Download Clinical Application of Echocardiography

ACC/AHA Pocket Guideline
Based on the ACC/AHA/ASE
2003 Guideline Update
Clinical
Application of
Echocardiography
March 2004
1
Clinical
Application of
Echocardiography
Special thanks to
March 2004
Writing Committee
Melvin D. Cheitlin, MD, MACC, Chair
Distributed through
support from
Bristol-Myers Squibb
Medical Imaging.
Bristol-Myers Squibb
Medical Imaging was not
involved in the development
of this publication and in
no way influenced
its contents.
William F. Armstrong, MD, FACC, FAHA
Gerard P. Aurigemma, MD, FACC, FAHA
George A. Beller, MD, FACC, FAHA
Fredrick Z. Bierman, MD, FACC
Jack L. Davis, MD, FACC
Pamela S. Douglas, MD, FACC, FAHA, FASE
David P. Faxon, MD, FACC, FAHA
Linda D. Gillam, MD, FACC, FAHA, FASE
Thomas R. Kimball, MD, FACC
William G. Kussmaul, MD, FACC
Alan S. Pearlman, MD, FACC, FAHA, FASE
John T. Philbrick, MD, FACP
Harry Rakowski, MD, FACC, FASE
Daniel M. Thys, MD, FACC, FAHA
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
A. Hierarchical Levels of Echocardiography Assessment . . . . . . . . . . . . . . . 4
Introduction
I.
© 2004 American College
of Cardiology Foundation and
American Heart Association, Inc.
II. Murmurs and Valvular Heart Disease
The following article was adapted from the
A. Recommendations for Echocardiography
.......................8
the Clinical Application of Echocardiography
B.
Recommendations for Echocardiography in Valvular Stenosis. . . . . . . . 10
(Journal of the American College of Cardiology
C.
Recommendations for
2003;42:954-70; Circulation 2003;108:114662; and Journal of the American Society of
Echocardiography 2003;16:1091-110). For a
copy of the full report or published summary
article, visit our Web sites at www.acc.org,
Echocardiography in Native Valvular Regurgitation . . . . . . . . . . . . . . . . 12
D.
Recommendations for Echocardiography in Mitral Valve Prolapse . . . . 14
F.
Recommendations for Echocardiography
in Infective Endocarditis: Native Valves . . . . . . . . . . . . . . . . . . . . . . . . . 15
www.americanheart.org, or www.asecho.org,
or call the ACC Resource Center at
Repeated Studies in Valvular Heart Disease . . . . . . . . . . . . . . . . . . . . . . 14
E.
G. Recommendations for Echocardiography in
Murmurs and Valvular Disease
in the Evaluation of Patients With a Heart Murmur . . . . . . . . . . . . . . . . . 9
ACC/AHA/ASE 2003 Guideline Update for
Interventions for Valvular Heart Disease and Prosthetic Valves . . . . . . . 17
1-800-253-4636, ext. 694.
H. Recommendations for Echocardiography
in Infective Endocarditis: Prosthetic Valves. . . . . . . . . . . . . . . . . . . . . . . 19
A. Acute Ischemic Syndromes
(Acute Myocardial Infarction and Unstable Angina) . . . . . . . . . . . . . . . . 23
B.
Chronic Ischemic Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Ischemic Heart Disease
IV. Ischemic Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Chest Pain
III. Chest Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
. . . . . . . . . . . . . . . 29
VI. Diseases of the Great Vessels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Great Vessels
VII. Systemic Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Hypertension
. . . . 38
A. Cardioversion of Patients With Atrial Fibrillation . . . . . . . . . . . . . . . . . . 43
B.
Syncope. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Screening
X. Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Arrhythmias
IX. Arrhythmias and Palpitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Neurological Disease
VIII. Neurological Disease and Other Cardioembolic Disease
iv
Cardiomyopathy, CHF, LVF
V. Cardiomyopathy, Congestive Heart Failure,
and Assessment of Left Ventricular Function
Introduction
Introduction
I. Introduction
These practice guidelines are intended to assist
Class I
Conditions for which there is evidence and/or
physicians in clinical decision making by describing
general agreement that a given procedure or
a range of generally acceptable approaches for the
treatment is useful and effective.
diagnosis, management, or prevention of specific
diseases or conditions. These guidelines attempt
Class II
Conditions for which there is conflicting evidence
to define practices that meet the needs of most
and/or a divergence of opinion about the useful-
patients in most circumstances. The ultimate judg-
ness/efficacy of a procedure or treatment.
ment regarding care of a particular patient must be
Class IIa Weight of evidence/opinion is in favor
made by the physician and patient in light of all of
of usefulness/efficacy.
the circumstances presented by that patient.
Class IIb Usefulness/efficacy is less well estab-
The guidelines will provide assistance to physicians
lished by evidence/opinion.
regarding the use of echocardiographic techniques
in the evaluation of such common clinical problems.
The recommendations concerning the use of
Class III
Conditions for which there is evidence and/or
echocardiography follow the recommendation
general agreement that the procedure/treatment
classification system (ie, Classes I, II, and III) used
is not useful/effective and in some cases may be
in other ACC/AHA guidelines:
harmful.*
*Because it is not likely that harm will occur by performing an echocardiogram, the
reason for the Class III designation in these guidelines is almost exclusively that there
is no evidence that performing an echocardiogram has been shown to be helpful in
that particular condition.
2
3
Introduction
Evaluation of the clinical utility of a diagnostic
for individual applications. The third criterion is the
test such as echocardiography is far more difficult
capability of a test to alter diagnostic and prognostic
than assessment of the efficacy of a therapeutic
thinking, ie, to offer added value. This level depends
intervention, because the diagnostic test can never
on the context in which the test is performed and is
have the same direct impact on patient survival or
therefore affected by such factors as what is already
recovery. Nevertheless, a series of hierarchical
known, the judged value of confirmatory data,
criteria are generally accepted as a scale by which
and the importance of reassurance in a particular
to judge worth.
clinical situation. Impact on diagnostic and prognos-
Introduction
A. Hierarchical Levels of
Echocardiography Assessment
tic thinking is an important link between test results
Hierarchical Levels of Echocardiography Assessment
4
and patient treatment. Subsequent criteria include
■
Technical capacity
therapeutic impact and health-related outcomes.
