ECHO can provide additional prognostic information:

• Echocardiographic RV dysfunction occurs in ≥25% of PE patients and is associated with more than 2-fold increased PE-related mortality 1, 2
• In normotensive patients with PE, RV dysfunction increases early PE-related mortality by 4-5% absolute risk 1
• Patients with normal echocardiographic findings have excellent outcomes with in-hospital PE-related mortality <1% 1

Key Prognostic Parameters to Assess

If ECHO is performed, focus on these validated markers:

• RV/LV diameter ratio ≥1.0 indicates worse prognosis 2
• Tricuspid annular plane systolic excursion (TAPSE) <16 mm predicts adverse outcomes 2
• Presence of right heart thrombi (found in 4-18% of PE patients) is associated with high early mortality 2
• Patent foramen ovale with right-to-left shunt increases mortality risk 2, 3

Clinical Algorithm for Your Patient

Step 1: Diagnosis is already established by CT—no ECHO needed for this purpose 1

Step 2: Assess clinical stability:

• Your patient is hemodynamically stable ✓
• No shock or hypotension ✓

Step 3: Risk stratification decision:

• CT shows right heart strain → intermediate-risk PE
• Consider ECHO to further refine risk and guide treatment intensity 2
• ECHO findings of severe RV dysfunction may prompt consideration of escalated therapy (closer monitoring, possible catheter-directed therapy) 4, 3

Step 4: Treatment implications:

• If ECHO shows severe RV dysfunction: Consider ICU-level monitoring, possible advanced therapies 3
• If ECHO shows mild or no RV dysfunction despite CT findings: Standard anticoagulation with ward-level monitoring may suffice 1
• Serial ECHO can monitor treatment response if initial RV dysfunction is present 3

Important Caveats

• CT and ECHO may disagree on RV strain: CT is highly sensitive (88%) but only moderately specific (39%) for RV strain compared to ECHO 5
• RV strain on both CT and ECHO predicts worse outcomes (30% event rate) than either modality alone 5
• ECHO adds positive prognostic value beyond CT alone in predicting clinical deterioration 5
• The positive predictive value of echocardiographic RV dysfunction for PE-related death is <10% in hemodynamically stable patients, so findings must be interpreted in clinical context 2

Bottom Line

While not necessary for diagnosis, obtaining an ECHO in your patient is reasonable and potentially beneficial for risk stratification given the CT evidence of right heart strain. This additional information can guide decisions about monitoring intensity and potential escalation of therapy beyond standard anticoagulation. 2, 3, 5