Echocardiography (Echo) 🫀
Guide for requesting echocardiography: TTE, TOE, and stress echo indications, urgency, request checklist, and when to phone cardiology for on-call NCHDs.
🧭 Workflow
- 1. Confirm echo will change management — is there a recent report on PACS? Has cardiology already requested one?
- 2. Choose study type — transthoracic (TTE) first-line; TOE or stress echo usually cardiology-led (see below).
- 3. Complete the request with a clear clinical question, relevant history, examination, ECG, and bloods.
- 4. Set urgency — emergency, urgent/same-day, or routine; match to clinical risk (see indications table).
- 5. Phone cardiology if unstable, suspected tamponade, mechanical complication of MI, or endocarditis with haemodynamic compromise — document verbal request in notes.
- 6. Chase result and act — arrange cardiology review if new significant findings (severe valve disease, LV dysfunction, vegetations, pericardial effusion).
🔬 Study types
- Transthoracic echo (TTE) — first-line for most inpatient indications. Non-invasive; image quality limited by habitus, COPD, and rhythm.
- Transoesophageal echo (TOE/TEE) — better valve and atrial appendage views. Usually requested by cardiology — e.g. endocarditis with non-diagnostic TTE, prosthetic valve infection, pre-cardioversion if TTE inadequate.
- Stress echo — exercise or pharmacological; typically outpatient/cardiology referral for stable angina or ischaemia assessment.
- Bedside / focused echo — may be available in ED/ICU for specific questions (tamponade, gross LV function, RV strain). Confirm local scope — not a substitute for formal TTE when indicated.
📋 Indications & urgency
Suspected cardiac tamponade
Emergency- Study
- TTE (bedside if available)
- Clinical question / notes
- Phone cardiology now — ?tamponade, RV diastolic collapse, effusion size. Do not delay for routine booking.
ACS with shock, new murmur, or sudden deterioration
Emergency- Study
- TTE
- Clinical question / notes
- ?mechanical complication — papillary muscle rupture, VSD, free-wall rupture, tamponade.
Acute pulmonary oedema / new heart failure
Urgent / same-day- Study
- TTE
- Clinical question / notes
- ?LV systolic dysfunction, valve disease, regional wall motion abnormality, diastolic function.
Suspected infective endocarditis
Urgent- Study
- TTE → TOE if needed
- Clinical question / notes
- ?vegetation, abscess, valve destruction, paravalvular leak. Blood cultures before antibiotics if safe. TOE if high suspicion and TTE negative or prosthetic valve.
New significant murmur + fever / embolic phenomena
Urgent- Study
- TTE
- Clinical question / notes
- ?endocarditis, valve pathology. Document fever curve, culture results, and embolic sites.
Syncope with structural heart disease, abnormal ECG, or red flags
Urgent- Study
- TTE
- Clinical question / notes
- ?cardiac cause — LV function, HCM, valve stenosis, pulmonary hypertension. See [Syncope](/syncope).
New atrial fibrillation — cardioversion planning
Routine–urgent- Study
- TTE
- Clinical question / notes
- ?LA thrombus / structural heart disease before rhythm control. Timing depends on AF duration and anticoagulation — discuss with cardiology.
Unexplained dyspnoea with suspected cardiac cause
Same-day- Study
- TTE
- Clinical question / notes
- ?LV/RV dysfunction, valve disease, PE-related RV strain (often with CTPA).
Suspected acute severe valve disease
Urgent- Study
- TTE
- Clinical question / notes
- ?critical AS/AR/MR — correlate with examination and BP. Phone if unstable.
Pre-chemotherapy baseline (anthracycline, trastuzumab, HER2 therapy)
Routine- Study
- TTE
- Clinical question / notes
- Baseline LVEF before cardiotoxic therapy — usually planned by oncology; chase if overdue.
Cardiotoxicity on treatment / falling LVEF
Urgent- Study
- TTE
- Clinical question / notes
- Repeat LVEF — hold therapy and discuss with oncology/cardiology per protocol.
Stable angina / ischaemia assessment
Routine- Study
- Stress echo
- Clinical question / notes
- Usually cardiology outpatient referral — not typically an intern overnight request.
