Ep 120 – Echocardiography

Echocardiography is an essential tool in a wide range of clinical scenarios. Appropriate use of an echocardiogram ("echo" scan) can improve clinical outcomes by increasing diagnostic accuracy, providing non-invasive or minimally invasive assessment of disease status and risk stratification and enabling real-time monitoring and guidance of interventional procedures. However, there can be confusion surrounding when to appropriately refer a patient from primary care. In this episode, Dr Roger Henderson looks at various conditions and when to consider the use of echo scans for them.

Key references

1. British Heart Foundation. https://www.bhf.org.uk/informationsupport/tests/echocardiogram.
2. Potter A, et al. Br J Gen Pract. 2021;71(708):333–334. doi: 10.3399/bjgp21X716441.
3. Wingate-Saul L, et al. Br J Cardiol. 2013;20:149–150. doi:10.5837/bjc.2013.30.

Key take-home points

• Conditions for which there is likely to be a low clinical yield in primary care from echo scanning include:
  • Heart murmur
  • Suspected heart failure (not confirmed)
  • Hypertension
  • Cardiac mass
  • Pulmonary disease
  • Palpitations
  • Pericardial disease
  • Established cardiomyopathy
  • Inherited cardiac disease
• No evidence of benefit from echo in an unchanged murmur in someone who is asymptomatic and who has had a previous normal echo scan, or in the assessment of an innocent (physiological) murmur.
• In suspected heart failure, if there is a normal physical examination, a normal electrocardiogram (ECG) and a normal N-terminal pro B-type natriuretic peptide level, then there is no indication for an echo scan (even if cardiomegaly is present on chest X-ray).
• The presence of simple cardiomegaly (without pulmonary congestion or other findings suggestive of cardiac disease) on chest X-ray does not warrant an echo, as the likely yield of identifying significant cardiac pathology is low.
• In hypertension, an echo is not indicated routinely to evaluate a patient with a normal 12-lead ECG and normal physical examination. However, hypertension in a patient under the age of 40 can trigger an echo to search for causes of secondary hypertension (such as coarctation of the aorta) and end-organ damage.
• Lung disease with no clinical suspicion of cardiac involvement or pulmonary hypertension does not warrant echocardiography.
• Classical vasovagal syncope does not require an echo, nor do palpitations without any ECG proof of an arrhythmia or clinical suspicion of heart disease on examination.
• Echo surveillance is mandated in patients who are primary-degree relatives of affected individuals with inherited cardiac diseases.
• Avoid repeating an echo scan in the absence of a change of patient symptoms or signs, or in patients with terminal or significantly life-limiting diseases or significant frailty, where an echo would not alter their management.