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Patients with cardiovascular disease are encountered in virtually every field of medicine, from the family practitioner and general internist to the surgeon and even the obstetrician. While other "advanced imaging" modalities such as cardiac MRI and CT are able to noninvasively evaluate cardiac structure and function and provide complimentary and additional information for the clinician, no modality other than echocardiography can provide a rapid noninvasive evaluation of the heart and great vessels. Echocardiography is available in virtually any clinical setting, from the emergency department to the ICU, the operating room and the stress lab, at the bedside and in the office.

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Thus, almost every patient with known or suspected cardiac disease will be evaluated with an echocardiogram, usually as the first line-imaging tool. Echocardiography has become by far the most frequently ordered and performed cardiovascular test after the electrocardiogram. As its use has expanded, the indications and "appropriateness" in clinical cardiology have come under increasing scrutiny. In this atlas, we will explore the utility of echocardiography in clinical medicine using a case-based format. We will highlight, when available, current clinical guidelines and appropriate use criteria that should guide the utilization of echocardiography. References are intended to direct the interested reader to core references and guideline statements, including references to recently published appropriate use criteria.

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Chapter 1 provides a brief review of the various echocardiographic methods commonly used in day-to-day practice.

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Coronary artery disease (CAD) remains the leading cause of death in the developed world. Chapter 2 explores the role of echo in the diagnosis and management of patients with known or suspected CAD.

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Echocardiography is instrumental in the management of patients with valvular heart disease, and in fact is the diagnostic test of choice in evaluating the patient with a heart murmur and with previously diagnosed valvular heart disease. It was the development and acceptance of Doppler echocardiography as a method to quantify valvular heart disease that led to the widespread acceptance and increasing utilization of echocardiography. Chapter 3 provides many examples of the use of echocardiography in patients with valvular heart disease.

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Assessment of ventricular function is one of the most frequently asked questions for the echocardiographer. After a complete history and physical, a comprehensive echocardiogram should be the initial diagnostic test in the management of the heart failure patient, according to the most recent heart failure guidelines. In Chapters 4 and 5, contributors from the University of Massachusetts provide insight into the echocardiographic assessment of the patient with new onset dyspnea, known or suspected heart failure, and a variety of cardiomyopathies.

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One of the initial descriptions of the use of echocardiography in the United States was a seminal paper by Dr. Harvey Feigenbaum in 1965 describing the use of cardiac ultrasound to detect pericardial fluid. Echocardiography remains the principal imaging method to assess pericardial disease, especially in the acute setting, and is the imaging method of choice to diagnose the presence of pericardial effusions. Chapter 6 explores the use of echocardiography in pericardial disease.

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In Chapter 7, various diseases of the aorta are discussed, and in Chapter 8, our colleagues in neurology give us their perspective on the use of echocardiography in the patient with a stroke or TIA.

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Contributors from the Cleveland Clinic, in Chapters 9 and 10, explore the use of echocardiography to evaluate intracardiac masses and address the use of echocardiography in patients with atrial fibrillation, a rapidly expanding patient population.

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Chapters 11 and 12 briefly review the use of echocardiography in patients with pulmonary hypertension and pulmonary embolism as well as selected systemic diseases that can affect the heart.

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Finally, in Chapter 13, the expanding role of echocardiography, especially transesophageal echo, in interventional procedures, is discussed.

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This atlas is not intended to replace or duplicate the many comprehensive textbooks in the field of echocardiography. Rather, the goal of this atlas is to highlight the current role of echocardiography in clinical cardiology and to provide the interested reader up to date references in the field. It is my hope that this atlas will be of interest to medical students who are increasingly being exposed to various ultrasound modalities in their training, house officers and fellows, as well as primary care physicians and the cardiologist.

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David A. Orsinelli, MD, FACC, FASE

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