■
Diagnostic performance
The definition of echocardiography used in this
■
Impact on diagnostic and prognostic thinking
document incorporates Doppler analysis, M-mode
■
Therapeutic impact
■
Health-related outcomes
echocardiography, two-dimensional transthoracic
echocardiography (TTE), and, when indicated,
transesophageal echocardiography (TEE).
The most fundamental criterion is technical capacity,
The differing capabilities of the several types of
including adequacy of equipment and study perfor-
available Doppler echocardiographic techniques
mance. The next is diagnostic performance, which
are outlined in Table 1. Recognizing the strengths
encompasses much of traditional diagnostic test
of each technique will enable the physician to
assessment, including delineation of the range of
order the appropriate study. Generally, a complete
clinical circumstances in which a test is applicable,
transthoracic echocardiogram and Doppler study
as well as test sensitivity, specificity, and accuracy
is called for unless otherwise specified.
5
Introduction
Echocardiography
M mode
2D
Spectral
Doppler
Color
Doppler
Echocardiography
++++
++++
—
—
++
Thickness of walls
++++
+++
—
—
+++
+
++++
—
—
+++
++++
+
—
—
+
Early closure of MV
Systolic anterior
motion of MV
LV mass (g)
++++
++++
+++
++++
—
—
—
—
+++
+
+++
—
—
++++
Masses in atrial
and right ventricle
+
++
—
—
++++
Anatomic valvular
pathology
++
++++
—
—
++++
+
++++*
++
++++
++++
++
++++
—
—
++
Pericardial effusion
Spectral
Doppler
Color
Doppler
TEE
Severity of
valve regurgitation
+
+
+++
+++
+++
Site of left-to-right,
right-to-left shunt
—
+++*
(together)
+++
++++
(together)
+++
RV and PA
systolic pressure
—
—
++++
—
—
LV filling pressure
—
—
++
—
—
Stroke volume
and cardiac output
+
++
(together)
+++
—
—
LV diastolic function
+
+
+++
—
—
Identify ischemia and
viable myocardium
with exercise or
pharmacological stress
—
+++
—
—
—
Diseases of the aorta
—
++
—
++
++++
Prosthetic valve
evaluation
+
++
++++
+++
++++
—
LV masses (tumor,
clot, vegetation)
Septal defects
2D
Murmurs and Valvular Disease
Chamber size
Relation of chambers
M mode
TEE
Anatomy-Pathology
Introduction
Table 1.
†
Doppler Echocardiography Capabilities in the Adult Patient
++++ indicates most helpful; +,least useful; —, not useful;
2D, two-dimensional; EF, ejection fraction; LV, left ventricular; MV, mitral valve; PA, pulmonary artery;
RV, right ventricular; and TEE, transesophageal echocardiography.
Function
Global LV systolic
function (EF)
† When the Doppler flow signal is suboptimal, administration of an echocardiographic contrast agent
++
++++
++
—
+++
Regional wall motion
+
+++
—
—
++++
Severity of
valve stenosis
+
++
++++
+++
++
6
may improve signal detection.
* With contrast (intravenous injection of agitated saline).
7
II. Murmurs and Valvular Heart Disease
A. Recommendations for Echocardiography
in the Evaluation of Patients With a Heart Murmur
Echocardiography is extremely useful in the
assessment of cardiac murmurs, stenosis and regur-
Class I
gitation of all four cardiac valves, prosthetic valve
symptoms.
function, and patients with infective endocarditis.
2. An asymptomatic patient with a murmur in
Echocardiography provides valuable information
whom clinical features indicate at least a moderate
probability that the murmur is reflective of structural
valve disease, identification and quantification of
heart disease.
lesions, detection and evaluation of associated
abnormalities, delineation of cardiac size and function, and assessment of the adequacy of ventricular
Class IIa
A murmur in an asymptomatic patient in whom
compensation. Echocardiography readily detects
there is a low probability of heart disease but in
structural abnormalities such as fibrosis, calcifica-
whom the diagnosis of heart disease cannot be
tion, thrombus, or vegetation and abnormalities of
reasonably excluded by the standard cardiovasc-
valvular motion such as immobility, flail or prolaps-
ular clinical evaluation.
ing leaflets, and prosthetic valve dehiscence. A full
echocardiographic evaluation should provide prognostic as well as diagnostic information, allow for
risk stratification, establish baseline data for subsequent examinations, and help guide and evaluate
Class III
In an asymptomatic adult, a heart murmur that
has been identified by an experienced observer as
functional or innocent.
the therapeutic approach.
Echocardiography often provides a definitive diagnosis and may obviate the need for catheterization
in selected patients.
8
9
Murmurs and Valvular Disease
regarding diagnosis, valvular morphology, origin of
Murmurs and Valvular Disease
1. A patient with a murmur and cardiorespiratory
Table 2. Purposes of Performing an
Echocardiogram in the Evaluation of Heart Murmurs
Class IIa
1. Assessment of the hemodynamic significance
■
Define the primary lesion and its cause and judge its severity
echocardiography.
■
Define hemodynamics
2. Re-evaluation of patients with mild to moderate
■
Detect coexisting abnormalities
aortic stenosis with LV dysfunction or hypertrophy
■
Detect lesions secondary to the primary lesion
■
Evaluate cardiac size and function
■
Establish a reference point for future observations
■
Re-evaluate the patient after an intervention
even without clinical symptoms.
