When should a 2D (two-dimensional) echocardiogram be ordered for patients with suspected or known cardiovascular disease, particularly those with symptoms of heart failure, history of hypertension, diabetes, coronary artery disease, myocardial infarction, valvular heart disease, or cardiomyopathy?

When to Order 2D Echocardiography

Order a 2D echocardiogram with Doppler in any patient presenting with dyspnea, chest pain, new murmur, hemodynamic instability, or suspected heart failure when the cardiac etiology is uncertain or when you need to assess cardiac structure and function to guide management. 1

Emergency and Acute Presentations

Acute Dyspnea

• Order 2D echo immediately when distinguishing cardiac versus non-cardiac causes of dyspnea in patients where clinical and laboratory findings are ambiguous. 1
• Order to assess left ventricular size, shape, and global/regional function in suspected heart failure. 1
• Order to detect acute valvular regurgitation, prosthetic valve dysfunction, or complications of myocardial infarction including acute mitral regurgitation, ventricular septal defect, or right ventricular involvement. 1
• Do NOT order for dyspnea when non-cardiac etiology is clearly apparent or in patients with normal blood pressure and physical examination without clinical evidence of heart disease. 1

Chest Pain

• Order 2D echo when chest pain occurs with suspected acute myocardial ischemia and baseline ECG is nondiagnostic, particularly if the study can be obtained during pain or soon after. 1
• Order for chest pain with clinical evidence of valvular, pericardial, or primary myocardial disease. 1
• Order for suspected aortic dissection. 1
• Order for severe hemodynamic instability accompanying chest pain. 1
• Do NOT order when chest pain has confirmed non-cardiac etiology or when ECG changes are already diagnostic of myocardial ischemia/infarction. 1

Hemodynamic Instability and Shock

• Order 2D echo emergently for differential diagnosis of hypotension or shock to detect cardiac versus non-cardiac etiologies. 1
• Order for rapid identification of pericardial effusion, left or right ventricular dysfunction, and acute valvular dysfunction. 1
• Order for rapid assessment of intravascular volume status. 1

New Cardiac Murmur

• Order 2D echo in patients with cardiac murmurs accompanied by symptoms or signs of heart failure, myocardial ischemia/infarction, syncope, thromboembolism, infective endocarditis, or clinical evidence of structural heart disease. 1
• Order to detect valvular vegetations indicating infective endocarditis. 1

Suspected or Known Cardiovascular Disease

Heart Failure

• Order 2D echocardiography with Doppler as the definitive test in all patients with suspected cardiomyopathy or clinical diagnosis of heart failure to determine left ventricular ejection fraction, assess LV size, wall thickness, regional wall motion abnormalities, and evaluate valve function. 1, 2
• The American College of Cardiology emphasizes that echocardiography should not be delayed, as it is essential to confirm heart failure and guide therapy. 2
• Order to assess diastolic function using E/e' ratio and estimate pulmonary artery systolic pressure. 1
• Order to evaluate global longitudinal strain, which can detect subclinical dysfunction before ejection fraction declines. 1
• Do NOT order routine reevaluation in clinically stable patients where no change in management is contemplated. 1

Acute Coronary Syndrome and Myocardial Infarction

• Order 2D echo for diagnosis of suspected acute ischemia or infarction not evident by standard means. 1
• Order for measurement of baseline left ventricular function. 1
• Order in patients with inferior myocardial infarction and bedside evidence suggesting possible right ventricular infarction. 1
• Order for assessment of mechanical complications including acute mitral regurgitation, ventricular septal defect, free-wall rupture, or mural thrombus. 1

Valvular Heart Disease

• Order 2D echocardiography with Doppler (not 2D echo alone) as the standard diagnostic test for all suspected valvular disease to provide hemodynamic measurements including pressure gradients, intracardiac pressures, and severity grading. 3
• Doppler is essential because it provides direct hemodynamic data that cannot be obtained from 2D imaging alone, including peak flow velocity for stenosis grading and regurgitant flow assessment. 3
• Order to define the primary lesion, judge its severity, detect coexisting abnormalities, evaluate cardiac function, and establish a reference point for future observations. 1

Pericardial Disease

• Order 2D echo in patients with suspected pericardial disease including effusion, constriction, or effusive-constrictive process. 1
• Order for suspected bleeding in the pericardial space from trauma or perforation. 1
• Order for detection of echocardiographic signs of tamponade, including right atrial collapse and diastolic right ventricular collapse. 1
• Order for echocardiographic guidance and monitoring of pericardiocentesis. 1

Pulmonary Hypertension

• Order 2D echocardiography with Doppler as the noninvasive screening test in all patients with clinical suspicion of pulmonary hypertension, per American Thoracic Society recommendations. 3
• Continuous-wave Doppler measurement of peak tricuspid regurgitation velocity estimates right ventricular systolic pressure with sensitivity of 79-100% and specificity of 68-98% for moderate disease. 3

Hypertension and Diabetes

• Order 2D echo in hypertensive patients to calculate left ventricular mass index, which is a recognized prognostic factor. 1
• Order to assess for left ventricular hypertrophy (concentric versus eccentric), calculate relative wall thickness, and evaluate diastolic function. 1
• Order in diabetic patients to detect early subclinical changes in systolic function using global longitudinal strain. 1

Cardiomyopathy

• Order 2D echo to measure wall thickness, cavity diameters, volumes, ejection fraction, and calculate left ventricular mass. 1
• Order to assess global longitudinal strain for incremental value over conventional methods and to detect regional patterns that suggest specific etiologies. 1
• Order to describe myocardial appearance (sparkling, hyper-trabeculation) to differentiate various cardiomyopathies. 1

Congenital Heart Disease in Adults

• Order 2D echo as the initial imaging modality, recognizing that it may be limited by poor acoustic windows, narrow intercostal spaces, obesity, or emphysema in adults. 1
• Order for periodic surveillance in virtually all congenital heart disease patients except those with repaired patent ductus arteriosus and select repaired atrial septal defects. 4
• Consider transesophageal echocardiography when transthoracic echo is non-diagnostic, as TEE provides new or altered diagnosis in 14% and new information in 56% of adult congenital heart disease patients. 1, 4

Cardiac Trauma

• Order 2D echo for detection of pericardial effusion, myocardial contusion or laceration, regional wall motion abnormalities, acute valvular regurgitation, and aortic dissection in patients with severe deceleration injury or chest trauma. 1
• Do NOT order for routine evaluation in mild chest trauma with no electrocardiographic changes or biomarker elevation. 1

Common Pitfalls to Avoid

• Always order echocardiography WITH Doppler for valvular disease, heart failure, or pulmonary hypertension—never order 2D echo alone, as Doppler provides essential hemodynamic data. 3
• Peak velocities must be obtained from multiple acoustic windows (apical, right parasternal, suprasternal, subcostal) to avoid underestimation from beam misalignment. 3
• Do not assume a normal 2D echo means no follow-up is needed in congenital heart disease patients, as periodic surveillance is indicated for virtually all patients. 4
• Recognize that 2D echo has technical limitations in adults with poor acoustic windows, and consider transesophageal echocardiography or cardiac MRI when initial studies are non-diagnostic. 1, 4
• Do not order routine reevaluation in uncomplicated endocarditis during antibiotic therapy or in clinically stable heart failure patients when no management change is contemplated. 1