Ecocardiografia > Ecocardiografia 2003 Acc Aha Pocket

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.

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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.

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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.

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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

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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

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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.

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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

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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.

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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.

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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