ABC | Volume 113, Nº1, July 2019

Statement Position Statement on Indications of Echocardiography in Adults – 2019 Arq Bras Cardiol. 2019; 113(1):135-181 Table 9 – Recommendations of transthoracic echocardiography in the evaluation of athletes of competitive and/or professional physical activities Recommendation Class of recommendation Level of evidence In the differentiation of “athlete’s heart” from conditions of pathological hypertrophy I B Assessment for release of competitive physical activity, when clinical consultation demonstrates the possibility of hypertrophic cardiomyopathy or other genetically transmissible ones I B Assessment for release of competitive physical activity, when clinical consultation shows signs of valvular heart disease or other structural cardiac changes I C In routine assessment of athletes when there is no suggestion of ventricular overload or hypertrophy by clinical consultation or ECG IIb C ECG: electrocardiogram. Table 10 – Recommendations of transthoracic echocardiography in patients with murmur Recommendation Class of recommendation Level of evidence Asymptomatic patients, with murmur suggestive of cardiopathy I C Asymptomatic patients with signs or exams (e.g., electrocardiogram) suggestive of cardiac disease I C Patients with murmur and low probability of heart disease that cannot be ruled out by clinical investigation, electrocardiogram, chest X-ray or directed ultrasound IIa C Patients without signs or symptoms suggestive of cardiopathy III C most frequent causes of sudden death during exertion in this population. 118,119 Although the usefulness of anamnesis and physical examination is consensual, the need for TTE and even for the electrocardiogram in population screening of athletes is not a matter of general agreement among cardiology associations. 120 However, if clinical evaluation suggests the likelihood of hypertrophic cardiomyopathy (or others of genetic origin), valvular heart disease or other structural cardiac changes, it becomes an essential investigative method (Table 9). 3. Heart Murmurs, Valvular Heart Disease, Valvar Prostheses and Endocarditis 3.1. Heart Murmurs  Heart murmurs are common findings, with prevalence between 5 and 52%. 121 They are produced when the laminar blood flow becomes turbulent, such as in stenoses or valve refluxes, emitting sound waves that can be detected with the aid of the stethoscope. It is important that during physical examination, even in asymptomatic patients, careful auscultation is performed in order to define its characteristics. 122 An innocent murmur can be defined as a short, smooth ejective noise (1 to 2++ in 4), audible at the left sternal border, followed by a second normal sound, in the absence of other abnormalities. 123 This finding, associated with normal chest x-ray and electrocardiogram, estimates a low probability of cardiac disease and, in this case, there is no need for complementary echocardiography. 124 However, due to inadequate training or maintenance of knowledge, characteristics of the murmur or patient’s anatomy, the auscultation may leave doubts about the existence of underlying organic causes. In such situations, the use of electronic stethoscope 125 and performing directed cardiac ultrasound, 126 if available, may be useful. In case of persisting doubt or suspicion of cardiac alteration, the echocardiography should be performed (Table 10). This systematic approach and investment in medical training allows for a rational use of resources, avoiding excessive diagnosis and unnecessary exams. 124 3.2. Native Valves Echocardiography is the standard diagnostic method for assessing heart valves. TTE should be performed in suspected and in diagnosed valvular heart disease, for evolutionary follow-up of moderate and important lesions, and changes in clinical status. 124 The examination identifies the mechanisms involved, quantifies hemodynamic severity and repercussion, estimates prognosis, and assists treatment decision. 127,128 In addition, physical exertion echocardiography can be performed to evaluate the behavior of echocardiographic parameters in asymptomatic patients and in cases of divergence between symptoms and the severity of the lesions estimated in the exams performed at rest. 24,127,129 Besides traditional echocardiographic techniques, recent applications, such as the strain and the 3D, have provided new anatomical and functional information. 130-132 3.2.1. Mitral Regurgitation TTE, in addition to diagnostic confirmation, provides information necessary for follow-up and decision making in mitral regurgitation(MR). 127 TTE identifies dilation of 150