doi:10.1136/hrt.2007.122796 2009;95;164-170 Heart

  Luc A Piérard and Patrizio Lancellotti  

Non-invasive imagingEchocardiography in the emergency room:

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NON-INVASIVE IMAGING

Echocardiography in theemergency roomLuc A Pierard, Patrizio Lancellotti

University Hospital, Departmentof Cardiology, Liege, Belgium

Correspondence to:Professor Luc Pierard,Department of Cardiology,University Hospital, B-4000Liege, Belgium; lpierard@chu.ulg.ac.be

The evaluation and management of patientswho arrive at the emergency department withacute symptoms and/or worrying clinical condi-tion is a daily challenge. Careful history taking—when it is possible—and clinical examinationremain the mandatory first steps. It is of theutmost importance to obtain a timely accuratediagnosis and to immediately stratify the risk tothe patient’s life. Therefore, choice of the correctinvestigation is essential. Among the possibletools, imaging modalities are frequently required.Echocardiography is the most versatile method.It is non-invasive, can be performed at thebedside, provides rapid results, and avoids con-trast injection and exposure of the patient toradiation. Echocardiography is now available inmost emergency rooms, allowing immediate,standard transthoracic examination by an emer-gency department physician. For some indica-tions and some ultrasonic modalities, specialisedand trained physicians or sonographers arenecessary for performance and interpretation.

This article focuses on the clinical informationthat can be obtained from echocardiographyaccording to the most frequent presentationssuggesting a cardiovascular emergency.

ACUTE CHEST PAIN: SUSPICION OF ACUTECORONARY SYNDROMEPatients with acute chest pain account for anotable proportion (20–30%) of medical admis-sions to the emergency department.1 Acute cor-onary syndromes can be easily identified in thepresence of typical chest pain and a diagnosticECG, and confirmed by serial changes in cardiacenzymes. However, a vast majority of patientshave atypical chest pain and/or normal or non-diagnostic ECG; early determination of serumtroponin frequently is negative. Marginal eleva-tions of troponin in this clinical setting result inuncertainty. To avoid unnecessary prolongedhospital observation (which is costly) and mis-taken discharge (with the associated potential forlitigation), rapid cost effective and accurate riskstratification is important. Numerous alternativestrategies are possible (table 1).

Echocardiography can be performed only at rest,conventionally or with implementation of anultrasound contrast agent. Echocardiography canalso be coupled with exercise or pharmacologicalstress testing.

Rest echocardiographyA brief echocardiographic examination can beperformed in ,10 min. The primary role of restechocardiography when performed in the emer-gency room is to assess the presence and extent ofregional wall motion abnormalities. A dyssynergicventricular region can be ischaemic, stunned,hibernating or necrotic. In particular, the distinc-tion between ongoing ischaemia and previousmyocardial infarction may be difficult; in addition,acute ischaemia can occur in segments adjacent tonecrotic tissue. On the other hand, the absence ofsegmental dyssynergy cannot definitely exclude arecent episode of ischaemia in the absence ofstunning. Regional wall motion abnormalities canalso be present in other conditions, such asmyocarditis, right ventricular (RV) pressure orvolume overload, pre-excitation, left bundle branchblock or the presence of a pacemaker.

The main limitation is that recording of reliableimages can be technically difficult if a skilledechocardiographer is not available. The interpreta-tion of subtle wall motion abnormalities requirestraining and experience. The current developmentof telemedicine may be helpful; an expert can guidethe recording and interpret images accurately.

A major advantage is the versatility of theechocardiogram. Cardiac causes of acute chest painother than coronary artery disease can be detected(box 1).

