In an adult presenting with chest pain, when is a two‑dimensional transthoracic echocardiogram indicated?

2D Echocardiography in Chest Pain: Clinical Indications

2D transthoracic echocardiography (TTE) is indicated in chest pain when there is suspected acute coronary syndrome with non-diagnostic ECG, clinical suspicion of structural heart disease (murmur, abnormal exam), suspected acute pericarditis, suspected aortic dissection, or when risk stratification is needed for prognostic assessment. 1

Acute Coronary Syndrome (ACS)

In patients with non-ST elevation ACS, TTE is essential for both diagnosis and risk stratification, as the presence of left ventricular systolic dysfunction independently predicts both short- and long-term cardiac events. 1 The European Heart Journal guidelines emphasize that TTE should be part of the comprehensive management approach alongside clinical parameters, ECG, biomarkers (high sensitivity troponin), and GRACE score assessment. 1

Key diagnostic capabilities in ACS:

• Regional wall motion abnormalities appear within seconds of coronary occlusion, well before necrosis develops, making TTE highly sensitive (93%) for detecting acute myocardial infarction. 1
• Wall motion abnormalities persist after symptom resolution due to myocardial stunning, so the echocardiogram does not need to be performed during active chest pain. 1
• A normal TTE effectively excludes major myocardial infarction and identifies low-risk patients who are unlikely to develop complications during hospitalization. 2

Critical timing consideration:

Do not delay reperfusion therapy in ST-elevation MI while waiting for echocardiography—initiate treatment immediately based on ECG findings. 1, 3 TTE should complement, not replace, urgent reperfusion strategies.

Chronic Stable Angina

In patients with confirmed chronic stable angina, TTE quantifies global LV function, which is an important prognostic parameter. 1 Regional wall motion abnormalities may provide evidence supporting a diagnosis of coronary artery disease even when overall LV function appears normal. 1

Advanced techniques including tissue Doppler, myocardial deformation imaging (global longitudinal strain), and diastolic function assessment are useful for detecting early myocardial dysfunction in those with preserved LV ejection fraction as an explanation for exercise-induced symptoms. 1

Acute Pericarditis

TTE is recommended in all patients in whom acute pericarditis is suspected. 1 The primary aims are:

• Identify pericardial effusion
• Exclude ventricular dysfunction due to myocardial involvement
• The presence of large pericardial effusion (>20 mm) is one of the major risk factors for poor prognosis and requires close monitoring. 1

Valvular Heart Disease

TTE is mandated in any patient presenting with chest pain during exercise who has a murmur or clinical evaluation consistent with aortic stenosis. 1 The development of chest pain during exercise in severe aortic stenosis (even without coronary artery disease) is a clear indication for intervention.

Acute Aortic Syndromes

While CT is the recommended first-line imaging modality for suspected aortic syndromes in the non-emergent setting, TTE may be used in the emergency room, particularly for assessment of the proximal ascending aorta. 1 In stable patients, TTE complements CT by providing information on:

• Presence, severity, and mechanism of aortic regurgitation
• Pericardial effusion
• Left ventricular function

Risk Stratification and Prognostic Value

The presence of regional wall motion abnormalities on initial 2D echo identifies a high-risk group likely to have AMI and important cardiac complications, who may benefit from intensive care unit admission. 2 Research demonstrates that early 2D echocardiography provides superior prognostic information compared to history, ECG, and troponin alone for predicting subsequent complications in patients with acute chest pain and non-diagnostic ECG. 4

Patients with initial 2D echo showing no regional wall motion abnormality are unlikely to develop AMI or clinical complications during hospitalization, suggesting safe discharge may be appropriate after excluding other causes. 2

When TTE is NOT Routinely Indicated

TTE is not indicated for chest pain when:

• The diagnosis of non-cardiac chest pain is clear (musculoskeletal, gastrointestinal)
• There is no clinical suspicion of structural heart disease on examination or 12-lead ECG
• The patient has low cardiovascular risk and normal ECG/biomarkers without concerning features 1

Enhanced Diagnostic Techniques

Contrast echocardiography should be used (Class I, Level A recommendation) when two or more contiguous LV segments are inadequately visualized, as this significantly improves accuracy for detecting wall motion abnormalities and has incremental prognostic value. 3

Global longitudinal strain measurement by speckle-tracking provides superior prognostic information compared to LVEF alone, with values worse than -15% suggesting underlying myocardial disease. 3

Common Pitfalls to Avoid

• Do not assume diffuse hypokinesis excludes significant coronary artery disease—50% of dilated cardiomyopathy patients with diffuse hypokinesis have CAD. 3
• Do not overlook diastolic dysfunction assessment, as it often precedes systolic dysfunction and causes symptoms despite preserved ejection fraction. 3
• Do not delay urgent interventions while waiting for echocardiography in clear ST-elevation MI or hemodynamically unstable patients. 1, 3