Synopsis
Use transthoracic echocardiography systematically to describe cardiac structure, ventricular and valve function, haemodynamics, limitations and findings that change clinical urgency.
- Begin with the clinical question, rhythm, blood pressure, body size and image quality because every measurement needs that context.
- A comprehensive transthoracic study surveys all chambers, valves, great vessels, pericardium and Doppler haemodynamics in linked views.
- Ejection fraction describes chamber volume change; it does not by itself establish stroke volume, filling pressure, myocardial health or cause.
Key red flags
A new large pericardial effusion with right-sided chamber collapse, plethoric inferior vena cava and compatible shock requires immediate senior review for tamponade management.
A new regional wall-motion abnormality with ongoing ischaemic symptoms or haemodynamic compromise requires an acute coronary syndrome pathway rather than routine outpatient follow-up.
Severe valve obstruction or regurgitation accompanied by exertional syncope, pulmonary oedema, resting breathlessness or ventricular deterioration needs urgent specialist assessment.
A suspected aortic dissection, prosthetic valve obstruction or infective endocarditis can be missed by a routine transthoracic study and often needs urgent complementary imaging.
Right ventricular enlargement, impaired longitudinal motion, septal flattening and altered pulmonary flow may indicate pulmonary hypertension, pulmonary embolic strain or shunt-related volume loading. Interpretation requires the clinical setting because no single sign proves the cause.
Thickened, restricted or prolapsing leaflets identify mechanism, while jet velocity, gradients, valve area calculations and regurgitant features describe severity. Chamber remodelling and pulmonary pressure provide evidence of chronic consequence. NICE says to offer urgent specialist assessment including echocardiography within 2 weeks for a systolic murmur with exertional syncope; if specialist assessment is unavailable, offer urgent echocardiography alone.
Describe effusion size, distribution and haemodynamic effect rather than equating fluid volume with tamponade. Masses, vegetations and thrombi require attention to location, mobility, artefact and the limits of transthoracic resolution.
Investigation priorities
Survey cardiac anatomy, ventricular function, valves, haemodynamics and pericardium non-invasively.
Management branches
A patient has symptoms, signs, ECG changes or a murmur suggesting structural heart disease.
- Confirm the clinical question, urgency, rhythm, blood pressure, height and weight before interpreting measurements.
- Acquire the comprehensive standard dataset, then add lesion-specific views and Doppler when an abnormality appears.