Echocardiogram (Echo): Why you may need one and what to expect

If you’re interested in learning about the significance of a transthoracic echocardiogram (also known as “Echo”), you’ve found the right source. This guide aims to provide you with a basic understanding of echocardiography and its vital role in Cardiology. I’ve also included a brief video to help you better understand the procedure.

What is an Echocardiogram

An echocardiogram is a test that examines the heart’s valves and chambers. During the test, a sonographer will use a transducer to capture ultrasound images of the heart by placing them on the chest. Importantly, this test is non-invasive and painless and does not expose the patient to harmful X-ray radiation. Moreover, it provides real-time visuals of the beating heart’s structure, valves, and blood flow patterns, thereby enabling early diagnosis and prompt treatment of various heart conditions. In summary, an echocardiogram is a quick and non-invasive diagnostic test that can help determine if symptoms like shortness of breath are related to heart problems.

Echocardiogram: When and why it might be necessary

There are several indications for performing an echocardiogram, which can aid in diagnosing, monitoring, and evaluating the effectiveness of treatments. Some typical situations when you may need an echocardiogram include:

When You Have a Heart Murmur

If your doctor detects an unusual sound during your heart examination, known as a heart murmur, an echocardiogram can help identify the root cause. This test provides detailed images of your heart’s structure and blood flow, enabling us to determine whether the murmur is due to a serious underlying heart condition or just an insignificant discovery.

When You Experience Chest Pain or Shortness of Breath

If you’re experiencing chest pain or shortness of breath, an echocardiogram can help investigate the cause. These symptoms may be related to various heart conditions, such as coronary artery disease, valve problems, or heart failure. We can determine if your symptoms are heart-related by visualizing your heart’s function and blood flow. Moreover, an echocardiogram is an essential part of the stress echocardiogram test, which helps investigate chest pain and breathing difficulties during physical exertion.

When You Have an Irregular Heartbeat (Arrhythmia)

If you experience an irregular heartbeat, also known as arrhythmia, an echocardiogram can help to identify any structural or functional issues that may be contributing to the problem. Arrhythmias can arise from various heart conditions or abnormalities, such as atrial fibrillation (AF) or damaged heart muscle resulting from a prior heart attack. An echocardiogram can provide valuable insights into the underlying cause of your arrhythmia and help guide treatment options.

When You Have a Cardiomyopathy (weakening of the heart muscle)

Cardiomyopathies are diseases that affect the heart muscle. They can reduce the heart’s ability to pump blood effectively, leading to heart failure. If there is a suspicion that you may have a cardiomyopathy, an echocardiogram is the standard test to diagnose this problem and monitor treatment progress.

When You Have a Valvular Heart Disease

The heart has four valves whose primary function is to ensure that the blood flows in a unidirectional manner, moving forward from one chamber to another without returning to the previous one. An echocardiogram is the most reliable test to evaluate the structure and function of these valves. Echo can easily detect two main valve issues: stenosis, which is the narrowing or inadequate opening of the valves, and regurgitation, which is the leaking or improper closure of the valves.

When You Have a Congenital Heart Defect

An echocardiogram detects new-born’s heart abnormalities, known as “congenital heart disease.” This test can detect defects such as holes between heart chambers or abnormal connections between blood vessels, enabling us to diagnose, treat, and monitor the condition.

When You Need to Monitor Your Heart Function and Treatment Progress

In certain heart conditions, we may recommend regular echocardiograms to monitor heart function and evaluate the effectiveness of treatments. We can adjust your treatment plan by monitoring heart function to achieve the best results.

The role of Echocardiogram in stroke evaluation and management

Transthoracic Echocardiogram is a vital test for stroke evaluation and management. A stroke occurs when the blood supply to part of the brain is stopped or reduced, usually due to a blocked or burst blood vessel. Notably, echocardiograms can identify potential cardiac sources of a stroke, such as:

Blood Clots in the Heart

A cardiac embolus is a type of blood clot that originates in the heart and then travels to the brain, causing a stroke. Echocardiogram can detect blood clots within the heart’s chambers, especially in patients with atrial fibrillation, characterized by an irregular and rapid heart rate. Atrial fibrillation significantly increases the risk of clot formation.

Patent Foramen Ovale (PFO)

A PFO is a small hole between the heart’s upper chambers from birth that usually closes shortly after. However, in around 25% of the population, the PFO remains open and does not cause any issues. In certain individuals with specific characteristics, the PFO may create an opening for blood clots to bypass the lungs and reach the brain, increasing the risk of stroke. An echocardiogram, particularly a Transesophageal Echocardiogram (TEE), can quickly identify a PFO and help determine if it is a potential cause of a stroke.