Class IIb
1. Re-evaluation of patients with mild to moderate
aortic valvular stenosis with stable signs and
symptoms.
2. Dobutamine echocardiography for the evaluation
of patients with low-gradient aortic stenosis and
B. Recommendations for
Echocardiography in Valvular Stenosis
Class I
1. Diagnosis; assessment of hemodynamic severity.
2. Assessment of left ventricular (LV) and right ventricular (RV) size, function, and/or hemodynamics.
3. Re-evaluation of patients with known valvular
stenosis with changing symptoms or signs.
ventricular dysfunction.
Class III
1. Routine re-evaluation of asymptomatic adult
patients with mild aortic stenosis having stable
physical signs and normal LV size and function.
2. Routine re-evaluation of asymptomatic patients
with mild to moderate mitral stenosis and stable
physical signs.
4. Assessment of changes in hemodynamic severity
and ventricular compensation in patients with
known valvular stenosis during pregnancy.
5. Re-evaluation of asymptomatic patients with
severe stenosis.
10
11
Murmurs and Valvular Disease
Murmurs and Valvular Disease
of mild to moderate valvular stenosis by stress
C. Recommendations for Echocardiography
in Native Valvular Regurgitation
Class I
8. Assessment of valvular morphology and regurgi-
1. Diagnosis; assessment of hemodynamic severity.
tation in patients with a history of anorectic drug
2. Initial assessment and re-evaluation (when
use, or the use of any drug or agent known to be
indicated) of LV and RV size, function, and/or
associated with valvular heart disease, who are
symptomatic, have cardiac murmurs, or have a
3. Re-evaluation of patients with mild to moderate
Murmurs and Valvular Disease
Murmurs and Valvular Disease
hemodynamics.
technically inadequate auscultatory examination.
valvular regurgitation with changing symptoms.
4. Re-evaluation of asymptomatic patients with
severe regurgitation.
Class IIb
1. Re-evaluation of patients with mild to moderate
mitral regurgitation without chamber dilation and
5. Assessment of changes in hemodynamic severity
without clinical symptoms.
and ventricular compensation in patients with
2. Re-evaluation of patients with moderate aortic
known valvular regurgitation during pregnancy.
regurgitation without chamber dilation and without
6. Re-evaluation of patients with mild to moderate
clinical symptoms.
regurgitation with ventricular dilation without
clinical symptoms.
7. Assessment of the effects of medical therapy
on the severity of regurgitation and ventricular
compensation and function when it might change
medical management.
Class III
1. Routine re-evaluation in asymptomatic patients
with mild valvular regurgitation having stable
physical signs and normal LV size and function.
2. Routine repetition of echocardiography in past
users of anorectic drugs with normal studies or
known trivial valvular abnormalities.
12
13
2. To exclude MVP in patients with first-degree
D. Repeated Studies in Valvular Heart Disease
relatives with known myxomatous valve disease.
A routine follow-up echocardiographic examination
is not indicated after an initial finding of minimal or
3. Risk stratification in patients with physical signs
mild abnormalities in the absence of a change in
of MVP or known MVP.
clinical signs or symptoms. Patients with more significant abnormalities on the initial study may be
Class III
1. Exclusion of MVP in patients with ill-defined
symptoms in the absence of a constellation of
of such changes, with the frequency determined by
Murmurs and Valvular Disease
Murmurs and Valvular Disease
followed echocardiographically even in the absence
clinical symptoms or physical findings suggestive
the hemodynamic severity of the lesion and the
of MVP or a positive family history.
extent of ventricular compensation noted on initial
and subsequent studies. Marked changes in the
2. Routine repetition of echocardiography in
echocardiographic findings, which may indicate an
patients with MVP with no or mild regurgitation
alteration in management even in the absence of
and no changes in clinical signs or symptoms.
changes in clinical signs and symptoms, should be
confirmed by re-evaluation at a shorter interval.
F. Recommendations for Echocardiography
in Infective Endocarditis: Native Valves
E. Recommendations for
Echocardiography in Mitral Valve Prolapse
Class I
Class I
Diagnosis; assessment of hemodynamic severity,
leaflet morphology, and/or ventricular compensation in patients with physical signs of mitral valve
prolapse (MVP).
1. Detection and characterization of valvular lesions,
their hemodynamic severity, and/or ventricular
compensation.*
2. Detection of vegetations and characterization
of lesions in patients with congenital heart disease
suspected of having infective endocarditis.
Class IIa
1. To exclude MVP in patients who have been
diagnosed but without clinical evidence to support
the diagnosis.
3. Detection of associated abnormalities
(eg, abscesses, shunts).*
continued next page
14
15
4. Re-evaluation studies in complex endocarditis
G. Recommendations for
Echocardiography in Interventions for
Valvular Heart Disease and Prosthetic Valves
(eg, virulent organism, severe hemodynamic
lesion, aortic valve involvement, persistent fever
or bacteremia, clinical change, or symptomatic
Class I
1. Assessment of the timing of valvular interven-
5. Evaluation of patients with high clinical suspicion
tion based on ventricular compensation, function,
of culture-negative endocarditis.*
and/or severity of primary and secondary lesions.
6. If TTE is equivocal, TEE evaluation of bacteremia,
2. Selection of alternative therapies for mitral valve
especially staphylococcus bacteremia and fungemia
disease (such as balloon valvuloplasty, operative
without a known source.
valve repair, and valve replacement).*
3. Use of echocardiography (especially TEE) in
Class IIa
guiding the performance of interventional tech-
1. Evaluation of persistent nonstaphylococcus
niques and surgery (eg, balloon valvotomy and
bacteremia without a known source.*
valve repair) for valvular disease.
2. Risk stratification in established endocarditis.*
4. Postintervention baseline studies for valve
function (early) and ventricular remodeling (late).
