Should a transthoracic echocardiogram be performed in a patient scheduled for cardiac catheterisation if a recent comprehensive echo is not available?

Should an Echo Be Done if the Patient Is Already Getting a Heart Cath?

Yes, a transthoracic echocardiogram should be performed in addition to cardiac catheterization when a recent comprehensive echo is not available, because catheterization and echocardiography provide complementary—not redundant—information that both impact clinical decision-making and patient outcomes.

Why Both Tests Are Necessary

Cardiac catheterization and echocardiography evaluate fundamentally different aspects of cardiac pathology. 1

• Catheterization primarily assesses:

  • Coronary artery anatomy and stenosis severity 1
  • Hemodynamic pressures (right heart catheterization) 1
  • Invasive measurements of cardiac output 1

• Echocardiography uniquely provides:

  • Left ventricular ejection fraction and regional wall motion 1
  • Comprehensive valvular structure and function 1
  • Detection of mechanical complications (ventricular septal defect, papillary muscle rupture, free wall rupture) 1
  • Pericardial effusion and tamponade 1
  • Left ventricular thrombus 1
  • Right ventricular function 1

Evidence-Based Rationale

In Acute Coronary Syndrome

The 2025 ACC/AHA guidelines give a Class I recommendation (strongest level) that assessment of LVEF is mandatory prior to hospital discharge in all ACS patients to guide therapy and risk stratification. 1

• Transthoracic echocardiography is the preferred modality because it provides comprehensive assessment of ventricular function, valvular function, and can detect mechanical complications 1
• Left ventriculography during catheterization provides incomplete information and cannot adequately assess valvular function or wall motion abnormalities 1
• If LVEF is reduced, repeat echocardiography at 6-12 weeks is required to guide ICD decision-making 1

In Suspected Pulmonary Hypertension

The ACR Appropriateness Criteria assign both right heart catheterization and transthoracic echocardiography a rating of 9 (usually appropriate), explicitly stating that both should be performed and are complementary examinations. 1

• Echocardiography is typically performed before catheterization 1
• Each modality provides distinct diagnostic information that cannot be obtained from the other 1

Following Percutaneous Coronary Intervention

There is no evidence supporting routine TTE following uncomplicated percutaneous revascularization in stable patients. 1

• However, TTE should be performed if:
  • Suspected peri-procedural myocardial infarction 1
  • Coronary dissection or guidewire perforation 1
  • Any change in clinical status 1
  • Baseline assessment prior to discharge after surgical revascularization 1

Clinical Decision Algorithm

Step 1: Determine Clinical Context

• If ACS/MI: TTE is mandatory regardless of catheterization plans 1
• If suspected pulmonary hypertension: Both TTE and catheterization are required 1
• If stable angina undergoing elective PCI: TTE only if no recent comprehensive study available 1

Step 2: Timing Considerations

• Pre-catheterization TTE is preferred to establish baseline ventricular function and detect unsuspected valvular disease 1
• Post-catheterization TTE is required if complications are suspected or if baseline study was not obtained 1

Step 3: Assess for High-Risk Features Requiring TTE

• New or worsening heart failure symptoms 1
• New cardiac murmur 1
• Hemodynamic instability 2, 3
• Suspected mechanical complications 1
• Need for risk stratification prior to discharge 1

Critical Pitfalls to Avoid

Do not assume that left ventriculography during catheterization substitutes for comprehensive echocardiography. Ventriculography cannot adequately assess:

• Valvular structure and severity of regurgitation 1
• Diastolic function 1
• Right ventricular function 1
• Pericardial disease 1

Do not delay echocardiography beyond 48 hours in acute MI, as this may miss early mechanical complications that require urgent surgical intervention 2

Do not rely solely on transthoracic imaging in prosthetic valve patients or suspected endocarditis—transesophageal echocardiography is significantly more sensitive and may be required 1, 4, 5

When Catheterization Alone May Be Sufficient

In highly selected cases of stable patients undergoing elective diagnostic catheterization who have:

• Recent (within 6-12 months) comprehensive TTE showing normal LV function 1
• No interval change in clinical status 1
• No new symptoms or examination findings 2, 3
• Uncomplicated procedural course 1

Even in these cases, a baseline TTE prior to discharge is reasonable to document post-procedure status and establish a new baseline for future comparison 1