Contrast echocardiographySlow bolus intravenous injections or continuousinfusion of an ultrasonic contrast agent containingsmall microbubbles results in the opacification ofthe left ventricle, improving endocardial borderdetection, and permits the observation of myocar-dial perfusion. The assessment of both regionalfunction and perfusion at the bedside represents asignificant advantage. A multicentre study com-pared contrast echocardiography and gated singlephoton emission computed tomography (SPECT)in more than 200 patients presenting to theemergency room with chest pain and non-diag-nostic ECG. Both methods provided more incre-mental information for early cardiac events thandid the demographic, clinical and ECG assessment.2

Another study in the same clinical setting usedcontrast echocardiography in 957 patients. Thistechnique provided accurate short, intermediate,and long term prognostic information. Normalregional function was most efficient for predicting

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lowest risk. For a given regional function, normalperfusion was indicative of a very low risk whereasabnormal perfusion identified a high risk for acutecoronary syndrome.3 However, the choice ofappropriate technical settings and correct inter-pretation of images require experience which is noteasily obtained by emergency department physi-cians.

Stress echocardiographyCurrent guidelines recommend pre-discharge exer-cise testing in patients with acute chest pain,normal or non-diagnostic ECG, and normal serumtroponin values. The diagnostic accuracy of STsegment changes is limited, however.

Exercise echocardiography requires trained phy-sicians, and patients who are capable of exercising.Echocardiograms are performed at rest and eitherimmediately after treadmill or bicycle exercise, orpreferably at peak stress during supine bicycleexercise.4

Exercise echocardiography and exercise SPECThave been shown to provide comparable short termprognostic information in the triage of chest painpatients, allowing safe early discharge; the negative

predictive value was 97% in both methods, butexercise echocardiography is preferable because of ahigher positive predictive value.5

Pharmacological stress echocardiography can beused in patients unsuitable for exercise testing.Graded dobutamine infusion with addition ofatropine if necessary, or high dose dipyridamoleand atropine, can be used as stressors. Earlydobutamine stress after admission to the emer-gency room has been shown to be feasible and safe.Pre-discharge dobutamine stress echocardiographyhas important and independent prognostic value inlow risk, troponin negative, chest pain patients.6 Ascompared to exercise ECG, dobutamine stressechocardiography was found to be more costeffective: the mean length of stay in the hospitalwas lower; and no event occurred in a 2 monthfollow-up in patients with a normal dobutaminetest, whereas the event rate was 11% in patientswith normal exercise ECG.7 Several studies com-bining patients submitted to exercise echocardio-graphy or dobutamine stress echocardiographyhave also demonstrated good risk stratification,especially through a high negative predictivevalue.8 9

In summary, echocardiography has an importantrole in the evaluation of chest pain in theemergency room when the ECG is non-diagnostic.Rest echocardiography alone has diagnostic limita-tions. Contrast or stress echocardiography havesubstantial value for the accurate detection ofacute coronary syndromes and for prediction orrisk. The strength of these methods is their highnegative predictive value. The positive predictivevalue depends on the patient’s characteristics, inparticular his probability of suffering from signifi-cant coronary artery disease.

ACUTE CHEST PAIN: OTHER CAUSES

PericarditisIndividuals with pericarditis usually present withchest pain, which is classically increased in thelying position and during inspiration. The pain canbe transient. The ECG may show ST segmentelevation but it is usually widespread and concaveupwards. A pericardial friction rub is audible inonly one third of patients and frequently transi-ent.10 Elevated cardiac troponin can be detected inhalf of the patients.11 Echocardiography is helpful ifpericardial effusion is detected; this occurs in twothirds of cases.12 However, regional wall motionabnormalities may be present if pericarditis isassociated with myocarditis, and small pericardialeffusion is a frequent complication of acutemyocardial infarction.

In the absence of pericardial effusion, increasedpericardial thickness is detectable, more easily fromthe subcostal window.

