ABC | Volume 113, Nº1, July 2019

Statement Position Statement on Indications of Echocardiography in Adults – 2019 Arq Bras Cardiol. 2019; 113(1):135-181 to the 3D. 4 Right cardiac catheterization remains the gold standard for diagnosis, since it allows the direct measurement of hemodynamic data in the pulmonary circulation and evaluates the capacity of response to vasodilator therapy through the pulmonary vasoreactivity test. Pulmonary thromboembolism (PTE) is another clinical condition of high mortality, which can cause complications such as chronic thromboembolic pulmonary hypertension (PH group IV). 170 Clinical suspicion, progress in diagnosis, and effective therapy are critical in reducing mortality in the acute event. The sensitivity and specificity of TTE for the diagnosis of PTE are 50 to 60% and 80 to 90%, respectively. In critical patients, TEE may increase this sensitivity. The visualization of the thrombus in the right atrium (RA), in the RV or in the trunk of the pulmonary artery ratifies the diagnosis. However, indirect signs are more commonly found, such as dilatation of the right cavities, RV contractile dysfunction, interventricular septal flattening, McConnel’s signal (apical region with preserved contractility and akinetic mean free wall segment, with sensitivity of 77% and specificity of 94%) and dilation of the inferior vena cava. The pulmonary artery acceleration time is a parameter with good sensitivity, since it is altered (< 100 ms) in cases of small pulmonary embolism.173 RV strain is an important tool because it shows the segment that presents reduced value and evaluates its deformity after reperfusion therapy. Patients who develop contractile dysfunction of the RV or patent foramen ovale present a reserved prognosis. 5. Coronary Artery Disease 5.1. Introduction Coronary artery disease has a wide clinical spectrum, ranging from asymptomatic severe disease, 175 long-term stable angina or acute coronary syndrome (ACS)/acute myocardial infarction (AMI) with hemodynamic instability as the first manifestation of the disease. 176,177 The echocardiography has applications in its diagnostic recognition, stratification of risk in the acute phase, follow-up and determination prognosis in the long term. 178,179 5.2. Acute Coronary Syndrome 5.2.1. Transthoracic Echocardiography In the scenario of a patient with acute chest pain and suspected coronary artery disease, echocardiography may be useful (Table 33) and should be routinely available in the emergency department and thoracic pain units. 180 Evidence of new or presumably contractile change from LV to TTE is one of the parameters in the third universal definition of myocardial infarction 181 and may in fact assist in the diagnosis/ prognostic determination of an ACS. In addition, TTE may aid in the differential diagnosis of chest pain and/or associated conditions, such as acute aortic dissection, aortic stenosis, hypertrophic cardiomyopathy, and pulmonary embolism. 180 By dividing LV into 16 or 17 segments, contractile segmental function is visually quantified based on systolic thickening (ST): hyperkinetic = 0 (ST > 70%); normal = 1 (ST = 50 to 70%); hypokinetic = 2 (ST < 40%); akinetic = 3 (ST < 10%); “dyskinetic = 4 (paradoxical movement/systolic expansion)”. The wall motion score index (WMSI) is the reference parameter to express the LV segmental function and its normality value is 1; values between 1 and 1.6 show a contractile alteration of mild degree; while WMSI values above 1.6 indicate greater involvement and worse prognosis. 182 Obviously, the absence of alterations in segmental contractility in resting TTE does not exclude the presence of coronary artery disease. 180 It should also be considered that the contractile alteration may occur in other conditions such as myocarditis, RV overload (volume/pressure), ventricular pre-excitation, Takotsubo type cardiomyopathy, left bundle branch block, chagasic cardiomyopathy or presence of pacemaker. 180 TTE is the exam of choice in cases of hemodynamic instability with suspected cardiac origin, as well as in the identification of mechanical complications of AMI. 179,180 However, it is necessary to avoid Table 32 – Recommendations of the echocardiography in pulmonary hypertension and thromboembolism 170,174 Recommendation Class of recommendation Level of evidence TTE recommended as a first line examination for noninvasive diagnostic investigation of suspected pulmonary hypertension I C TTE recommended in the assessment of signs of pulmonary hypertension in symptomatic patients with portal hypertension or liver disease and in all indicated to hepatic transplantation I B TTE recommended as an initial examination for the assessment of pulmonary hypertension in patients with systemic sclerosis and annually I C TTE recommended for noninvasive diagnostic assessment of patients with pulmonary disease with suspected pulmonary hypertension I C High-risk pulmonary embolism, in the presence of shock or hypotension, TTE at the bedside or angiotomography (depending on the patient’s clinical conditions or availability) I C High-risk pulmonary embolism with signs of right ventricular dysfunction, unstable for angiography (TTE at the bedside with Doppler of lower limbs and/or TEE to assess pulmonary artery thrombus) IIb C Not recommended in asymptomatic HIV positive patients for the detection of pulmonary hypertension III C TTE: transthoracic echocardiography; TEE: transesophageal echocardiography; HIV: human immunodeficiency virus. 161