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INTRODUCTION

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Echocardiography is the principal imaging method employed to assess patients with known or suspected congestive heart failure. The appropriate use criteria for echocardiography highlight the important and appropriate role of echocardiography in the evaluation of these patients, as do the guidelines for the use of imaging in heart failure.1,2 The recently published guidelines for the management of patients with CHF as well as the guidelines for the use of imaging in CHF both emphasize the central role that echocardiography plays in the initial evaluation and ongoing management of these patients.2,3 "Although a complete history and physical examination are important first steps, the most useful diagnostic test in the evaluation of patients with or at risk for HF (eg, postacute MI) is a comprehensive 2-dimensional echocardiogram; coupled with Doppler flow studies, the transthoracic echocardiogram can identify abnormalities of myocardium, heart valves, and pericardium."3

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In this chapter, Dr. Aurigemma and his colleagues will provide insight into the role of echocardiography in the clinical management of these patients, including the evaluation of the patient presenting with dyspnea, CHF due to systolic and diastolic dysfunction, and the critical role that echocardiography plays in the decision-making process for device therapy (ICD and CRT). In addition, we will visit the important role of echocardiography in the evaluation and management of patients with left ventricular assist devices (LVAD) and the cardiac transplant patient.

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SECTION 1: ECHOCARDIOGRAPHY IN THE EVALUATION OF THE DYSPNEIC PATIENT

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CLINICAL CASE PRESENTATION

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A 71-year-old woman, who was brought by her family to the emergency room, was admitted to the cardiology service for the evaluation of progressive dyspnea. She is visiting her family from a foreign country. Her major complaint is dyspnea on exertion and episodes of chest pain. The chest pain is nonexertional. The dyspnea began approximately 6 months ago and was thought to be due to deconditioning. However, it has progressed to the point where she can barely walk 50 feet without becoming severely short of breath. The emergency department has diagnosed congestive heart failure, and you are asked to direct further evaluation.

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She denies paroxysmal nocturnal dyspnea or orthopnea and is able to lie flat in bed. There is mild peripheral edema. She has occasional spasms of coughing; the cough is not productive. She has lost 8 pounds since the shortness of breath was first noted. The medical history is significant only for hypertension for which she has been prescribed lisinopril and hydrochlorothiazide. She takes these medications faithfully. She is a lifelong nonsmoker and does not drink alcohol.

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Examination revealed a frail, elderly woman in no respiratory distress. She becomes dyspneic, however, in moving from her chair to the bed for examination. Vital signs: her blood pressure is 155/70 mm Hg, her heart rate is 92 beats/min and regular, her room air pulse oximetry is 94%, ...

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