Aortic dissectionDissection of the aorta is a life threateningcondition for which rapid diagnosis and correctmanagement are essential.13 Chest pain is typically

Table 1 Resting imaging modalities for triage of patients with acute chest pain and non-diagnostic ECG

Methods Advantages Limitations

Coronary angiography High accuracy Invasive

Low uncertainty Limited immediate availability

Restingechocardiography

Widely availableDiagnosis of causes other than CAD

Difficult interpretation of regionaldyssynergy

Normal if no ischaemia at rest

Contrastechocardiography

Improved endocardial detectionRegional function and perfusionRapid examination

Challenging interpretation of perfusionimages

Multislice CT Rapid image acquisition Requires apnoea and contrast injection

Diagnosis of causes other than CAD Radiation

Coronary anatomy

Cardiac MRI Detection of function, perfusion andnecrosis

No isotopes

Limited immediate availabilityQuantitative information

SPECT High negative predictive value Not available ‘‘after hours’’

Wide validation

CAD, coronary artery disease; CT, computed tomography; MRI, magnetic resonance imaging; SPECT, singlephoton emission computed tomography.

Box 1 Acute chest pain—cardiac causes detectable by restechocardiography

c Acute coronary syndromec Pericarditisc Aortic dissection (low sensitivity of transthoracic echocardiography)c Hypertrophic cardiomyopathyc Aortic stenosisc Mitral valve prolapse

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severe, and immediately of maximum intensity.Clinical suspicion is easier if the pain is migratingand in the presence of specific malperfusionsyndrome. Rapid and non-invasive diagnosticimaging is required; the choice of the modalitydepends on the relative immediate availability.14

Transthoracic echocardiography can be performedwithout delay to visualise the aortic root and arch,but the distal ascending aorta and descending aortaare more difficult to evaluate. The specificity ishigh (90%). The sensitivity has been shown to varyfrom 55–75%; the proportion of false negativestudies decreases when all ultrasonic windows areused, including right parasternal, subcostal, supr-asternal, abdominal or even dorsal views. Clearly, anormal transthoracic echocardiographic examina-tion cannot rule out aortic dissection. A majorpitfall is the possibility of reverberation artefacts.The presence of a mobile intimal flap separatingthe true and false lumen can be observed in theproximal ascending aorta. Severe complications canalso be identified from the transthoracic approach:acute aortic regurgitation, pericardial effusion, orregional wall motion abnormalities suggestive ofdissection involving a coronary artery.

Transoesophageal echocardiography is the pre-ferred ultrasonic modality (fig 1).15 The blindregion is limited to the most distal part of theascending aorta and the proximal part of the arch.An intimal flap, a large false lumen and a truelumen are diagnostic. The assessment of entry isessential to distinguish between type A and type B,as their management strategies are strikinglydifferent.16 Several features may be able to differ-entiate the true and false lumen. The false lumen isusually larger; its diameter increases in diastole;intense spontaneous contrast is frequent in the

presence of blood stasis; and thrombus can beobserved. Accuracy of transoesophageal echocar-diography requires skilled hands. This method ofimaging is the preferred first choice in theemergency room in centres where an experiencedcardiologist is readily available.17 The positivepredictive value is of course dependent on thedisease prevalence and is lower than magneticresonance imaging (MRI) in the low prevalencepopulations.18

Other causes of acute aortic syndrome includeintramural haematoma and penetrating athero-sclerotic ulcers. Although their managementremains controversial, proper identification is ofclinical importance. Transthoracic echocardiogra-phy is of limited value and the transoesophagealapproach is more efficient. The semiology ofintramural haematoma is well known: .7 mmcrescent or circumferential heterogenous thicken-ing of the aortic wall. Longitudinal extension isusually important. Sometimes, an echo-free regionmay be observed, suggesting haemorrhage orliquefaction of the haematoma. If the diagnosis isquestionable, other imaging modalities such asMRI may be necessary.19 A penetrating athero-sclerotic ulcer most frequently occurs in thedescending aorta; the transoesophageal window isthus mandatory, but computed tomography andMRI perform better.

