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Cardiac tests - echocardiography

Cardiologists Dr Clive Handler and Dr Gerry Coghlan continue their series on commonly used tests in primary care with a look at echocardiography

Cardiologists Dr Clive Handler and Dr Gerry Coghlan continue their series on commonly used tests in primary care with a look at echocardiography

This is the most powerful diagnostic non-invasive cardiac imaging test for assessing valve anatomy and physiological disorders. It is widely available, cheap and completely safe. Echocardiography is usually combined with Doppler measurements of blood flow across diseased valves and septal defects. Small laptop computer-sized machines are now affordable enough for use in primary care and offer acceptable diagnostic quality.

Value and limitations

41210581Echocardiography provides important anatomical and functional information about the heart muscle, chamber sizes, ventricular wall thickness, valves and intracardiac connections. The pericardial space and pericardium may be visualised easily, and this is useful as part of the evaluation of breathlessness in patients with chest or breast malignancy.

A normal echocardiogram excludes heart failure, indicates that a heart murmur is probably caused by turbulence of blood in a normal heart rather than an underlying structural heart abnormality, and excludes pathological enlargement of the heart (cardiomegaly), a question that is commonly raised as an incidental finding on a chest X-ray.

Images may not be of diagnostic quality in obese patients and those with chronic airways disease. Interpretation of left ventricular function is subjective, but is made more objective by measurements of left ventricular end-systolic and end-diastolic dimensions.

The severity of heart valve conditions is assessed by examining the anatomical appearance of the valve, the flow characteristics with Doppler examination, and the haemodynamic consequences of the valve lesion for left ventricular function, dimensions and wall thickness. Intervention for heart valve conditions should be undertaken before left ventricular impairment occurs.

The severity of heart failure is assessed by examining right and/or left ventricular wall movement (pumping action of the ventricles) and thickening (the normal ventricular wall thickens in systole), and chamber dimensions.

What conditions may be diagnosed by echocardiography?

The following common cardiac diagnoses may be clinched by echocardiography:

• heart failure

• aortic stenosis and its gradient – significant left ventricular impairment will result in a spuriously low aortic valve peak systolic gradient

• aortic regurgitation

• mitral stenosis and valve area – this determines severity and need for intervention

• mitral valve prolapse

• mitral regurgitation

• hypertensive heart muscle disease

• left ventricular impairment caused by infarction

• dilated cardiomyopathy

• hypertrophic cardiomyopathy.

Serial echocardiography is useful for:

• monitoring the progression of valvular heart disease to decide on the timing of valve surgery and its effects on left ventricular dimensions and function

• assessing the effects of antihypertensive treatment on left ventricular wall thickness

• after myocardial infarction, investigating recovery and resolution of left ventricular impairment.

The test

The test is completely harmless and carries no risk in pregnant women. It is performed in a darkened room so that the heart images can be seen more easily on the monitor. The patient is asked to take off their outer clothing and lie at an angle of about 45° on their left side. Ultrasound jelly is then applied to the transducer, which is pressed firmly over the chest and moved in order to find a satisfactory echo-window in an intercostal space.

The transducer is angled and rotated so as to obtain several views of the heart. The patient will hear a ‘whooshing' noise, which is the sound of the electronic Doppler signal denoting blood flow. The test can be completed within a few minutes depending on the question being asked and the echogenicity of the patient.

The report

This should provide both anatomical and physiological information. Colour flow Doppler examination may show physiological mitral and/or tricuspid regurgitation. Heart failure is excluded if left ventricular function is normal.

Dr Clive Handler is consultant in pulmonary hypertension at the Royal Free Hospital, London

Dr Gerry Coghlan is consultant cardiologist at the National Pulmonary Hypertension Unit, Royal Free Hospital, London

This article is based on a chapter in Management of Cardiac Problems in Primary Care by Dr Clive Handler and Dr Gerry Coghlan, published by Radcliffe.

Radcliffe Publishing is offering a 20% discount to Pulse readers (usual price £29.95+p&p, offer price £23.96+p&p). To claim, order via www.radcliffe-oxford.com or by telephone on 01235 528820. Please quote discount code ‘Pulse'. Offer expires 31 May 2009.

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indications patient Patient information Patient information

• Echocardiography is an ultrasound examination of the heart
• It is the same test as the ultrasound tests done in pregnancy, and is completely harmless and painless
• The test provides useful information about the structure and strength of the heart muscle, the heart valves and the size of the heart chambers; it is useful in all age groups
• It tells us if your heart is weak and whether you might benefit from certain tablets
• You will be asked to lie on a couch, and some ultrasound jelly will be put on your chest
• A probe is then pressed fairly hard on the chest wall and ultrasound pictures are displayed on a TV screen
• If you hear a ‘whooshing' noise, this is the sound of a Doppler test being done at the same time, which provides useful information about the flow of blood through the heart valves
• It tells us whether the valves are working properly or if they are narrowed or leaky
• The test does not usually take longer than 10 to 15 minutes
• You can eat and drink normally before and after the test

The report should include structural information and blood flow based on Doppler Doppler echo

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