Acute care echocardiography guidelines offer clarifying insights

Echocardiography recommendations from two professional associations offered a better picture on how cardiologists in the emergency department should and shouldn’t use the technique. The guidelines were published in the February issue of the European Heart Journal.

The European Association of Cardiovascular Imaging and the Acute Cardiovascular Care Association collaborated to provide guidance through a number of acute cardiovascular care scenarios, including those for cardiac arrest, acute coronary syndrome and acute chest pain, as well as provide a rundown of the types of echocardiography available to physicians.

Below is a sample of the recommendations made by Patrizio Lancellotti, MD, PhD, of University Hospital in Liège, Belgium, and colleagues.

In cases of acute chest pain, the authors recommend echocardiography be used when:

• Myocardial ischemia is suspected with cardiac necrosis biomarkers and non-diagnostic echocardiogram, and a resting echocardiogram can be performed during pain;
• Underlying cardiac disease is present;
• Patient has hemodynamic instability that doesn’t respond to simple therapy; or
• Acute aortic syndromes, myocarditis, pericarditis or pulmonary embolism are suspected.

It was not recommended for patients where the cause for acute chest pain was non-cardiac or when patients had confirmed myocardial ischemia or infarction.

In cases of suspected pericardial disease, echocardiography was recommended for:

• Effusion, constriction or a combination of both;
• Pericardial friction rubs with acute MI, persistent pain, nausea and hypotension;
• Suspected pericardial bleeding; or
• As guidance of or follow-up for pericardiocentesis.

When the patient had suspected or confirmed pulmonary embolism, echocardiography was recommended for:

• Hypotension or shock is present and computed tomography is not immediately available;
• Distinguishing cardiac against non-cardiac dyspnea when other clinical and laboratory tests are ambiguous; or
• As guidance of therapy in intermediate risk for pulmonary embolism.

Echocardiography was considered reasonable when looking for emboli and suspected clots in the right atrium, ventricle or main pulmonary artery branches or for risk-stratification in non-high risk pulmonary embolism.

It was not recommended for cases of suspected or confirmed pulmonary embolism to electively diagnose where the patient was hemodynamically stable or normotensive.

For patients with suspected acute traumatic aortic injuries, they recommended transesophageal echocardiography and to guide surgical anesthetic decisions. Transesophageal echocardiography was not recommended for patients with cervical spine fractures.

Lancellotti et al noted that echocardiography can be a powerful diagnostic and monitoring tool, particularly when the right type is used for the patient conditions at hand. Different types of echocardiography, including transthoracic, transesophageal, contrast, lung ultrasound, focused cardiac ultrasound and pocket-sized imaging devices, each have their place in assessing acute cardiac conditions. However, knowing when best to use them and when they may be contraindicated is important.

Because of this, they recommended two levels of additional competence with echocardiography in the emergency department—independent and expert operator levels—to ensure the best use of the varying echocardiographic techniques in the fast-paced acute care setting.