Valvular Heart Disease and Stroke

Heart valve diseases can cause blood flow disruption and increase the risk of stroke. For example, rheumatic heart disease and mitral valve stenosis can lead to blood clot formation in the left atrium, significantly increasing the risk of stroke. Infection of the heart valves can cause the formation of bacterial clumps called vegetations, which can detach and travel to the brain, causing a stroke. Mechanical heart valves also increase the propensity for clot formation and, consequently, the risk of stroke. An echocardiogram is the ideal test to evaluate all these conditions.

Left Ventricular Dysfunction and Heart Attack

A severely weakened or damaged left ventricle (main heart chamber) leads to blood stasis (slow or sluggish blood flow) within the heart. Stasis is especially concerning in people who have recently experienced a significant heart attack. Due to the impairment of the heart muscle, the blood flow around the affected areas (infarct zone) slows down, leading to the formation of blood clots. These loose clots can easily detach from the walls, travel to the brain and result in a large stroke in the sufferers of the heart attack. An echocardiogram can assess left ventricular function and help identify the clots.

Cardiac Masses

Cardiac masses are abnormal growths within the heart. They can be benign (non-cancerous) or malignant (cancerous). They originate from various parts of the heart and can increase the risk of stroke by detaching and travelling to the brain. Echocardiograms play a crucial role in detecting and characterizing these masses, helping to guide diagnosis and treatment decisions.

- Benign Cardiac Masses:

Benign cardiac masses include myxomas, rhabdomyomas, and fibromas. The most common type of benign cardiac tumour is myxomas, which typically occur in the atria and can cause obstruction of blood flow or embolization, leading to stroke. Rhabdomyomas and fibromas are less common and usually occur in the ventricles. An echocardiogram identifies these masses’ location, size, and attachment site, aiding in diagnosis and treatment.

Case 1: Left atrial myxoma

Video: A 38-year-old man presented with palpitations. As part of the work-up, an Echocardiogram revealed the presence of a mobile mass in the left atrium. The mass appeared benign and was attached to the left atrial wall by a stalk, along with a few loosely attached strands. Due to the high risk of detachment of fragments and embolization to the brain, leading to a stroke, it is crucial to remove the mass surgically.

Images: Figure 1 displays the Left Atrial mass on a CT Coronary Angiogram before his surgery, while Figure 2 illustrates the mass after surgical removal. The mass was fragile and could easily be fragmented during resection. This raises the probability of embolization, leading to a devastating stroke in a young individual. Following the surgery, a pathology report confirmed that the mass was a benign Myxoma.

- Malignant Cardiac Masses:

Malignant cardiac masses, or cardiac malignancies, can be either primary (originating in the heart) or metastatic (spreading to the heart from another location). Primary cardiac malignancies, such as sarcomas and lymphomas, are rare. Metastatic cardiac malignancies (Case-2) are more common and can originate from cancers in the lung, breast, skin or other organs. Echocardiograms can detect the presence of these masses and help assess their impact on heart function.

Case 2: Metastatic Melanoma in the Left Ventricle

Video: A 65-year-old man presented with a stroke. During the investigations, he underwent an Echocardiogram that revealed a mobile mass in his left ventricle. Further tests and pathological reports confirmed that the mass was melanoma, a form of malignant skin cancer. Unfortunately, part of the mass had metastasized to his brain, causing a stroke.

- Valvular Masses:

Valvular masses, such as papillary fibroelastomas and valve strands, are growths that occur on the heart valves. Papillary fibroelastomas are the most common type of valvular mass and are usually present on the aortic or mitral valve. These masses can cause valve dysfunction or serve as a source of emboli, leading to stroke or other complications. Echocardiograms, particularly Transesophageal Echocardiograms (TEE), are highly effective in detecting and characterizing valvular masses.

In summary, echocardiograms play a vital role in evaluating and managing stroke patients by identifying potential cardiac sources of emboli, such as blood clots, patent foramen ovale, valvular heart disease, left ventricular dysfunction, infective endocarditis, and masses. By providing detailed images of the heart’s structure and function, echocardiograms help guide treatment decisions and reduce the risk of recurrent strokes. If you have experienced a stroke or are at high risk for one, your doctor may recommend an echocardiogram.

