84

CARDIOLOGY UPDATE

Echocardiography and the general physician

G J Heatlie, M Giles
...............................................................................................................................

Postgrad Med J 2004;80:84–88. doi: 10.1136/pmj.2003.010363

Doctors from many medical specialties request generates sound waves typically at 2.5 MHz that
is 2.5 million times per second. When encounter-
echocardiography as part of their assessment of patients ing an object, sound waves are scattered or
with a wide range of pathology. Recent advances in the reflected back towards the probe from the
technology and techniques of echocardiography are object’s interface with adjacent structures; this
is repeated in many times per second to build up
discussed. The role of echocardiography in acute medicine a moving real time image of the heart.
is reviewed and its place in general medicine is also The Doppler principle is familiar to all school-
discussed. children as the explanation for the change in
tone of the siren of an approaching fire engine.
........................................................................... The change in frequency of the returning signal
is related to the velocity of the moving object,

S
ince the pioneering work of Edler in the whether this is a fire engine or red blood cells!
1950s, echocardiography machines have Doppler information is normally presented as a
evolved into highly complex and sophisti- graph of blood velocity against time—pulsed
cated instruments, allowing detailed analysis of wave Doppler measuring velocity at a point and
cardiac anatomy and function. They have continuous wave Doppler measuring the highest
become so widely available that approximately velocity along a scan line.
1 000 000 echo studies are performed each year Thus images and velocities can be acquired by
in the UK, a figure likely to double over the next the same probe by measuring different attributes
few years following proposals within the of the same signal (reflected intensity and
National Service Framework for Coronary Heart frequency), providing single dimensional (M-
Disease and recommendations by the National mode), two dimensional, and Doppler images.
Institute for Clinical Excellence. The quality of images in modern echo
Echocardiography is the first choice for cardiac machines is very high with recent technological
imaging as: advances in computing power and probe tech-
nology allowing high resolution. The footprint of
(1) It provides detailed information with mini- the probe is very small allowing easy access
mal patient discomfort. between ribs, while retaining sufficiently high
(2) It uses ultrasound which allows repeat density of scan lines.
studies as often as is necessary.
(3) Results are immediately available. RECENT TECHNOLOGICAL ADVANCES
(4) Unlike alternative technologies, machines The most important physical principle to have
are portable, particularly the new generation of made an impact on image quality in recent years
hand held units. is second harmonic imaging. Interrogation of the
received beam at twice the transmitted frequency
The most common reason for requesting an allows construction of an image from a signal
echocardiogram is to assess left ventricular that, although smaller in amplitude, produces
function, accounting for over 50% of studies in much less noise and hence generates a much
the UK and North America.1 However the clearer image. This technique is most valuable
indications for an echocardiogram include when normal imaging produces suboptimal
almost the full spectrum of cardiovascular dis- images.
ease, from ventricular function and valvular Second harmonic imaging is also useful when
disease to arrhythmias and chest pain. agents are injected to provide contrast to improve
There are a number of competing modalities delineation of cardiac chambers. For example,
including magnetic resonance imaging, nuclear agitated saline helps in the diagnosis of septal
scintigraphy, and positron emission tomography. defects. Recent development of transpulmonary
Considerable technical advances in magnetic echo contrast agents is a leap forward allowing
See end of article for resonance imaging in cardiology have reduced left ventricular cavity opacification (LVO) and
authors’ affiliations image acquisition time and increased frame rates
....................... augmentation of the Doppler measurement of
to make it a viable alternative to echocardiogra- left heart blood flow. These agents are micro-
Correspondence to: phy. It is also more versatile than echo, giving
Dr Grant Heatlie, Queens detailed images of structure and blood flow but
Medical Centre, Derby ...................................................
Road, Nottingham NG7
at present its use at the bedside or in theatre is
2UH, UK; grant.heatlie@ impractical due to cost and size. Abbreviations: COPD, chronic obstructive pulmonary
virgin.net disease; ECG, electrocardiography; LVH, left ventricular
hypertrophy; LVO, left ventricular cavity opacification;
Submitted 25 May 2003 PRINCIPLES OF ECHOCARDIOGRAPHY RVSP, right ventricular systolic pressure; TOE,
Accepted 23 June 2003 Echo machines are powerful computers linked to transoesophageal echocardiography; TTE, transthoracic
....................... an ultrasound generating system. The probe echocardiography

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Echocardiography and the general physician 85

Figure 1 A tissue Doppler image in

the four chamber view. Bottom left is the
normal grey scale image and top left is
a colour Doppler image where the
colour encodes myocardial motion. At a
selected point (square) of the
myocardium the velocity information is
extracted and displayed as a velocity/
time graph. The point labelled 1
corresponds to peak systolic contraction
velocity, 2 is the peak passive
relaxation velocity (passive left
ventricular filling), and 3 is the peak
myocardial velocity during active left
ventricular filling.