Pulmonary embolismChest pain is frequent (65%) in patients admittedto the emergency room with a pulmonary embo-lism, but is usually associated with dyspnoea. Bothsymptoms and clinical signs are not specific andthe differential diagnosis is frequently difficultwith acute coronary syndromes or other condi-tions.20 If echocardiography is immediately avail-able, important information can be rapidlyobtained. The visualisation of a large mobile,serpentine thrombus trapped in the right heartchambers (embolism in transit) is rare but makesthe diagnosis evident.21 Transoesophageal echocar-diography is a useful method to visualise pulmon-ary embolism, especially if it is central. In this case,the sensitivity is 90–95% and the specificity is100%.22 In practice, echocardiography providesexcellent assessment of the acute haemodynamicconsequences. The main findings, although non-specific, are dilatation of the right heart chambersand of the inferior vena cava, abnormal motion ofthe interventricular septum, and an abnormal ratioof right ventricular (RV) diameter or area to leftventricular (LV) diameter or area. A ratio betweenend diastolic right to LV diameter .0.6 and a ratioof end diastolic right to LV area .1.0 are consistentwith massive pulmonary embolism associated withRV dysfunction (fig 2).23

Another interesting feature is hypokinesis of themid RV free wall and preserved contraction of theRV apex: the so-called McConnell sign.24 RVsystolic pressure, and thus systolic pulmonaryarterial (PA) pressure in the absence of pulmonaryvalve stenosis, can be estimated from the peak

Figure 1 Transoesophageal echocardiographic examination obtained in a patient withacute aortic dissection. EO, entry orifice; FL, false lumen; H, intense spontaneous contrast+ thrombus; TL, true lumen.

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velocity of the tricuspid regurgitant jet andapplication of the simplified Bernoulli equation:PA systolic pressure = right atrial pressure + 4V2.Right atrial pressure is estimated by clinicalexamination of the jugular veins or by the diameterof the inferior vena cava and its respiratorychanges. In the presence of a first episode ofpulmonary embolism, systolic PA pressure cannotincrease to more than 40–50 mm Hg. A chronicprocess—repetitive episodes of pulmonary embo-lism or chronic cor pulmonale—is probable if thePA pressure is .60 mm Hg (peak velocity oftricuspid regurgitant jet .3.5 m/s). New ultrasonicmodalities such as tissue Doppler imaging, permit-ting the measurement of RV free wall velocitiesand strain, can add significant information on RVfunction.

The parameters cited above not only help in thediagnosis of pulmonary embolism but can alsopredict prognosis. They could be used and inte-grated with troponin and B type natriureticpeptide (BNP) elevation to decide upon thetherapeutic option—for example, anticoagulationversus thrombolytic therapy.25 26

HYPOTENSION AND JUGULAR VEIN DISTENSIONThe association of hypotension and elevatedjugular venous pressure may be present in different

clinical conditions, such as acute heart failure,cardiac tamponade, RV infarction, severe pulmon-ary embolism, and exacerbation of chronic obstruc-tive pulmonary disease (COPD). Echocardiographyis well suited to potentially provide rapid diagnosisin this clinical setting.

Cardiac tamponadeCardiac tamponade corresponds to acute or sub-acute compression of the heart. It results fromimportant and/or rapid accumulation of fluid inthe pericardial space that increases intrapericardiacpressure above intracavitary pressure. Diastolicfilling is reduced and ventricular ejection iscompromised. Compensatory tachycardia andvasoconstriction initially maintain a normal car-diac output. At a critical level of intrapericardialpressure, cardiac output and arterial pressure fall.Pulsus paradoxus is present: LV stroke volumedecreases during inspiration because of reduced LVpreload and paradoxal motion of the interventri-cular septum resulting from RV volume overload.These clinical features correspond to the echocar-diographic findings. The echocardiographic diag-nosis of this life threatening condition is usuallyrapid and simple (fig 3).