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The role of Echocardiogram in cancer patients and chemotherapy

Transthoracic Echocardiogram has become a crucial tool in monitoring chemotherapy patients. Cancer patients undergoing chemotherapy have an increased risk of developing cardiovascular complications, particularly those with a history of heart disease. Various cardiac complications have been reported, including:

- Heart rhythm abnormalities (Arrhythmias)
- Heart enlargement and pump failure (dilated cardiomyopathy)
- Spasms of the cardiac vessels, resulting in chest pain or heart attack
- Inflammation of the surrounding sac of the heart, causing pericarditis and fluid accumulation (pericardial effusion)

Chemotherapeutic agents involved in cardiac complications:

Many chemotherapy drugs, particularly a class of medications called anthracyclines, are known to be cardiotoxic and may cause damage to the heart muscle (Chemotherapy-induced Cardiomyopathy). Anthracyclines, such as doxorubicin and epirubicin, are commonly used to treat various types of cancer, including breast cancer, lymphoma, and leukemia, due to their effectiveness in targeting cancer cells. Other chemotherapy agents, such as trastuzumab (Herceptin), a monoclonal antibody used to treat HER2-positive breast cancer, and tyrosine kinase inhibitors, like sunitinib and sorafenib, have also been associated with cardiotoxic effects. Newer immunotherapy agents, such as checkpoint inhibitors, have been reported to cause myocarditis, an inflammation of the heart muscle. However, their potential cardiotoxic effects warrant close monitoring of heart function. Echocardiograms can help detect and monitor these effects, allowing timely intervention to minimize cardiac damage.

Baseline Evaluation:

An echocardiogram assesses the patient’s heart function before chemotherapy, especially for cardiotoxic drugs. It determines if the heart can tolerate the chemotherapy regimen and sets a baseline for future echocardiograms.

Monitoring Cardiac Function and Early Detection of Cardiotoxicity:

Regular echocardiograms are common to monitor the patient’s cardiac function during chemotherapy, particularly the left ventricular ejection fraction (LVEF). LVEF is the percentage of blood pumped out of the left ventricle with each heartbeat. The normal range for LVEF is between 55-70%. If the LVEF decreases below this range, it may indicate that the chemotherapy drugs are adversely affecting the heart muscle. GLS, or Left Ventricle Global Strain, is a more sensitive parameter than LVEF for monitoring cardiac function during chemotherapy. It can detect early signs of heart muscle damage. If significant Cardiotoxicity is detected, doctors may adjust the dosage, change chemotherapy drugs, or introduce heart-protective medications such as ACE inhibitors or beta-blockers.

Long-term Follow-up:

After undergoing chemotherapy, it is crucial to continue monitoring the patient’s heart function, as cardiotoxic effects may appear after the treatment is completed. Moreover, patients who have experienced chemotherapy-induced Cardiotoxicity are at a higher risk of developing long-term cardiac complications, such as chronic heart failure or arrhythmias. Regular echocardiograms are recommended to monitor heart function and ensure prompt management and treatment of any issues that may arise.

In summary, echocardiograms are crucial in assessing and monitoring heart function in chemotherapy patients. By early detection of cardiac complications, we can help mitigate the potential risks associated with cardiotoxic chemotherapy drugs. Furthermore, ongoing monitoring with echocardiograms allows for the timely management of any long-term cardiac effects, ultimately improving patient care and quality of life.

How Often Should You Get an Echocardiogram? Factors to Consider

Understanding the frequency of echocardiograms is crucial for individuals with various heart health concerns, as it helps ensure proper monitoring and management of their conditions. The frequency at which you should undergo an echocardiogram depends on several factors, including your heart condition, risk factors, symptoms, and doctor’s recommendations. Some general guidelines for echocardiogram frequency are as follows:

Healthy Individuals:

Routine echocardiograms are usually unnecessary for individuals without known heart conditions or risk factors. However, some people may choose to have a baseline echocardiogram as part of a comprehensive health assessment, especially if they have a family history of heart disease. Moreover, if new symptoms or concerns arise, such as chest pain, shortness of breath, or a heart murmur, we may recommend an echocardiogram to investigate the cause.

Monitoring Existing Heart Conditions:

For patients with known heart conditions, such as heart valve disease (e.g., aortic stenosis or mitral valve prolapse), cardiomyopathy (e.g., hypertrophic cardiomyopathy or dilated cardiomyopathy), or congenital heart defects, the frequency of echocardiograms will depend on the severity of the condition. Generally, you may require regular echocardiograms every 6 to 12 months or more frequently if the condition warrants closer monitoring. Your cardiologist will determine the appropriate frequency based on your specific situation.

After Heart Surgery or Intervention:

Following a heart surgery such as valve replacement or valve repair, you may require frequent echocardiograms to monitor your recovery and ensure the intervention’s success. The frequency of echocardiograms depends on the type of surgery or intervention performed and your post-operative recovery. Initially, you may need echocardiograms every few weeks or months, but the frequency will decrease as your condition stabilizes.

