When should an echocardiogram be ordered in patients with symptoms such as chest pain, shortness of breath, or palpitations, and a history of hypertension (High Blood Pressure), diabetes, or previous heart conditions?

Indications to Order an Echocardiogram

Order an echocardiogram when patients present with chest pain, shortness of breath, or palpitations AND have clinical findings suggesting cardiac disease—but not as a screening test in asymptomatic patients or those with clearly non-cardiac symptoms. 1

Appropriate Indications for Echocardiography

Chest Pain Scenarios

Order echocardiography for chest pain in these specific situations:

• Chest pain with non-diagnostic ECG and cardiac biomarkers, especially when the study can be performed during active pain or shortly after its resolution 1
• Chest pain with clinical evidence of valvular or pericardial disease on physical examination (Class I indication) 1
• Hemodynamically unstable patients with chest pain unresponsive to simple therapeutic measures 1
• Suspected acute aortic syndromes, myocarditis, pericarditis, or pulmonary embolism based on clinical presentation 1
• Known or suspected coronary artery disease (Class II indication) 1

Do NOT order echocardiography for:

• Chest pain with confirmed myocardial infarction already evident by standard means (ECG/biomarkers) 1
• Clearly non-cardiac chest pain 1

Shortness of Breath (Dyspnea) Scenarios

Order echocardiography for dyspnea when:

• Clinical findings suggest significant coronary, valvular, or hypertensive heart disease 1
• Distinguishing cardiac versus non-cardiac etiology when clinical and laboratory findings are ambiguous 1
• Suspected heart failure requiring assessment of left ventricular size, shape, and function 1
• Detection of acute valvular regurgitation or prosthetic valve dysfunction 1
• Suspected complications of myocardial infarction including acute mitral regurgitation, ventricular septal defect, or right ventricular involvement 1

Do NOT order echocardiography for:

• Dyspnea without clinical evidence of heart disease, pulmonary hypertension, or significant lung disease (Class III indication) 1
• Patients with normal blood pressure and normal physical examination 1
• Hyperventilation syndrome 1

Palpitations and Arrhythmias

Order echocardiography for:

• Sustained or non-sustained atrial fibrillation, supraventricular tachycardia, or ventricular tachycardia 1
• Frequent ventricular premature contractions or exercise-induced ventricular premature contractions 1

Do NOT order echocardiography for:

• Infrequent atrial or ventricular premature contractions without other evidence of heart disease 1
• Asymptomatic isolated sinus bradycardia 1

Risk Factor Considerations (Hypertension, Diabetes, Previous Heart Disease)

Hypertension

Order echocardiography in hypertensive patients when:

• Symptoms are present (chest pain, dyspnea) suggesting cardiac involvement 1
• Clinical findings suggest left ventricular hypertrophy or diastolic dysfunction 1
• The study can detect and quantify left ventricular hypertrophy, which is comparable to cardiac catheterization for assessing severity 1

Important caveat: Hypertension alone without symptoms or abnormal physical examination does NOT justify echocardiography 1

Diabetes

Diabetes itself is not an indication for echocardiography unless accompanied by symptoms or clinical findings suggesting cardiac disease 1

Previous Heart Conditions

Order echocardiography when:

• Symptoms develop in patients with known underlying cardiac disease (valvular, pericardial, or primary myocardial disease) 1
• Clinical status changes in patients with known coronary artery disease 1

Do NOT order echocardiography for:

• Routine surveillance of ventricular function with known coronary artery disease and no change in clinical status or cardiac exam 1
• Patients with prior normal ventricular function and no change in clinical status or cardiac exam 1

Additional Appropriate Indications

Order echocardiography for:

• Syncope even without other cardiovascular symptoms (appropriate use score 7) 1
• Suspected pulmonary hypertension including evaluation of right ventricular function and estimated pulmonary artery pressure 1
• Prior testing concerning for heart disease including abnormal chest X-ray, ECG, or cardiac biomarkers 1

Do NOT order echocardiography for:

• Lightheadedness/presyncope without other symptoms or signs of cardiovascular disease 1
• Initial evaluation of ventricular function as screening with no symptoms or signs of cardiovascular disease 1
• Routine perioperative evaluation with no symptoms or signs of cardiovascular disease 1

Clinical Algorithm

Step 1: Assess for symptoms (chest pain, dyspnea, palpitations, syncope) 1

Step 2: Perform thorough cardiovascular examination looking for:

• Abnormal heart sounds suggesting valvular disease 1
• Signs of heart failure 1
• Elevated blood pressure with end-organ manifestations 1

Step 3: Obtain ECG and consider cardiac biomarkers 1

Step 4: Order echocardiography if:

• Symptoms present WITH abnormal examination findings 1
• Non-diagnostic ECG/biomarkers in acute chest pain 1
• Hemodynamic instability 1
• Suspected specific cardiac conditions (aortic dissection, pulmonary embolism, myocarditis) 1

Step 5: Do NOT order if symptoms absent or clearly non-cardiac etiology established 1