Class IIb
Routine re-evaluation in uncomplicated endocarditis
5. Re-evaluation of patients with valve replace-
during antibiotic therapy.
ment with changing clinical signs and symptoms,
suspected prosthetic dysfunction (stenosis,
Class III
Evaluation of transient fever and nonpathological
regurgitation), or thrombosis.*
murmur without evidence of bacteremia or new
murmur.
Class IIa
Routine re-evaluation study after baseline studies
of patients with valve replacements with mild to
*TEE may frequently provide incremental value in addition to information obtained by
TTE. The role of TEE in first-line examination awaits further study.
moderate ventricular dysfunction without changing
clinical signs or symptoms.
continued next page
16
17
Murmurs and Valvular Disease
Murmurs and Valvular Disease
deterioration).
H. Recommendations for Echocardiography
in Infective Endocarditis: Prosthetic Valves
Class IIb
Routine re-evaluation at the time of increased
Class I
1. Detection and characterization of valvular lesions,
failure rate of a bioprosthesis without clinical
their hemodynamic severity, and/or ventricular
evidence of prosthetic dysfunction.
compensation.*
Murmurs and Valvular Disease
Murmurs and Valvular Disease
2. Detection of associated abnormalities (eg,
Class III
abscesses, shunts).*
1. Routine re-evaluation of patients with valve
replacements without suspicion of valvular
3. Re-evaluation in complex endocarditis (eg, viru-
dysfunction and with unchanged clinical signs
lent organism, severe hemodynamic lesion, aortic
and symptoms.
valve involvement, persistent fever or bacteremia,
clinical change, or symptomatic deterioration).*
2. Patients whose clinical status precludes
therapeutic interventions.
4. Evaluation of suspected endocarditis and
negative cultures.*
* TEE may provide incremental value in addition to information obtained by TTE.
5. Evaluation of bacteremia without a known source.*
Class IIa
Evaluation of persistent fever without evidence of
bacteremia or new murmur.*
Class IIb
Routine re-evaluation in uncomplicated endocarditis
during antibiotic therapy.*
Class III
Evaluation of transient fever without evidence of
bacteremia or new murmur.
* TEE may provide incremental value in addition to that obtained by TTE.
18
19
III. Chest Pain
50%. The absence of regional wall motion abnormalities
identifies a subset of patients unlikely to have had either an
Chest pain can result from many cardiac and non-
acute infarction or ischemia, with a weighted mean negative
cardiac causes. In mature adults, the most common
predictive accuracy of approximately 98%. In a patient with
clinical cardiac disorder presenting as chest pain is
previous myocardial infarction (either clinically evident or
coronary artery disease (CAD). Nonetheless, some
silent), the resting echocardiogram can confirm that event
patients with chest pain and suspected CAD have
and evaluate its functional significance.
other relevant cardiovascular abnormalities that
Recommendations for
Echocardiography in Patients With Chest Pain
can cause chest pain. These disorders, including
hypertrophic cardiomyopathy, valvular aortic
stenosis, aortic dissection, pericarditis, MVP, and
Class I
1. Diagnosis of underlying cardiac disease in
and diagnostic echocardiographic findings.
patients with chest pain and clinical evidence of
In patients with chest pain known to be of noncar-
valvular, pericardial, or primary myocardial disease
diac origin, further cardiac testing is usually unnec-
(see sections II, IV, V, and VI).
essary. In patients for whom the character of chest
2. Evaluation of chest pain in patients with sus-
pain or the presence of risk factors raises concern
pected acute myocardial ischemia, when baseline
about possible CAD, the role of echocardiography
electrocardiogram (ECG) and other laboratory
has grown over the last 5 to 10 years. Echocardi-
markers are nondiagnostic and when study can
ography can be performed when possible during
be obtained during pain or within minutes after
chest pain in the emergency room; the presence of
its abatement (see section IV).
regional systolic wall motion abnormalities in a
patient without known CAD is a moderately accurate indicator of an increased likelihood of acute
Chest Pain
Chest Pain
acute pulmonary embolism, produce distinctive
3. Evaluation of chest pain in patients with suspected aortic dissection (see section VI).
myocardial ischemia or infarction by pooled data
4. Evaluation of patients with chest pain and
with a positive predictive accuracy of approximately
hemodynamic instability unresponsive to simple
therapeutic measures.
continued next page
20
21
Class III
1. Evaluation of chest pain for which a noncardiac
A. Acute Ischemic Syndromes (Acute
Myocardial Infarction and Unstable Angina)
etiology is apparent.
2. Diagnosis of chest pain in a patient with
ECG changes diagnostic of myocardial ischemia/
infarction (see section IV).
Echocardiography can be used to rapidly diagnose the presence
of regional contraction abnormality resulting from acute
myocardial infarction, evaluate the extent of associated regional
dysfunction, stratify patients into high- or low-risk categories,
document serial changes in ventricular function, and diagnose
important complications. Some patients with acute chest pain
have unstable angina; in these individuals, echocardiography
IV. Ischemic Heart Disease
can also be helpful in diagnosis and risk assessment.
Recommendations for Echocardiography in the
Diagnosis of Acute Myocardial Ischemic Syndromes
Echocardiography has become an established and
powerful tool for diagnosing the presence of CAD
Class I
1. Diagnosis of suspected acute ischemia or
ischemic syndromes and those with chronic coronary
infarction not evident by standard means.
atherosclerosis. Transthoracic imaging and Doppler
2. Measurement of baseline LV function.
techniques are generally sufficient for evaluation of
3. Evaluation of patients with inferior myocardial
patients with suspected or documented ischemic
infarction and clinical evidence suggesting possible
heart disease. However, TEE may be needed in some
RV infarction.
patients, particularly those with serious hemodynam-
4. Assessment of mechanical complications and
ic compromise but nondiagnostic TTE studies. In
mural thrombus.*
Chest Pain
Chest Pain
and defining its consequences in patients with acute
these circumstances, TEE can distinguish among
Ischemic Heart Disease
Class IIa
complications of infarction, or hypovolemia and can
Identification of location/severity of disease in
Ischemic Heart Disease
extensive infarction with pump failure, mechanical
patients with ongoing ischemia.
guide prompt therapy. Stress echocardiography is
useful for evaluating the presence, location, and
severity of inducible myocardial ischemia, as well
Class III
Diagnosis of acute myocardial infarction already
evident by standard means.
as for risk stratification and prognostication.