Chemotherapy Patients:

In patients receiving cardiotoxic chemotherapy drugs, echocardiograms may be performed before starting treatment to establish a baseline, during treatment to monitor for potential cardiac complications, and after completing therapy to assess the heart’s recovery. The frequency of echocardiograms depends on factors such as the specific chemotherapy regimen, the patient’s age, pre-existing heart conditions, and the physician’s recommendations. Close collaboration between the oncologist and cardiologist is essential to determine the appropriate monitoring schedule.

Pregnant Women:

Pregnant women with pre-existing heart conditions or those who develop pregnancy-related heart problems, such as gestational hypertension or preeclampsia, may require echocardiograms to monitor their heart health throughout pregnancy. The frequency of echocardiograms will depend on the specific condition and the obstetrician’s or cardiologist’s recommendations.

Athletes:

Competitive athletes, particularly those participating in high-intensity sports, may undergo periodic echocardiograms as part of their pre-participation screening or ongoing health assessments. This helps identify underlying heart conditions that could put them at risk during intense physical activity. The frequency of echocardiograms for athletes may vary based on their sport, level of competition, and governing body guidelines.

Individuals with Cardiovascular Risk Factors:

People with multiple cardiovascular risk factors, such as hypertension, diabetes, obesity, or a strong family history of heart disease, may benefit from periodic echocardiograms to assess their heart health and detect any early signs of cardiac dysfunction. The frequency of echocardiograms in this group will depend on the individual’s specific risk profile and their doctor’s recommendations.

Patients with Systemic Diseases Affecting the Heart:

Certain systemic diseases, such as lupus, rheumatoid arthritis, ankylosis spondylitis, Marfan’s syndrome, or sarcoidosis, can affect the heart and require periodic echocardiograms to monitor cardiac involvement. The frequency of echocardiograms in these patients will depend on the specific disease, its severity, and any cardiac symptoms.

The frequency of echocardiograms may differ for each individual depending on their heart health status, underlying conditions, and ongoing treatments. It is vital to work closely with your physician, understand why you need an echocardiogram, and follow their advice to ensure that you receive the appropriate level of monitoring and care for your specific situation.

What to Expect During an Echocardiogram: Procedure, Duration, and Comfort

Understanding what happens during an echocardiogram is essential for individuals undergoing this diagnostic test. The echocardiogram procedure is non-invasive, painless, and relatively quick, providing valuable insights into your heart’s structure and function. Here’s what you can expect during the process:

Patient Preparation:

Before the echocardiogram, you may be asked to remove clothing from your upper body and wear a gown. You will lie down on an examination table, and small electrodes will be placed on your chest to monitor your heart rate during the procedure.

Application of Ultrasound Gel:

The sonographer or technician will apply a water-based gel to your chest. The gel helps conduct the ultrasound waves and ensures optimal contact between the transducer and your skin. While the gel may feel cold initially, it is necessary to obtain clear images of your heart.

Image Acquisition:

The sonographer will place the handheld transducer (a device that emits and receives ultrasound waves) on your chest and move it over different areas to obtain images of your heart from various angles. You may be asked to change positions or hold your breath briefly during the procedure to capture the best images. The transducer sends high-frequency sound waves into your body, which bounce off your heart and return to the transducer, converting the sound waves into electrical signals. A computer will process and display these signals as real-time images on a screen, allowing cardiologists to assess your heart’s structure and function. In some cases, the sonographer may need to apply slight pressure with the transducer to obtain clearer images, which may cause minor discomfort.

Duration and Potential Discomfort:

The echocardiogram typically takes about 30 minutes to complete, although the duration may vary slightly depending on the complexity of the case and the need for additional images.

Post-Procedure:

After the echocardiogram, the sonographer will remove the electrodes and gel from your chest, and you can get dressed. You can resume your normal activities immediately following the procedure, as no recovery time is needed. Your cardiologist will review the images and provide you with the results, along with any necessary recommendations for further testing or treatment.

An echocardiogram is a safe, noninvasive, and relatively quick procedure that provides valuable information about heart health. Understanding what to expect during the test can help you feel more prepared and comfortable.

Conclusion

Echocardiography is an indispensable diagnostic tool in cardiology that enables physicians to assess the structure and function of the heart non-invasively. Although it is not used as a routine screening test for the general population, an echocardiogram is crucial in diagnosing heart abnormalities, monitoring disease progression, and guiding evidence-based treatment decisions for patients with symptoms or risk factors.

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Dr Reza Moazzeni | Cardiologist Sydney (Westmead)

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