Emergency echocardiography: the European Association of Cardiovascular Imaging recommendations

Abstract

It is widely recognized that echocardiography is the single most versatile and cost-effective imaging technique to assess patients with unstable cardiovascular diseases. Mobility and relative low cost of echocardiographic machines, including hand-held devices, allow their use virtually everywhere.1–4 In addition, in expert hands, echocardiography may provide instantaneous and comprehensive assessment of cardiac structure and function as well as haemodynamics, with minimal discomfort or risk for the patient, without using radiological contrast media or ionizing radiations. Since the physician who performs echo may be the same who is managing the patient, the echo data can be readily used to speed up the decision-making process. These characteristics make the technique even more attractive in the emergency setting, since it is safely and easily repeatable any time there is a change in patient haemodynamics, or a need to follow-up previously detected abnormalities. Accordingly, echocardiography is already included into patient management algorithms for the majority of cardiovascular emergencies. However, although general diagnostic power of echocardiography could be hardly challenged, for an adequate interpretation in particular clinical situations it is essential to fully understand its advantages and limitations, in order to reduce the likelihood of potential catastrophic diagnostic and therapeutic errors. The expanding use of echocardiography examinations by non-cardiologists or cardiologists with insufficient formal training in the emergency setting urged scientific societies to set standards for optimal education and training, and to identify the level of competence in echocardiography that should be reached by emergency health-care professionals. Precise and strict requirements need to be defined in order to ensure the quality and the accuracy of the data obtained by echocardiography, particularly in the emergency setting. The purpose of this document is to provide recommendations for the safe and efficient use of echocardiography to assess patients presenting with cardiovascular emergencies and to set up/propose standards for adequate education and training of physicians performing echocardiography in the emergency setting. In addition, the principles, practical aspects, and specific considerations related to echocardiography in the emergency settings are discussed. Detailed description of echocardiographic signs of particular cardiovascular entities that may be presented to emergency physicians can be found elsewhere.4 The present document is released by the European Association of Cardiovascular Imaging (EACVI) and developed in accordance with the principles outlined in the European Society of Cardiology (ESC) Core Curriculum,5 European Association of Echocardiography (EAE) core syllabus,6 and EAE recommendations for training, competence, and quality improvement in echocardiography,1 and is intended to complement them by addressing key issues specifically related to the use of echocardiography in cardiac emergencies. The term emergency echocardiography throughout this document refers to the use of echocardiography in the assessment of patients with unstable cardiovascular diseases. It should be distinguished from the routine use of echocardiography in emergency environments. For example, the use of stress echocardiography in chest pain units is not considered as emergency echocardiography, since it is applied in clinically stable patients. Emergency echocardiography is a comprehensive echocardiographic study,7 which should also be distinguished from the focused cardiovascular ultrasound or examinations performed with pocket-size imaging devices (echo scanning), which may be a part of the clinical examination. Thus, the term emergency echocardiography is reserved for an investigation performed by a person who is able to independently perform the study using a fully equipped echocardiographic machine and interpret results unaided. Performing an echocardiographic examination in a patient with suspected or known cardiovascular disease presenting as an emergency case may be challenging. Key decisions should be made quickly, in a stressful situation, characterized often by difficulties in acquiring good images. Physicians in charge are frequently forced to interpret suboptimal studies, having limited time for consultations with colleagues. Under these circumstances, interpretation errors or missing critical abnormalities are likely to occur more often and they might seriously affect patient's management and outcome. From the ethical point of view, emergency echocardiography should be performed by anyone who knows how to get valuable information from it and use it in the decision-making process. ‘Know how’ includes: ability to obtain adequate images (imaging technique) and ability to interpret them in the specific clinical context (reading/interpretation). Improperly acquired and/or poor-quality images may r