When to repeat 2D (two-dimensional) echocardiography in a patient with preserved ejection fraction (EF)?

When to Repeat 2D Echocardiography in Patients with Preserved Ejection Fraction

Repeat echocardiography in patients with preserved EF should be performed when there is a significant change in clinical status, after treatment that may affect cardiac function, or when considering device therapy—but routine serial imaging without clinical indication is not recommended. 1

Clinical Indications for Repeat Imaging

Mandatory Indications (Class I)

• Significant change in clinical status warrants repeat echocardiography, including new or worsening symptoms of heart failure (dyspnea, orthopnea, edema, reduced exercise tolerance) 1
• After treatment interventions that may have significantly affected cardiac function, such as initiation of guideline-directed medical therapy, revascularization procedures, or valve interventions 1
• Consideration for cardiac device therapy (pacemaker, ICD, or CRT) requires updated assessment of ventricular function 1
• Recovery from a clinical event such as myocardial infarction, acute decompensated heart failure, or arrhythmia necessitates repeat evaluation 1

Surveillance Intervals for Specific Conditions

For valvular heart disease with preserved EF, structured surveillance intervals apply 1:

• Mild aortic regurgitation (progressive): Every 3-5 years 1
• Moderate aortic regurgitation: Every 1-2 years 1
• Severe asymptomatic aortic regurgitation: Every 6-12 months 1
• If significant fall in EF or increase in LV size observed: Repeat at 3-6 month intervals unless clinical deterioration occurs 1

For hypertrophic cardiomyopathy screening in asymptomatic first-degree relatives 1:

• Adults: Every 3-5 years after initial screening 1
• Children and adolescents from high-risk families: Every 1-2 years 1
• Other children and adolescents: Every 2-3 years 1

What NOT to Do

Routine repeat measurement of LV function in the absence of clinical status change or treatment interventions should NOT be performed (Class III: No Benefit). 1 This represents a strong recommendation against serial imaging without clinical indication, as it does not improve outcomes and increases healthcare costs 1.

Special Considerations for HFpEF Patients

When Preserved EF Masks Underlying Dysfunction

Even with normal ejection fraction (≥50%), patients may have significant cardiac dysfunction requiring closer monitoring 2, 3:

• Reduced tissue Doppler velocities (septal E' <8 cm/s or lateral E' <10 cm/s) indicate diastolic dysfunction and warrant cardiology referral 2
• Elevated E/E' ratio >15 suggests high left ventricular filling pressures despite preserved EF 2, 3
• Left atrial enlargement (LA volume index ≥34 mL/m²) is a highly sensitive marker of chronic diastolic dysfunction requiring follow-up 2, 3
• Impaired global longitudinal strain (GLS values <-16%) indicates early systolic dysfunction even with normal EF 2, 4

Red Flags Requiring Urgent Re-evaluation

• New heart failure symptoms (dyspnea, orthopnea, edema) despite previously preserved EF 2, 3
• Significant changes in functional capacity measured by exercise tolerance or cardiopulmonary testing 2
• Elevated natriuretic peptides (BNP/NT-proBNP) suggesting decompensation 2, 3

Practical Algorithm for Decision-Making

1. Assess clinical status: Has there been any change in symptoms, functional capacity, or clinical events since last echo? 1

   • If YES → Repeat echo
   • If NO → Proceed to step 2

2. Review treatment interventions: Has the patient received any therapy that could affect cardiac function? 1

   • If YES → Repeat echo
   • If NO → Proceed to step 3

3. Evaluate for device therapy candidacy: Is the patient being considered for pacemaker, ICD, or CRT? 1

   • If YES → Repeat echo
   • If NO → Proceed to step 4

4. Check for specific disease surveillance needs: Does the patient have valvular disease or HCM requiring scheduled surveillance? 1

   • If YES → Follow disease-specific intervals
   • If NO → Do NOT repeat echo routinely 1

Common Pitfalls to Avoid

• Do not assume higher EF always means better function: EF is load-dependent and cannot distinguish between preload, afterload, and intrinsic contractility 4
• Do not rely on single EF measurement for borderline values (41-49%): Serial measurements using the same equipment and methodology are recommended 4
• Do not ignore diastolic parameters: Assess left atrial size and diastolic function if heart failure symptoms are present, as diastolic dysfunction can coexist with preserved systolic function 4, 3
• Do not order routine surveillance imaging: This provides no benefit and is explicitly discouraged by guidelines 1

Additional Testing When Dysfunction is Suspected

When preserved EF appears discordant with clinical presentation 2, 4:

• Global longitudinal strain (GLS) detects subclinical LV dysfunction before EF impairment 2, 4
• Natriuretic peptides (BNP/NT-proBNP) support diagnosis of HFpEF 2, 3
• Cardiac MRI provides tissue characterization to detect fibrosis, infiltration, or hypertrophy 2