* TEE is indicated when TTE studies are not diagnostic.
22
23
Recommendations for Echocardiography in
Risk Assessment, Prognosis, and Assessment of
Therapy in Acute Myocardial Ischemic Syndromes
Class I
1. Assessment of infarct size and/or extent of
Class IIb
jeopardized myocardium.
Assessment of late prognosis (2 years or more after
acute myocardial infarction).
2. In-hospital assessment of ventricular function
when the results are used to guide therapy.
Class III
3. In-hospital or early postdischarge assessment of
Routine re-evaluation in the absence of any change
in clinical status.
the presence/extent of inducible ischemia whenever
baseline abnormalities are expected to compromise
ECG interpretation.*
* Exercise or pharmacological stress echocardiogram.
† Dobutamine stress echocardiogram.
4. Assessment of myocardial viability when required
†
to define potential efficacy of revascularization.
B. Chronic Ischemic Heart Disease
In patients with chronic ischemic heart disease, echocardiogra-
1. In-hospital or early postdischarge assessment of
phy is useful for a range of recommendations, including diag-
the presence/extent of inducible ischemia in the
nosis, risk stratification, and clinical management decisions.
absence of baseline abnormalities expected to
Quantitative indices of global and regional systolic function
compromise ECG interpretation.*
(including fractional shortening, fractional area change, ejec-
2. Re-evaluation of ventricular function during
tion fraction, and wall motion score) are valuable in describing
recovery when results are used to guide therapy.
LV function, determining prognosis, and evaluating the results
3. Assessment of ventricular function after
revascularization.
24
of therapy. Doppler techniques are also extremely valuable for
evaluating both systolic and diastolic ventricular function in
patients with chronic ischemic heart disease.
25
Ischemic Heart Disease
Ischemic Heart Disease
Class IIa
Recommendations for
Echocardiography in Diagnosis and
Prognosis of Chronic Ischemic Heart Disease
electronically paced ventricular rhythm, more than
Class I
1. Diagnosis of myocardial ischemia in symptomatic
1 mm of ST depression at rest, complete left bundle-
individuals.*
branch block.*
2. Exercise echocardiography for diagnosis of
2. Detection of coronary arteriopathy in patients
myocardial ischemia in selected patients (those for
who have undergone cardiac transplantation.
†
whom ECG assessment is less reliable because of
3. Detection of myocardial ischemia in women with
digoxin use or those with LV hypertrophy, more
an intermediate pretest likelihood of CAD.*
than 1 mm of ST depression at rest on the baseline
ECG, pre-excitation [Wolff-Parkinson-White] syndrome, or complete left bundle-branch block) with
Class IIb
1. Assessment of an asymptomatic patient with
an intermediate pretest likelihood of CAD.
positive results from a screening treadmill test.*
3. Assessment of global ventricular function at rest.
2. Assessment of global ventricular function with
4. Assessment of myocardial viability (hibernating
exercise.*
†
myocardium) for planning revascularization.
5. Assessment of functional significance of coronary
lesions (if not already known) in planning percutaneous transluminal coronary angioplasty.*
Class III
1. Screening of asymptomatic persons with a low
likelihood of CAD.
2. Routine periodic reassessment of stable patients
1. Prognosis of myocardial ischemia in selected
3. Routine substitution for treadmill exercise testing
patients (those in whom ECG assessment is less
in patients for whom ECG analysis is expected to
reliable) with the following ECG abnormalities:
suffice.*
pre-excitation (Wolff-Parkinson-White) syndrome,
* Exercise or pharmacological stress echocardiogram.
†Dobutamine stress echocardiogram.
26
27
Ischemic Heart Disease
Ischemic Heart Disease
for whom no change in therapy is contemplated.
Class IIa
V. Cardiomyopathy, Congestive
Heart Failure, and Assessment
of Left Ventricular Function
1. Assessment of LV function when needed to guide
The evaluation of ventricular systolic function is
institution and modification of drug therapy in
the most common recommendation for echocardio-
patients with known or suspected LV dysfunction.
graphy. Current techniques permit a comprehensive
2. Assessment for restenosis after revascularization
assessment of LV size and function. LV cavity
in patients with atypical recurrent symptoms.*
measurements and wall thickness at end diastole
and end systole and shortening fraction may be
obtained with precision by M-mode echocardiogra-
Class IIa
1. Assessment for restenosis after revascularization
phy. Two-dimensional echocardiography, because
in patients with typical recurrent symptoms.*
of its superior spatial resolution, is used to guide
2. Assessment of LV function in patients with previ-
appropriate positioning of the M-mode beam and is
ous myocardial infarction when needed to guide
used for direct measurements of ventricular dimen-
possible implantation of implantable cardioverter-
sions and for calculation of LV volumes and ejection
defibrillator in patients with known or suspected LV
fraction. An advantage of two-dimensional (com-
dysfunction.
pared with M-mode) echocardiography is that the
chamber volumes, ejection fraction, and LV mass of
an abnormally shaped ventricle can be determined.
Class III
Routine assessment of asymptomatic patients after
Therefore, in most laboratories, two-dimensional
revascularization.
echocardiography is the principal noninvasive
method used to quantify LV volumes and assess
Ischemic Heart Disease
*Exercise or pharmacological stress echocardiography.
global and regional systolic function. LV mass and
volume quantification by echocardiography requires
high-quality images, meticulous attention to proper
beam orientation, and the use of geometric models
to approximate LV shape.