bubbles around 5 microns in diameter and contain fluoro- cardiography. Wall motion abnormalities appear before
carbon gas. They are non-linear oscillators (the energy electrocardiography (ECG) changes in the ischaemic heart
emitted by the bubbles is at a mixture frequencies) so are and these are often more easily seen with contrast enhance-
suited to second harmonic imaging where the frequency ment of left ventricular images.
interrogated by the probe is twice the transmitted frequency. Intravascular ultrasound is sometimes employed during
In addition to LVO, these agents can be used to observe coronary arteriography to improve definition of coronary
myocardial perfusion in real time. Single microbubbles are lesions. Less commonly intracardiac ultrasound is used to
visible and, after the destruction of all the contrast within the guide interventional procedures such as atrial septal defect
image by a powerful ultrasound pulse, the rate of reperfusion closures.
in different vascular beds can be calculated. As image quality Three dimensional echocardiography is now available,
improves, techniques that are undergoing development will giving real time three dimensional views. It will have an
become routine. important role in congenital heart disease. As the views are
More recently the Doppler principle has been applied to similar to what the surgeon is used to seeing in the operating
myocardial motion so that ‘‘speed/time’’ graphs of muscle theatre, it is likely that this will be employed widely as a
velocity can be generated; these provide a novel, quantitative method of pre operative assessment of valvular disease. It
perspective on left ventricular function. It also allows precise may also be employed in interventional cardiology to guide
measurements of timing of contraction within the ventricles placement of intracardiac catheters.
(fig 1). An extension of this method allows analysis of local
myocardial deformation (strain/strain rate imaging). It is
likely that this will have a variety of applications and may
become the method of choice to select patients for
biventricular pacing.

OTHER MODALITIES OF ECHOCARDIOGRAPHY

The interposition of lung tissue can restrict ‘‘echo windows’’,
reducing image quality in some patients quite markedly.
Transoesophageal echocardiography (TOE) reduces the dis-
tance between echo probe and heart so higher frequencies
can be used, giving better resolution. Visualisation of
structures posterior in the chest such as the left atrium,
mitral and aortic valves is excellent, although the left
ventricular apex is not particularly well seen. TOE is, of
course, an unpleasant, invasive test with a low morbidity due
to the risk of haematoma and oesophageal perforation.
TOE should be considered an alternative as complementary
to, rather than in competition with, transthoracic echocar-
diography (TTE).
Stress echocardiography is now widely available and has
been validated to demonstrate the presence of myocardial
ischaemia or viability.2 3 It employs physiological (exercise) or Figure 2 A transoesophageal image of aortic dissection. The false
pharmacological (such as dobutamine) stress during echo- lumen is marked with an asterisk.

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86 Heatlie, Giles

Ischaemic heart disease

Stress echocardiography is now available in the UK and is
more sensitive and specific than exercise ECG testing,
accurately predicting cardiovascular risk after presentation
with chest pain. It may also be used to help diagnose the
presence of significant coronary artery disease with a similar
sensitivity and specificity to other imaging techniques.
The advent of tissue Doppler myocardial imaging in the
latest generation of echo machines will improve interobserver
reproducibility (a current concern) and measure (two
dimensional) myocardial deformation (strain) in real time.
Real time myocardial perfusion imaging is likely to move
from the research to the clinical arena in the near future.

Aortic dissection
Echocardiography has an important part to play in suspected
thoracic aortic dissection (fig 2). The sensitivity and
Figure 3 A mass (in this case an infective vegetation) associated with specificity of TOE is similar to that of contrast enhanced
the non-coronary cusp of the aortic valve.
computed tomography, although slightly inferior to magnetic
resonance imaging.4 The investigation of choice usually
ECHOCARDIOGRAPHY AND THE ACUTE MEDICAL depends on local expertise as well as factors including when
TAKE the patient last ate. The relative risks of an invasive procedure
Acute myocardial infarction (and its effects on haemodynamics) have to be measured
Echocardiography is not routinely required acutely in against the risk of moving the patient to a non-clinical area in
uncomplicated myocardial infarction. It does have a role in a radiology department.
the investigation of unexplained hypotension and murmurs, Transthoracic echo is often seen as an unhelpful investiga-
providing a rapid and safe bedside assessment of global and tion for acute aortic dissection due to sensitivity and
regional right and left ventricular and valvular function. specificity of around 50% and 60% respectively. While it can
Myocardium may be locally acutely stunned by infarction never exclude dissection, TTE can positively identify some
but remain viable and spontaneously improve, while other dissections and can give important information about
conditions such as acidosis can reversibly suppress global complications such as pericardial effusion and aortic regur-
myocardial function. gitation.4
Hypotension may complicate inferior myocardial infarc-
tions. The right ventricle often lies in the same vascular Pulmonary embolus
territory as the inferior wall of the left ventricle and so can be Echocardiography can identify specific cardiac abnormalities
damaged simultaneously. The combination of echocardio- but should not be relied upon to diagnose pulmonary
graphy and central venous pressure measurements can avoid embolus. For example, TTE often detects a dilated right
unnecessary pulmonary artery catheterisation. heart with pulmonary hypertension in acute pulmonary
Two important complications of acute infarction are embolus, providing adjunctive information in the clinical
ventricular septal defect and acute severe mitral regurgita- context of an acutely hypoxic, hypotensive patient which can
tion, both of which can be diagnosed rapidly and severity be used to guide the need for lytic therapy.
established. Transoesophageal echo can demonstrate clot in the
Occasionally an unexplained pericardial effusion will be proximal pulmonary arteries if present but has a low overall
found at the time of a myocardial infarction. An injection of sensitivity for the diagnosis of pulmonary embolus.5
transpulmonary echo contrast can be helpful to diagnose a
free wall rupture, which may not otherwise be seen on echo
and is important to differentiate from other causes of Table 1 The original Duke’s criteria for the diagnosis of
pericardial effusion. endocarditis.6 Two major, one major and three minor, or
five minor criteria are necessary for the diagnosis of
endocarditis
Major Duke’s criteria Minor Duke’s criteria