Two dimensional echocardiography shows thepresence, location and volume of pericardial effu-sion. The presence of fibrin, thrombus, sponta-neous contrast or separated effusion usuallyimplies surgical drainage. The most importantaspect in the emergency room is the assessmentof haemodynamic consequences.27 Indeed, therepercussions mainly depend on the rapidity offluid accumulation rather than on effusion size.The earlier sign indicating a risk of tamponade isright atrial diastolic collapse, but its specificity ismoderate. Diastolic RV collapse occurs later, ismore specific, and is best appreciated in theparasternal short axis view. Dilatation of theinferior vena cava without change during deepinspiration has a good sensitivity but a moderatespecificity for the diagnosis of tamponade. Pulsedwave Doppler is essential. Changes in velocitiesduring inspiration should be recorded at low speed.The most interesting characteristics includeinspiratory increase of peak pulmonary ejectionvelocity (.40%) and of RV inflow velocity(.85%), as well as a parallel reduction duringinspiration of LV inflow and aortic ejectionvelocities.

If the patient’s condition requires urgent peri-cardiocentesis, the procedure can be echocardio-graphically guided.27 The subcostal view isimportant to determine the distance between thepatient’s skin and the effusion. If necessary, thecorrect position of the pericardial needle can bevisualised and, in the case of doubt, agitated salinecontrast can be injected to confirm the intraper-icardial position of the needle. Echocardiographycan of course be used to verify whether theeffusion has been completely drained.Transoesophageal echocardiography is rarely indi-cated in this setting.

Figure 2 Echocardiographic examination of a patient admitted for a recurrent episode ofpulmonary embolism. The right ventricle (RV) was enlarged compared with the leftventricle (LV) and the ratio between end diastolic RV to LV diameter was .0.6. The trans-tricuspid pressure gradient (TTPG) was notably increased, indicating severe pulmonaryhypertension.

Figure 3 Echocardiographic examination of a patient admitted for cardiac tamponade.The diagnosis was confirmed by the combination of a pericardial effusion (PE), acomplete right ventricular collapse, and the significant respiratory changes in mitral Ewave velocity.

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Acute decompensated heart failureNumerous patients, especially the elderly, areadmitted to the emergency room for acute decom-pensated heart failure (figs 4 and 5). In addition tohypotension and jugular vein distension, thesepatients present with dyspnoea and orthopnoea.Pulmonary rales, peripheral oedema and hepato-jugular reflux provide evidence of elevated fillingpressures. Rapid measures of BNP or NT-proBNPenhance the accuracy of diagnosis. Rapid distinc-tion between heart failure due to systolic versusdiastolic dysfunction should be obtained sincethere are significant differences in treatment. An

immediate echocardiogram at the bedside in theemergency room makes it possible to visualisedilatation of the heart chambers, diffuse or regionalabnormalities in contraction, functional mitraland/or tricuspid regurgitation or, in contrast,normal LV volume, enlarged left atrium, LVhypertrophy and preserved ejection fraction.Numerous additional measures and detailed eva-luation of systolic and diastolic function can beobtained later during the hospital stay.

Severe pulmonary embolismThe role of echocardiography in this clinical settinghas been already described.

ACUTE PULMONARY OEDEMAAcute cardiogenic pulmonary oedema may resultfrom acute events or from acute deterioration of achronic disease. The main mechanisms includereduced outflow, reduced inflow or backward flow.Some conditions are obvious causes of pulmonaryoedema, such as a large acute myocardial infarctionor severe tachyarrhythmias. The patients shouldfirst be treated with oxygen, nitrates and loopdiuretics. Physical examination is insensitive indetecting a cardiac murmur. Thus, Doppler echo-cardiography can be useful and performed whentreatment has been initiated.