28
29
Cardiomyopathy, CHF, LVF
Class I
Recommendations for
Echocardiography in Assessment of
Interventions in Chronic Ischemic Heart Disease
Cardiomyopathy, CHF, LVF
large number of indices of diastolic function based on infor-
LV contractile function in view of its high spatial and temporal
mation from M-mode and two-dimensional echocardiography
resolution and its ability to define regional wall thickening and
Doppler mitral and pulmonary flow profiles have been investi-
endocardial excursion. Controversy still surrounds the optimal
gated. The most commonly used Doppler indices are the early
method for assessing regional LV function; however, virtually
E wave and late A wave and their ratio, the deceleration time
all carefully tested methods have yielded useful data.
Most instances of systolic dysfunction are due to ischemic
heart disease, hypertensive disease, or valvular heart disease.
However, primary disorders of the heart muscle are often
encountered and are usually of unknown etiology. The disorders are often categorized as dilated/congestive, hypertrophic,
and restrictive. Ultrasound techniques permit a comprehensive assessment of morphology and function and often allow
assessment of hemodynamic status regardless of etiology. For
these reasons, echocardiography often provides important
insight into the etiology of congestive heart failure signs and
symptoms.
of the E wave, and the isovolumic relaxation time (Table 3).
When these variables are used for the evaluation of impaired
relaxation and the semiquantification of filling pressures, care
must be taken to understand their limitations. Impaired relaxation may be overdiagnosed in patients with decreased preload
and tachycardia. Normal values also need to be adjusted for
age. Validation of filling pressures has been performed predominantly in patients with a decreased LV ejection fraction
and sinus rhythm.
Table 3.
Doppler Echocardiographic Indices of Diastolic Function
Diastolic dysfunction, defined as heart failure in the presence
■
Mitral inflow velocities (E wave, A wave, E/A ratio)
of an ejection fraction greater than 40%, is common. This syn-
■
Mitral E-wave deceleration time
drome is related to the inability of the LV to fill adequately at
■
Isovolumic relaxation time
■
Pulmonary vein systolic and diastolic velocities (S, D, S/D ratio)
put with exercise. Given that the optimal management for the
■
Pulmonary vein atrial systolic reversal (PVa)
patient with heart failure with normal ejection fraction (and
■
Difference between PVa and mitral A-wave duration
probably the patient's prognosis) is likely to be quite different
■
Mitral annular velocities as measured by Doppler tissue imaging:
normal pressure. There are other, subtler manifestations of
diastolic dysfunction, including failure to augment cardiac out-
from that for the heart failure patient with reduced ejection
E' (early), A' (late), and ratio of mitral E to Doppler tissue E'
fraction, it is important that the proper diagnosis be made. A
■
30
Color M-mode flow propagation
31
Cardiomyopathy, CHF, LVF
Echocardiography is well suited for the assessment of regional
Cardiomyopathy, CHF, LVF
Cardiomyopathy, CHF, LVF
Recommendations for
Echocardiography in Patients With
Dyspnea, Edema, or Cardiomyopathy
8. Contrast echocardiographic assessment of
Class I
1. Assessment of LV size and function in patients
myocardial infarct zone during interventional
with suspected cardiomyopathy or clinical diagnosis
septal alcohol ablation studies.
of heart failure.*
2. Edema with clinical signs of elevated central
venous pressure when a potential cardiac etiology is
Class IIb
1. Re-evaluation of patients with established
cardiomyopathy when there is no change in
suspected or when central venous pressure cannot
clinical status but where the results might
be estimated with confidence and clinical suspicion
change management.
of heart disease is high.*
2. Re-evaluation of patients with edema when
3. Dyspnea with clinical signs of heart disease.
a potential cardiac cause has already been
4. Patients with unexplained hypotension, especially
demonstrated.
in the intensive care unit.*
5. Patients exposed to cardiotoxic agents, to determine the advisability of additional or increased
dosages.
6. Re-evaluation of LV function in patients with
established cardiomyopathy when there has been a
documented change in clinical status or to guide
medical therapy.
7. Suspicion of hypertrophic cardiomyopathy based
on abnormal physical examination, ECG, or family
history.
Class III
1. Evaluation of LV ejection fraction in patients
with recent (contrast or radionuclide) angiographic
determination of ejection fraction.
2. Routine re-evaluation in clinically stable patients
in whom no change in management is contemplated and for whom the results would not change
management.
3. In patients with edema, normal venous pressure,
and no evidence of heart disease.
*TEE is indicated when TTE studies are not diagnostic.
32
33
VI. Diseases of the Great Vessels
Recommendations for Echocardiography
in Suspected Thoracic Aortic Disease
Echocardiography can be used effectively to
visualize the entire thoracic aorta in most adults.
Class I
Complete aortic visualization by combined trans-
2. Aortic aneurysm.*
thoracic imaging (left and right parasternal,
suprasternal, supraclavicular, and subcostal win-
3. Aortic intramural hematoma.
dows) frequently can be achieved. Visualization
4. Aortic rupture.
of the proximal portion of the innominate veins
5. Aortic root dilation in Marfan syndrome or other
along with the superior vena cava can be achieved
connective tissue syndromes.*
in nearly all patients with the use of the right
supraclavicular fossa and suprasternal notch
6. Degenerative or traumatic aortic disease with
approaches. Similarly, the proximal inferior vena
clinical atheroembolism.
cava and hepatic (subcostal) and pulmonary (apical
7. Follow-up of aortic dissection, especially when
and transesophageal) veins can be visualized in
complication or progression is suspected.
many patients. Biplane or multiplane TEE provides
8. First-degree relative of a patient with Marfan
high-resolution images of the aortic root, the
syndrome or other connective tissue disorder for
ascending aorta, and the descending thoracic and
which TTE is recommended.*
upper abdominal aorta. The only portion of the
aorta that cannot be visualized is a small segment
of the upper ascending portion adjacent to the
tracheobronchial tree.