1. Positive blood cultures with a 1. Predisposing cardiac condition

typical organism
2. Evidence of endocardial 2. Fever
involvement from
echocardiography
3. Vascular phenomena: emboli,
mycotic aneurysm, Janeway’s lesion
4. Immunological phenomena:
glomerulonephritis, splinter
haemorrhages, Roth’s spots, Osler’s
nodes
5. Positive blood cultures with
organism consistent but not typical for
endocarditis
6. Positive echocardiography with
findings consistent with but not typical
for endocarditis

Figure 4 A large mass in the left atrium (in this case a myxoma) is seen
prolapsing through the mitral valve.

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Echocardiography and the general physician 87

Arrhythmias Table 2 Other diseases that affect cardiac structure

Echocardiography can provide valuable information in the
management of atrial fibrillation. Echo variables such as left Diabetes Impairment of systolic and diastolic
atrial size and left ventricular function correlate with the cardiac function
Chronic hypothyroidism Impairment of systolic and diastolic
success of electrical cardioversion acutely as well as to the
cardiac function, pericardial effusion
likelihood of maintaining sinus rhythm in the longer term.6 Acromegaly Left ventricular hypertrophy
Echo should normally be requested once the ventricular Hyperparathyroidism Valvular and myocardial calcification
response to atrial fibrillation is controlled because at high Chronic renal failure Valvular calcification, left ventricular
heart rates diastolic relaxation time is brief, making assess- hypertrophy and reduced function,
pericardial thickening and effusion
ment of left ventricular function difficult.
Assessment of left ventricular function by echo in patients
with non-syncopal sustained ventricular tachycardia is
crucial. Such patients who also have impaired left ventricular
function secondary to ischaemic heart disease have a high Right ventricular ejection fraction provides important
mortality rate and are best treated with an implantable prognostic information in a wide range of patients, particu-
defibrillator. Patients who have normal (or near normal) left larly those with heart failure and low left ventricular ejection
ventricular function have a good prognosis and may be fractions. Unfortunately, due to the complexity of right
managed medically. ventricular anatomy, it has not proved possible to accurately
quantify right ventricular function using echocardiography,
Occult infection and suspected infective endocarditis although the advent of three dimensional echo should
Infective endocarditis (fig 3) is often included in the eventually achieve this. At present, echocardiography relies
differential diagnosis of sepsis. Confirmation or exclusion of on a simple visual assessment or on semiquantitative
infective endocarditis relies on the established diagnostic methods. Of these, the easiest is the measurement of the
Duke’s criteria (table 1), in which echocardiography is one of motion of the tricuspid valve annulus towards the apex
the major criteria.7 during systole by M-mode or tissue Doppler, which correlates
The sensitivity of TTE for identifying native valve vegeta- well with right ventricular ejection fraction.9 The index of
tions is 46% and for TOE 93%. Importantly a negative TOE has myocardial performance is another semiquantitative assess-
a predictive value of 96%.8 ment, which has shown promise in the assessment of
In suspected prosthetic valve endocarditis, TTE is less patients with pulmonary hypertension. It is obtained from
helpful as the prosthetic valve produces acoustic shadows Doppler derived systolic and diastolic time intervals and is
which obscure important structures. In this situation, TOE is easy to perform, reproducible, and not significantly affected
mandatory, providing a more complete assessment and by variables such as heart rate, ventricular size, or pressures.10
clearer views of both prosthestic valve and supporting Dyspnoea is a universal symptom in respiratory medicine
structures. In particular, TOE is superior at visualising the clinics and very common in cardiac clinics. Transthoracic
aortic root for complications such as aortic root abscess. echo can help to differentiate ‘‘cardiac’’ breathlessness due to
Indications for TOE include a normal TTE despite the impaired left ventricular function or valvular disease from
presence of one major or two minor Duke’s criteria, the ‘‘respiratory’’ breathlessness.
presence of prosthetic valves and all cases of endocarditis Patients with chronic obstructive pulmonary disease
confirmed with TTE. (COPD) can be difficult echo subjects due to hyperinflated
lungs attenuating the ultrasound beam. The presence of
Monitoring of valvular disease pulmonary hypertension in COPD is a poor prognostic