Hypertensive crises induce exacerbation of dia-stolic dysfunction. In this setting, systolic dysfunc-tion is not observed, even transiently; the LVejection fraction can be normal and similar to thatfound later after treatment.28

Doppler echocardiography can rapidly revealvalvular heart disease, such as severe aorticstenosis, severe acute aortic regurgitation due toendocarditis or rupture of a sinus of Valsalva in theLV, huge mitral regurgitation resulting frompapillary muscle or primary chordae rupture, orsevere dysfunction of a prosthetic valve. Dynamicexacerbation of chronic ischaemic mitral regurgita-tion is another condition, probably more difficultto ascertain, because early treatment, especiallyglyceryl trinitrate, substantially decreases mitralregurgitant volume. Ischaemic mitral regurgitationmay appear to be mild or moderate, although itcould have been severe at the onset of thesyndrome. If this condition is suspected, exerciseDoppler echocardiography could reveal it a fewdays later, showing a dynamic increase in mitralregurgitation resulting in an increase in pulmonaryvascular pressure.29 30

CONCLUSIONSEchocardiography should be available in theemergency room for immediate or rapid observa-tion at the bedside of many possible abnormalitiesthat help diagnose cardiovascular syndromes ordiseases. This quite versatile imaging method canfind a place in the diagnostic algorithm of mostclinical acute presentations. This article has onlyfocused on the most frequent or importantapplications.

Figure 4 Echocardiographic examination showing depressed left ventricular (LV)systolic function in a patient admitted for acute dyspnoea.

Figure 5 Echocardiographic examination showing preserved left ventricular (LV)systolic function in a patient admitted for acute dyspnoea. The diagnosis of hypertrophiccardiomyopathy was made. The spectral tissue Doppler derived E/Ea ratio revealed anincreased LV filling pressure confirming the diagnosis of diastolic heart failure. E, earlymitral inflow velocity; Ea, diastolic mitral annular velocity.

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Competing interests: In compliance with EBAC/EACCME guide-lines, all authors participating in Education in Heart have disclosedpotential conflicts of interest that might cause a bias in the article.The authors have no competing interests.

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Glasgow: general practices vary despite adjustments for age, sexand deprivation. Br J Gen Pract 1999;49:551–4.

2. Kaul S, Senior R, Firschke C, et al. Incremental value of cardiacimaging in patients presenting to the emergency department withchest pain and without ST-segment elevation: a multicenter study.Am Heart J 2004;148:129–36.

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6. Bholasing R, Cornel JH, Kamp O, et al. Prognostic value ofpredischarge dobutamine stress echocardiography in chest painpatients with a negative cardiac troponin T. J Am Coll Cardiol2003;41:596–602.

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c Study reporting the superiority of early dobutamine stressechocardiography in patients presenting with chest pain.

8. Colon PJ, Cheirif J. Long-term value of stress echocardiography inthe triage of patients with atypical chest pain presenting to theemergency department. Echocardiography 1999;16:171–7.

c Study showing the prognostic value of stress echo-cardiography in patients presenting with acute chest pain.

9. Jeetley P, Burden L, Senior R. Stress echocardiography is superiorto exercise ECG in the risk stratification of patients presenting withacute chest pain with negative troponin. Eur J Echocardiogr2006;7:155–64.

c Important study reporting the superiority of stressechocardiography in patients presenting with acute chestpain.

10. Imazio M, Demichelis B, Parrini I, et al. Day-hospital treatment ofacute pericarditis: a management program for outpatient therapy.J Am Coll Cardiol 2004;43:1042–6.

11. Bonnefoy E, Godon P, Kirkorian G, et al. Serum cardiac troponin Iand ST-segment elevation in patients with acute pericarditis. EurHeart J 2000;21:832.

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14. Cigarroa JE, Isselbacher EM, DeSanctis RW, et al. Diagnosticimaging in the evaluation of suspected aortic dissection. Oldstandards and new directions. N Engl J Med 1993;328:35–43.

15. Nienaber CA, von Kodolitsch Y, Nicolas V, et al. The diagnosis ofthoracic aortic dissection by noninvasive imaging procedures.N Engl J Med 1993;328:1–9.

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c Important study comparing the accuracy of magneticresonance imaging versus transoesophagealechocardiography for the diagnosis of thoracic aorticdissection.