Class IIa
Follow-up of a patient with surgically repaired
aortic dissection.*
*TTE should be the first choice in these situations, and TEE should only be
used if the examination is incomplete or additional information is needed.
Note: TEE is the technique that is indicated in examination of the entire
aorta, especially in emergency situations.
34
35
Great Vessels
Great Vessels
1. Aortic dissection, diagnosis, location, and extent.
VII. Systemic Hypertension
Echocardiography is the noninvasive procedure
of choice in the evaluation of the cardiac effects
Class IIa
1. Identification of LV diastolic filling abnormalities
of systemic hypertension, the most common cause
with or without systolic abnormalities.
of LV hypertrophy and congestive heart failure in
2. Assessment of LV hypertrophy in a patient with
adults. In borderline hypertensive patients without
borderline hypertension without LV hypertrophy on
evidence of LV hypertrophy by ECG, a goal-directed
ECG to guide decision making regarding initiation
echocardiogram to evaluate LV hypertrophy may be
of therapy. A limited goal-directed echocardiogram
indicated. The value of repeated studies in asymp-
may be indicated for this purpose.
Hypertension
Hypertension
tomatic hypertensive patients with normal LV
function is not clearly established.
Class IIb
Class III
Class I
1. When assessment of resting LV function,
hypertrophy, or concentric remodeling is important
in clinical decision making (see LV function).
Risk stratification for prognosis by determination
of LV performance.
Recommendations for
Echocardiography in Hypertension
1. Re-evaluation to guide anti-hypertensive therapy
based on LV mass regression.
2. Re-evaluation in asymptomatic patients to assess
LV function.
2. Detection and assessment of functional significance of concomitant CAD by stress echocardiography (see coronary disease).
3. Follow-up assessment of LV size and function
in patients with LV dysfunction when there has
been a documented change in clinical status or to
guide medical therapy.
36
37
VIII. Neurological Disease
and Other Cardioembolic Disease
Two-dimensional echocardiography is the only
technique that is easily applied and widely available
for evaluation of a potential cardioembolic source.
Examinations can be performed either from a
TEE indicates transesophageal echocardiography; TTE, transthoracic echocardiography.
* TTE is sufficient; TEE may be additive but is not essential. “TTE sufficient” identifies
disease entities for which TTE is sufficient to establish a diagnosis and for which TEE
is unlikely to provide additional information. When detected with TTE, further evaluation
by TEE is not necessary in all patients. "TEE additive" identifies entities for which docu-
transthoracic or transesophageal approach. Table 4
mented incremental diagnostic yield can be obtained by performing TEE after negative
outlines the relation between TEE and TTE for
TTE or entities for which the likelihood of unique TEE-identified abnormalities is high
detection of potential cardioembolic sources.
enough to warrant TEE even after adequate TTE.
These categories assume that high-quality TTE is feasible and has been conducted to
Table 4. Transthoracic Versus
Transesophageal Echocardiography for
Detection of Potential Cardioembolic Source
evaluate all potential cardiac sources of embolus. When adequate TTE is not feasible,
TEE is essential.
Neurological Disease
(Primarily or Alone)
Mitral stenosis
Left atrial thrombus
Dilated cardiomyopathy
Left atrial spontaneous
contrast
Left ventricular aneurysm
Left ventricular thrombus
Mitral valve prolapse
Vegetation
Neurological Disease
Diagnosis by TEE
Diagnosis by TTE*
Atrial septal aneurysm
Patent foramen ovale
Aortic atheroma
Atrial septal defect
38
39
Recommendations for Echocardiography
in Patients With Neurological Events or
Other Vascular Occlusive Events
IX. Arrhythmias and Palpitations
In the setting of arrhythmias, the utility of echocardiography lies primarily in the identification
Class I
1. Patients of any age with abrupt occlusion of a
of associated heart disease, the knowledge of
major peripheral or visceral artery.
which will influence treatment of the arrhythmia
or provide prognostic information. In this regard,
2. Younger patients (typically younger than 45 years)
echocardiographic examination is frequently
with cerebrovascular events.
performed to assess patients with atrial fibrillation
3. Older patients (typically older than 45 years) with
or flutter, re-entrant tachycardias, ventricular
neurological events without evidence of cerebrovas-
tachycardia, or ventricular fibrillation. Although
Neurological Disease
cular disease or other obvious cause.
echocardiography has provided useful insights
4. Patients for whom a clinical therapeutic decision
into the effects of arrhythmias on cardiac function,
(eg, anticoagulation) will depend on the results of
there is no recommendation for repeated clinical
echocardiography.
testing for this purpose unless there has been a
change in clinical status or the result might affect
Class IIa
a therapeutic decision.
Patients with suspicion of embolic disease and
with cerebrovascular disease of questionable
Recommendations for Echocardiography in
Patients With Arrhythmias and Palpitations
significance.
Patients with a neurological event and intrinsic
cerebrovascular disease of a nature sufficient to
cause the clinical event.
Class I
Arrhythmias
Class IIb
1. Arrhythmias with clinical suspicion of structural
heart disease.
2. Arrhythmia in a patient with a family history of
Class III
Patients for whom the results of echocardiography
a genetically transmitted cardiac lesion associated
will not affect a decision to institute anticoagulant
with arrhythmia, such as tuberous sclerosis, rhab-
therapy or otherwise alter the approach to diagnosis
domyoma, or hypertrophic cardiomyopathy.
or treatment.
40
continued next page
41
3. Evaluation of patients as a component of
A. Cardioversion of Patients
With Atrial Fibrillation
the workup before electrophysiological ablative
procedures.
