Invited Commentary
Recognized and Unrecognized Value of Echocardiography in Guideline and Consensus Documents Regarding Patients With Chest Pain

https://doi.org/10.1016/j.echo.2022.10.024Get rights and content

Highlights

  • Role of echocardiography is not adequately represented in recent CP guidelines.

  • Level of evidence has increasingly influenced guideline recommendations.

  • Doppler echo has unique advantages to assess patients with exertional dyspnea.

  • POCUS allows immediate first look assessment in patients with CP.

  • Innovation in echo will further enhance the value of echo for CP assessment.

Guideline and consensus documents have recently been published on the important topic of the noninvasive evaluation of patients presenting with chest pain (CP) or patients with known acute or chronic coronary syndromes. Authors for these documents have included members representing multispecialty imaging societies, yet the process of generating consensus and the need to produce concise written documents have led to a situation where the particular advantages of echocardiography are overlooked. Broad guidelines such as these can be helpful when it comes to “when to do” noninvasive cardiac testing, but they do not pretend to offer nuances on “how to do” noninvasive cardiac testing. This report details the particular value of echocardiography and potential explanations for its understated role in recent guidelines. This report is categorized into the following sections: (1) impact of the level of evidence on guideline creation; (2) versatility of echocardiography in the assessment of CP and the inimitable role for echo Doppler echocardiography in the assessment of dyspnea; (3) value of point-of-care ultrasound in assessing CP and dyspnea; and (4) the future role of echocardiography in ischemic heart disease.

Section snippets

Level of Evidence Is Not Synonymous With Impact on Patient Care

Clinician-scientists in cardiovascular medicine have been at the forefront of efforts to use large randomized controlled clinical trials (RCTs) instead of observational studies or clinical reasoning to guide recommendations. Large trials evaluating new therapies for acute myocardial infarction and heart failure were instrumental in establishing efficacy and identifying those most likely to benefit. A logical outcome has been that guideline documents written over the past 30 years from the

Unique Role of Resting and Exercise Echo/Doppler for CP and/or Dyspnea

In the initial evaluation of patients with suspected cardiac CP, the value of resting TTE is of paramount importance because it may reveal causes of cardiac-related CP unrelated to CAD. In the case of stable CP in a patient at intermediate or high risk, the ACC/AHA CP guideline states that either anatomic imaging with CCT or functional testing is appropriate.13 Functional testing includes pharmacologic or exercise stress testing with either echocardiography or nuclear perfusion imaging,

Appropriate Role of Point-of-Care Echocardiography

A case presentation that coincided with the writing of this manuscript highlights the value of point-of-care ultrasound (POCUS) in the management of those presenting with CP. A 60-year-old man with no past medical history presented to the emergency department with a recent complaint of substernal chest pressure. The patient was recently seen and discharged from 2 other regional emergency rooms within the past week with a diagnosis of noncardiac CP based on the lack of diagnostic ECG changes and

Future Directions

Advances in echocardiography continue to improve our diagnostic accuracy, sensitivity, and understanding of patients with CP and have the potential to identify novel prognostic indices and therapeutic targets in ischemic heart disease.

Artificial intelligence (AI) and machine learning (ML) are promising approaches to increase accuracy and reduce the subjectivity and operator-dependency of LV function assessment by ultrasound and could accurately identify conditions such as CAD (area under the

Conclusions

These guidelines emphasize the evaluation of CP in general and remind us that many causes of CP are noncardiac or cardiac but nonischemic. Echocardiography provides recognized and unrecognized value in the assessment of these patients. The unique versatility and comprehensive capabilities of TTE allows recognition of nonischemic causes for cardiac CP or anginal equivalents at the bedside as a rapid, initial noninvasive investigation. Cardiac POCUS can play an important role in providing rapid

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  • Cited by (1)

    Conflicts of Interest: Dr. Sorrell is supported as the Anthony N. DeMaria Endowed Chair of Cardiovascular Imaging and by grant nos. W81XWH1910533 and 2R44HL120370-02. Dr. Lindner is supported by grants R01-HL078610, R01-HL130046, R01-HL165422, and P51-OD011092 from the National Institutes of Health and by grant 18-18HCFBP_2-0009 from NASA. Dr. Pellikka is supported as the Betty Knight Scripps Professor of Cardiovascular Disease Clinical Research, Mayo Clinic. Drs. Muraru and Kirkpatrick have no disclosures.

    Raymond Stainback, MD, FASE, served as guest editor for this report.

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