Transesophageal examination | Stress echocardiography

Transthoracic echocardiography is an examination with not known side effects, has a widespread availability, represents a low-cost high-effective approach and can be used in a large variety of clinical questions. However, even if the possibility of becoming a wide range screening method exists, echocardiography examinations should be rationalized to meet criteria of incremental clinical value.

The following lists of indications are based in recent publications regarding appropriateness and clinical application of echocardiography, as well as appropriateness criteria for stress echocardiography. Indications displayed below represent only class I indications, i.e. conditions for which there is evidence and/or general agreement that a given procedure is useful and effective. Newest publications classify these indications as grouped in score 7 to 9, i.e. appropriate test for specific indication (test is generally acceptable and is a reasonable approach for the indication).

Only some indications grouped under score 9 are listed below. For extensive content please refer to: Douglas PS et al. J Am Coll Cardiol 2007;50:187–204 and Douglas PS et al. Circulation 2008;117:1478-1497. These guidelines provide an estimate of the reasonableness of the use of echocardiography in different settings. However, clinical judgment will still be playing the most important role in determining whether to order an specific imaging modality for an individual patient.

Appropriate Use Criteria for Echocardiography, 2011.


Indications for transthoracic examination   (selected main indications)

– Symptoms potentially due to suspected cardiac etiology.

– Assessment of known or suspected adult congenital heart disease.

– Evaluation of suspected complication of myocardial ischemia/infarction.

– Initial evaluation of murmur in patients for whom there is a reasonable suspicion of valvular or structural
heart disease.

– Initial evaluation of prosthetic valve for establishment of baseline after placement.

– Initial evaluation of suspected infective endocarditis with positive blood cultures or a new murmur.

– Evaluation of cardiac mass (suspected tumor or thrombus).

– Evaluation of pericardial conditions: i.e. pericardial effusion, constrictive pericarditis.

– Known or suspected Marfan disease for evaluation of proximal aortic root and/or mitral valve.

– Initial evaluation of known or suspected cardiomyopathy.

Indications for transesophageal examination

– Evaluation of suspected acute aortic pathology including dissection/transsection.

– To determine mechanism of regurgitation and determine suitability of valve repair.

– To diagnose/manage endocarditis with a moderate or high pre-test probability (e.g., bacteremia, especially staph
bacteremia or fungemia).

– Persistent fever in patient with intracardiac device.

– Evaluation of patient with atrial fibrillation/flutter to facilitate clinical decision-making with regards to
anticoagulation and/or cardioversion and/or radiofrequency ablation.



Indications for stress echocardiographic examination   (some score 8 indications also included here)

Initial evaluation of chest pain syndrome or anginal equivalent

– Intermediate pre-test probability of CAD, ECG uninterpretable OR unable to exercise.


Worsening symptoms: abnormal catheterization OR abnormal prior stress imaging study

– Re-evaluation of medically managed patients.


Chest pain syndrome or anginal equivalent, prior test result

– Coronary artery stenosis of unclear significance (cardiac catheterization or CT angiography).


Preoperative evaluation for noncardiac surgery, high-risk nonemergent surgery

– Poor exercise tolerance (< 4 METs, < 75 Watts at bicycle exercise).


Risk assessment post-revascularization (PCI or CABG), symptomatic

– Evaluation of chest pain syndrome, not in the early post-procedure period.


Ischemic cardiomyopathy, assessment of viability/ischemia

– Known CAD on catheterization, patient eligible for revascularization.


Valvular stenosis

– Evaluation of equivocal aortic stenosis, evidence of low cardiac output, use of dobutamine.


Use of contrast with stress echo

– Selective use of contrast, 2 or more contiguous segments are NOT seen on noncontrast images.

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© Derliz Mereles

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