Recommendations for
Echocardiography Before Cardioversion
Class IIa
1. Arrhythmia requiring treatment.
2. TEE or intracardiac ultrasound guidance of
Class I
radiofrequency ablation procedures.
1. Patients requiring urgent (not emergent)
cardioversion for whom extended precardioversion
anticoagulation is not desirable.*
Class IIb
1. Arrhythmias commonly associated with, but
2. Patients who have had prior cardioembolic events
without clinical evidence of, heart disease.
thought to be related to intra-atrial thrombus.*
2. Evaluation of patients who have undergone
3. Patients for whom anticoagulation is contraindi-
radiofrequency ablation in the absence of com-
cated and for whom a decision about cardioversion
plications. (In centers with established ablation
will be influenced by TEE results.*
programs, a postprocedural echocardiogram may
4. Patients for whom intra-atrial thrombus has
not be necessary.)
been demonstrated in previous TEE.*
3. Postoperative evaluation of patients undergoing
5. Evaluation of patients for whom a decision
the Maze procedure to monitor atrial function.
concerning cardioversion will be impacted by
Class III
function or coexistent mitral valve disease).
1. Palpitation without corresponding arrhythmia or
other cardiac signs or symptoms.
2. Isolated premature ventricular contractions for
which there is no clinical suspicion of heart disease.
Class IIa
Patients with atrial fibrillation of less than 48 hours’
duration and other heart disease.*
continued next page
42
43
Arrhythmias
Arrhythmias
knowledge of prognostic factors (such as LV
B. Syncope
Class IIb
1. Patients with atrial fibrillation of less than 48
hours’ duration and no other heart disease.*
Recommendations for Echocardiography
in the Patient With Syncope
2. Patients with mitral valve disease or hypertrophic cardiomyopathy who have been on longterm anticoagulation at therapeutic levels before
Class I
cardioversion, unless there are other reasons for
1. Syncope in a patient with clinically suspected
heart disease.
anticoagulation (eg, prior embolus or known
2. Periexertional syncope.
thrombus on previous TEE).*
3. Patients undergoing cardioversion from
atrial flutter.*
Class IIa
Syncope in a patient in a high-risk occupation
(eg, pilot).
Class III
1. Patients requiring emergent cardioversion.
2. Patients who have been on long-term anticoagu-
Class IIb
Syncope of occult etiology with no findings of heart
disease on history or physical examination.
lation at therapeutic levels and who do not have
mitral valve disease or hypertrophic cardiomyopathy
Class III
1. Recurrent syncope in a patient in whom previous
for anticoagulation (eg, prior embolus or known
echocardiographic or other testing demonstrated a
thrombus on previous TEE).*
cause of syncope.
3. Precardioversion evaluation of patients who have
2. Syncope in a patient for whom there is no clinical
undergone previous TEE and with no clinical suspi-
suspicion of heart disease.
cion of a significant interval change.
3. Classic neurogenic syncope.
*TEE only.
44
45
Arrhythmias
Arrhythmias
before cardioversion, unless there are other reasons
X. Screening
Echocardiography has several properties that promote its use as a screening tool; however, of the
many conditions that echocardiography is capable
of identifying, few meet the criteria for screening
Table 5. Diagnostic Criteria for Marfan Syndrome:
1995 Ghent Nosology*
To make an initial diagnosis, at least two
of the following major criteria must be met:
1. Aortic dilation (by comparison with nomograms
asymptomatic individuals. Among those that meet
these criteria are heritable diseases of the heart and
great vessels when the target group for screening
accounting for age and body size).
2. Ectopia lentis (detected by slit lamp examination
with dilated pupils).
is the family of an affected individual. The most
common diseases that fall into this category are
3. Skeletal abnormalities, four of the following:
cardiomyopathy and Marfan syndrome (Table 5).
■
Positive thumb and wrist signs
Recent advances in molecular genetics have
■
Greater than 20° scoliosis
identified a familial basis for many forms of
■
Pectus carinatum or pectus excavatum
requiring surgery
cardiomyopathy. Although genetic testing will likely
become more widely available as a screening tool
■
Pes planus (demand displacent of medial malleolus)
in the future, echocardiography currently plays a
■
Abnormal upper/lower segment ratio
pivotal role in the process. Genetic testing and
■
Arm span greater than 105% of height
■
Typical facies (malar hypoplasia, deep-set eyes,
echocardiography will likely always play complementary roles in screening, the former documenting
retrognathia)
the genetic substrate for the disease and the latter
defining its manifestations and progression. Three
4. Dural ectasia.
forms of myopathy in which there is a defined role
5. Positive diagnosis of Marfan syndrome or death
for echocardiographic screening are hypertrophic
due to dissection plus positive skeletal features in
cardiomyopathy, dilated cardiomyopathy, and
a first-degree relative.
Screening
Screening
arrhythmogenic RV dysplasia.
*In families in which a firm phenotypic diagnosis of the Marfan syndrome has been
established, mutation or linkage analysis for fibrillin-1 can be used to diagnose Marfan
syndrome on a molecular basis in equivocally affected relatives or prenatally.
46
47
Recommendations for Echocardiography to
Screen for the Presence of Cardiovascular Disease
Class I
1. Patients with a family history of genetically
transmitted cardiovascular disease.
2. Potential donors for cardiac transplantation.
3. Patients with phenotypic features of Marfan
syndrome or related connective tissue diseases.
4. Baseline and re-evaluations of patients undergoing chemotherapy with cardiotoxic agents.
5. First-degree relatives (parents, siblings, or
children) of patients with unexplained dilated
cardiomyopathy in whom no etiology has been
identified.
Class IIb
Patients with systemic disease that may affect
the heart.
Class III
1. The general population.
2. Routine screening echocardiogram for participation in competitive sports in patients with normal
cardiovascular history, ECG, and examination.
Screening
Competitive athletes without clinical evidence of
heart disease.
48