| Clinical scenario | Study | Urgency | Clinical question / notes |
|---|---|---|---|
| Suspected cardiac tamponade | TTE (bedside if available) | Emergency | Phone cardiology now — ?tamponade, RV diastolic collapse, effusion size. Do not delay for routine booking. |
| ACS with shock, new murmur, or sudden deterioration | TTE | Emergency | ?mechanical complication — papillary muscle rupture, VSD, free-wall rupture, tamponade. |
| Acute pulmonary oedema / new heart failure | TTE | Urgent / same-day | ?LV systolic dysfunction, valve disease, regional wall motion abnormality, diastolic function. |
| Suspected infective endocarditis | TTE → TOE if needed | Urgent | ?vegetation, abscess, valve destruction, paravalvular leak. Blood cultures before antibiotics if safe. TOE if high suspicion and TTE negative or prosthetic valve. |
| New significant murmur + fever / embolic phenomena | TTE | Urgent | ?endocarditis, valve pathology. Document fever curve, culture results, and embolic sites. |
| Syncope with structural heart disease, abnormal ECG, or red flags | TTE | Urgent | ?cardiac cause — LV function, HCM, valve stenosis, pulmonary hypertension. See [Syncope](/syncope). |
| New atrial fibrillation — cardioversion planning | TTE | Routine–urgent | ?LA thrombus / structural heart disease before rhythm control. Timing depends on AF duration and anticoagulation — discuss with cardiology. |
| Unexplained dyspnoea with suspected cardiac cause | TTE | Same-day | ?LV/RV dysfunction, valve disease, PE-related RV strain (often with CTPA). |
| Suspected acute severe valve disease | TTE | Urgent | ?critical AS/AR/MR — correlate with examination and BP. Phone if unstable. |
| Pre-chemotherapy baseline (anthracycline, trastuzumab, HER2 therapy) | TTE | Routine | Baseline LVEF before cardiotoxic therapy — usually planned by oncology; chase if overdue. |
| Cardiotoxicity on treatment / falling LVEF | TTE | Urgent | Repeat LVEF — hold therapy and discuss with oncology/cardiology per protocol. |
| Stable angina / ischaemia assessment | Stress echo | Routine | Usually cardiology outpatient referral — not typically an intern overnight request. |
📝 Every request checklist
- Clear clinical question — e.g. “?LV dysfunction in new pulmonary oedema”, “?vegetation in IE”, “?LA thrombus before cardioversion”.
- Relevant history — cardiac PMH, valvular disease, devices, recent MI, chemotherapy, endocarditis risk factors.
- Examination — murmur, JVP, oedema, perfusion, BP, heart sounds.
- ECG attached or summarised — rhythm, ischaemia, conduction disease.
- Bloods where relevant — troponin, BNP/NT-proBNP, U&E, FBC, blood cultures if endocarditis suspected.
- Prior echo report reviewed — date and key findings if available.
- Urgency stated and reason for urgency documented.
- Contact number and ward location for portable/bedside studies.
☎️ When to phone cardiology
- Haemodynamic instability with suspected cardiac cause — tamponade, massive PE with RV failure, mechanical MI complication.
- Suspected acute severe aortic stenosis with syncope, angina, or heart failure.
- Endocarditis with new heart block, abscess concern, or persistent bacteraemia despite antibiotics.
- Need for urgent TOE or bedside echo and no clear pathway to request overnight.
- Uncertain whether echo is needed vs other imaging — ask before ordering a vague “echo please”.
- Positive or non-diagnostic urgent TTE with patient still unwell — escalate for interpretation and plan.
📞 Example OOH script (SBAR)
- Situation: “Hi, [Name], I'm [Your Name], intern on [ward/ED]. I need to discuss an urgent echocardiogram for [age/sex] with [presentation].”
- Background: “[Admission reason]. PMH: [cardiac history]. On [meds]. Vitals: [BP/HR/SpO₂ — stable/unstable].”
- Assessment: “Exam: [murmur, JVP, oedema, perfusion]. ECG: [rhythm/changes]. Bloods: [troponin/BNP/cultures]. I'm concerned about [?tamponade / ?mechanical complication / ?endocarditis / ?acute HF].”
- Recommendation: “Can you accept an urgent TTE — clinical question: [specific question]. Patient is [bedbound/portable OK]. Prior echo: [none / date and summary].”
- Document cardiology doctor spoken to, time, and agreed plan in the notes.
⚠️ Common pitfalls
- Requesting “echo” without a question — slows reporting and may not be prioritised appropriately.
- Ordering routine echo for stable chronic AF rate control when not planning cardioversion — may be outpatient.
- Delaying antibiotics or cultures in suspected endocarditis while awaiting echo — treat empirically per microbiology advice.
- Assuming normal TTE excludes endocarditis — TOE may still be needed if suspicion remains high.
- Forgetting to chase cardiotoxicity monitoring echo before next chemotherapy cycle.
Note Template
Ready-to-use clinical note structure
🕒 08 / 10 / 2026 — 16:08 ATRP re: echocardiography request Patient: [age] [sex] Location: [ward / ED / ICU] Admission Dx: [reason for admission] 🧾 Indication: • Study requested: [TTE / TOE / stress echo — usually TTE] • Clinical question: [?LV dysfunction / ?vegetation / ?tamponade / ?LA thrombus / etc.] • Urgency: [routine / urgent same-day / emergency] 🩺 Context documented on request: • History & exam: [murmur, JVP, oedema, perfusion, fever, embolic phenomena] • ECG: [rhythm, ischaemia, conduction — summarise] • Bloods: [troponin, BNP, blood cultures if IE suspected] • Prior echo: [none / date — LVEF and key findings] • Relevant PMH: [IHD, valve disease, device, chemotherapy] ☎️ Cardiology communication: • Discussed with: [cardiology doctor name / not required] • Time: [__] • Outcome: [echo accepted / bedside arranged / TOE referral / deferred] 📌 Plan: • [Await result / treat pending echo / cardiology review arranged] • [Antibiotics / diuresis / anticoagulation — as applicable] 👤 [Your Name], [Role] IMC: _______
Educational reference only. Medical disclaimer