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18. Moore AG, Eagle KA, Bruckman D, et al. Choice of computedtomography, transesophageal echocardiography, magneticresonance imaging, and aortography in acute aortic dissection:International Registry of Acute Aortic Dissection (IRAD).Am J Cardiol 2002;89:1235–8.

19. Nienaber CA, Sievers HH. Intramural haematoma in acute aorticsyndrome: more than one variant of dissection? Circulation2002;106:284–5.

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Echocardiography in the emergency room: key points

Acute coronary syndrome

c Echocardiography is helpful in patients with non-diagnostic ECG and negativetroponin.

c The absence of segmental dyssynergy on resting echocardiography cannotexclude recent ischaemia.

c Rest echocardiography alone has diagnostic limitations.c Normal perfusion on contrast echocardiography is indicative of very low risk.c Stress echocardiography is recommended in patients with non-diagnostic ECG

and negative troponins.c The positive predictive value of stress echocardiography is mainly based upon

the likelihood of significant coronary artery disease.

Acute heart failure

c Rapid diagnosis in patients presenting with hypotension and jugular veindistension.

c Immediate risk stratification and provides help in clinical decision making.c Distinction between heart failure due to systolic versus diastolic dysfunction.c Cardiac tamponade: association of pericardial effusion, right atrial diastolic

collapse and respiratory changes (.40% of decrease) in mitral E velocity.c Severe pulmonary embolism: association of right ventricular dilatation,

hypokinesis of the mid right ventricular free wall, significant pulmonaryhypertension and elevated BNP.

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22. Leibowitz D. Role of echocardiography in the diagnosis andtreatment of acute pulmonary thromboembolism. J Am Soc Echo2001;14:921–6.

c An excellent review on the role of echocardiography in thediagnosis of pulmonary embolism.

23. Goldhaber SZ. Thrombolysis for pulmonary embolism. N Engl J Med2002;347:1131–2.

24. McConnell MV, Solomon SD, Rayan ME, et al. Regional RVdysfunction detected by echocardiography in acute pulmonaryembolism. Am J Cardiol 1996;78:469–73.

25. Douketis JD, Crowther MA, Stanton EB, et al. Elevated cardiactroponin levels in patients with submassive pulmonary embolism.Arch Intern Med 2002;162:79–81.

26. ten Wolde M, Tulevski II, Mulder JW, et al. Brainnatriuretic peptide as a predictor of adverse outcome inpatients with pulmonary embolism. Circulation2003;107:2082–4.

27. Maisch B, Seferovic PM, Ristic AD, et al. Guidelines on thediagnosis and management of pericardial disease. Eur Heart J2004;25:587–610.

28. Gandhi SK, Powers JC, Nomeir AM, et al. The pathogenesis ofacute pulmonary edema associated with hypertension. N Engl J Med2001;344:17–22.

c Important study showing that acute pulmonary oedemaresults from acute diastolic dysfunction and not from acutesystolic dysfunction in hypertensive patients.

29. Pierard LA, Lancellotti P. The role of ischemic mitral regurgitationin the pathogenesis of acute pulmonary edema. N Engl J Med2004;351:1627–34.

c First clinical paper showing that dynamic mitralregurgitation could represent a mechanism of acutepulmonary oedema.

30. Levine RA. Dynamic mitral regurgitation – more than meets theeye. N Engl J Med 2004;351:1681–4.

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Activating your subscription to Heart: If you have not yet activated your online subscription to Heart,please visit journals.bmj.com/cgi/activate/basic and enter your six digit (all numeric) customer number(found above your address label with your print copy). If you have any queries, please contactsubscriptions@bmjgroup.com

Case based learning: You may also be interested in the cardiology interactive case histories publishedin association with Heart, for more information please see: heart.bmj.com/misc/education.dtl#ichs

Education in Heart

170 Heart 2009;95:164–170. doi:10.1136/hrt.2007.122796

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