When should a 2‑dimensional transthoracic echocardiogram be ordered in an older adult with known cardiovascular disease who presents with new or worsening dyspnea, murmur, chest pain, syncope, or suspected endocarditis?

When to Order 2D Transthoracic Echocardiography in Older Adults with Known Cardiovascular Disease

Order 2D transthoracic echocardiography immediately in any older adult with known cardiovascular disease who presents with new or worsening dyspnea, new murmur, chest pain with suspected structural etiology, syncope with clinical suspicion of cardiac cause, or any clinical suspicion of endocarditis. 1

Emergency Indications Requiring Immediate TTE

New or Worsening Dyspnea

• Immediate TTE is mandatory when severe dyspnea suggests acute heart failure, valvular decompensation, or hemodynamic instability, as early imaging separates cardiogenic shock from respiratory failure and directs urgent treatment. 1
• TTE identifies acute heart failure with or without preserved ejection fraction, acute valvular regurgitation, pulmonary arterial disease, pericardial disease, and complications of acute myocardial infarction. 1
• Focus assessment on left ventricular size and function, right ventricular size and function, valvular function, and pericardium. 1

New or Changed Murmur

• TTE is mandated in any patient with a new murmur or change in existing murmur, particularly when accompanied by dyspnea or chest pain, to assess for acute valvular regurgitation, stenosis progression, or endocarditis. 1
• Acute valvular regurgitation represents a life-threatening structural abnormality requiring immediate echocardiographic confirmation. 1

Chest Pain

• Order TTE immediately when chest pain is accompanied by non-diagnostic ECG, clinical suspicion of structural heart disease (murmur, abnormal physical exam), suspected acute pericarditis, or suspected aortic dissection. 2
• In non-ST-elevation acute coronary syndrome, TTE is essential for diagnosis and risk stratification; left ventricular systolic dysfunction independently predicts both short- and long-term cardiac events. 2
• Regional wall-motion abnormalities appear within seconds of coronary occlusion and persist after symptom resolution due to myocardial stunning, so the echocardiogram does not need to be performed during active chest pain. 2
• Critical caveat: Reperfusion therapy for ST-elevation MI must not be delayed while awaiting echocardiography; treatment should be initiated immediately based on ECG findings. 2

Syncope

• TTE is required to rule out structural cardiac disease when there is clinical suspicion on examination or following 12-lead ECG abnormalities. 1
• A normal TTE is an important finding that helps direct diagnosis and management by excluding structural causes such as aortic stenosis, hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, and pulmonary hypertension. 1
• In the presence of impaired left ventricular function on TTE, additional tests to evaluate cardiac causes for syncope should be performed. 1

Suspected Endocarditis

• TTE is recommended in all patients in whom infective endocarditis is suspected as the initial imaging modality. 1
• Repeat TTE is indicated following a negative study when clinical suspicion remains high, or with any change in clinical status in proven endocarditis. 1
• Focus assessment on valve morphology, vegetations, hemodynamic consequences including left and right ventricular size and function, aorta, and pericardium. 1

Non-Emergency Indications in Known Cardiovascular Disease

Change in Heart Failure Status

• Order TTE when there is any change in heart failure status to guide prognosis and therapeutic decisions, including selection for device therapy, pharmacotherapy, and transplant. 1
• TTE quantifies left ventricular ejection fraction <35% and acts as a gatekeeper for appropriate implantable cardioverter-defibrillator and cardiac resynchronization device implantation. 1

Progression of Valvular Disease

• Asymptomatic patients with severe aortic regurgitation require TTE every 6 months to detect left ventricular ejection fraction <50% or left ventricular enlargement (end-diastolic dimension >70 mm; end-systolic dimension >50 mm), which determine poor survival after valve replacement. 1
• Asymptomatic patients with severe aortic stenosis require TTE every 6 months to detect left ventricular ejection fraction <50%, velocity >5.5 m/s, or progression in peak velocity >0.3 m/s/year. 1
• Patients with mild or moderate valvular disease require re-evaluation yearly, with intervals extended to 2-3 years in those without significant calcification. 1

Chronic Stable Angina with Clinical Change

• There is no indication for routine TTE in patients with stable coronary artery disease in the absence of a change in clinical status. 1
• Sudden deterioration with recurrence of chest pain or other evidence of clinical compromise should trigger re-evaluation. 1
• TTE quantifies global left ventricular function, which is an important prognostic parameter, and detects regional wall-motion abnormalities that provide evidence of coronary artery disease. 1, 2

Situations Where TTE Is NOT Routinely Indicated

• When the diagnosis of non-cardiac chest pain is clear (musculoskeletal, gastrointestinal). 2
• When there is no clinical suspicion of structural heart disease on physical examination or 12-lead ECG. 2
• Routine screening in asymptomatic older adults without specific clinical indication. 1
• Stable known cardiovascular disease without change in clinical status. 1

Key Assessment Focus Areas

• Left ventricular assessment: Size, wall thickness, systolic and diastolic function, regional wall motion abnormalities. 1
• Right ventricular assessment: Size, function, and estimation of pulmonary artery pressure. 1
• Valvular assessment: Morphology, stenosis severity, regurgitation severity, and hemodynamic consequences. 1
• Pericardial assessment: Effusion presence and size (>20 mm indicates high risk), tamponade physiology. 1, 2
• Aortic assessment: Proximal ascending aorta for dissection or aneurysm. 1

Common Pitfalls to Avoid

• Do not delay urgent interventions (reperfusion therapy, hemodynamic support) while awaiting echocardiography in ST-elevation MI or hemodynamically unstable patients. 2
• Do not assume preserved ejection fraction excludes significant cardiac pathology; diastolic dysfunction, valvular disease, and pulmonary hypertension can occur with normal systolic function. 3
• Recognize that TTE has limitations in adults due to acoustic windows, body habitus, and lung disease; consider transesophageal echocardiography when transthoracic windows are inadequate. 1
• Be aware of ultrasound artifacts that can mimic pathology such as aortic dissection, thrombus, or vegetations. 4