This forms a large part of the echo workload. Most of this is indicator independent of other factors.
done from cardiology clinics, with the aim of determining the Cor pulmonale also occurs with interstitial lung disease
optimum timing of intervention. This is a complex issue and and tends to present late in the course of the disease. The
will not be covered in detail here. pulmonary artery pressure mirrors the degree of hypoxaemia.
The exception is CREST syndrome where pulmonary hyper-
ECHOCARDIOGRAPHY AND THE RESPIRATORY tension is a major feature and presents early, even in the
PHYSICIAN absence of interstitial lung disease.
Pulmonary arterial hypertension develops in the presence of
chronic lung disease, causing right ventricular pressure Echo and the neurologist
overload. The right ventricle compensates by muscular The role of echocardiography in the diagnosis and manage-
hypertrophy, conformational changes, and developing higher ment of patients presenting with neurological disorders is
filling pressures. These changes are described as cor pulmo- controversial. Most investigators have demonstrated that
nale. some clinical evidence of heart disease must be evident for
It is possible to monitor pulmonary pressures as disease echocardiography to be diagnostically useful. The main
states progress or during therapeutic interventions by study- exception is patients over 45 years of age where a patent
ing pulmonary and tricuspid regurgitation which can be foramen ovale and atrial septal aneurysms are two or three
observed in most patients. Right ventricular systolic pressure times more common than in older patients.11 However,
(RVSP) can be estimated relatively easily from the peak echocardiography is a widely used tool in the diagnosis, risk
regurgitant velocity of the tricuspid valve and adding an stratification, and management of syncope and embolic
estimate of right atrial pressure, which can be obtained either stroke patients.
clinically or by studying the inferior vena cava. In the absence Echocardiography is used in syncope primarily to confirm
of pulmonary stenosis, RVSP equals pulmonary systolic or exclude the presence of obstructive cardiac lesions such as
pressure. End diastolic and mean pulmonary artery pressures aortic stenosis or hypertrophic cardiomyopathy. Syncope is
can similarly be estimated from pulmonary regurgitant more likely to be due to a malignant tachyarrhythmia if left
profiles. Other signs of pulmonary hypertension such as ventricular systolic function is impaired.
right ventricular enlargement and hypertrophy, interventri- Up to 40% of ischaemic strokes are embolic in nature and
cular septal flattening, and right ventricular impairment may the heart is usually the embolic source. TTE can be used to
be present. find and assess most sources of embolus ranging from left

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88 Heatlie, Giles

atrial myxoma (fig 4) to left ventricular mural thrombus. Other diseases

Other potential sources of embolus such as patent foramen A variety of renal, endocrine, and nutritional disorders may
ovale and left atrial appendage thrombus usually require TOE affect cardiac structure and function as illustrated in table 2.
for diagnosis. Echocardiography can thus provide a wide range of
information in a variety of non-cardiac diseases.
ECHO AND THE GENERAL PHYSICIAN
CONCLUSIONS
Pericardial effusion
Echocardiography is an important tool to assist the general
Inflammatory, neoplastic, endocrine, traumatic, and other
physician in the diagnosis and management of medical
disease processes lead to an accumulation of fluid in the
emergencies and in the investigation of cardiac manifesta-
pericardial space. Echocardiography allows the definition of
tions of many diseases. It is readily available and recent
size and localisation of any pericardial collection. As fluid
technological developments mean that the image quality is
accumulates the normally negative pressure in the pericardial
high for most patients. Its cost, portability, and flexibility will
space increases and becomes positive, affecting the haemo-
ensure its position as the principle cardiac imaging modality
dynamics of the heart. Its effect is more marked in the right
for the foreseeable future.
heart due to lower pressure. The clinical and echocardio-
graphic signs of tamponade then develop, including right .....................
atrial and right ventricular wall diastolic collapse and marked Authors’ affiliations
respiratory swings in the left heart blood flow, reflecting G J Heatlie, Queens Medical Centre, Nottingham, UK
reduced filling of the right ventricle. Echo can be used to M Giles, Department of Cardiology, Nottingham City Hospital, UK
guide therapeutic pericardiocentesis.
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