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 33 – Recommendations of transthoracic echocardiography in acute coronary syndrome Recommendation Class of recommendation Level of evidence Assessment of global and segmental ventricular function I C Differential diagnosis of alternative causes of chest pain: severe aortic stenosis, hypertrophic cardiomyopathy, pulmonary embolism, aortic dissection*, pericarditis and the presence of cardiac tumors I C Chest pain with hemodynamic instability and suspected cardiac origin I C Suspected mechanical complications in myocardial infarction: left ventricular aneurysm, rupture of free wall or papillary muscle, ventricular septal defect, pericardial effusion I C Assessment of right ventricular impairment in the presence of inferior wall myocardial infarction I B During chest pain of possible ischemic origin, with electrocardiogram and non-conclusive cardiac enzymes IIa B Calculation of global longitudinal strain using speckle tracking as an adjunct to existing diagnostic algorithms and risk classification in patients with suspected coronary disease& IIa B Assessment of patients in the presence of chest pain with a confirmed diagnosis of myocardial ischemia/ infarction III C Evaluation of chest pain in patients whose non-cardiac etiology is evident III C * Complementation with transesophageal echocardiography increases accuracy and can provide additional information to the transthoracic one; &in the absence of preexisting structural heart disease, prior myocardial infarction, or left bundle branch block. Table 34 – Recommendations of stress echocardiography in acute coronary syndrome Recommendation Class of recommendation Level of evidence Patients with clinically controlled low risk unstable angina* before deciding the invasive strategy IIa A To assess the functional significance of moderate coronary obstruction at angiography, as long as the result interferes with the procedure IIa C Risk stratification after uncomplicated myocardial infarction IIa A Investigation of patients with suspected microvascular disease& to establish whether segmental change occurs in conjunction with angina and electrocardiographic abnormalities IIa C Strain and strain rate parameters derived from speckle tracking as an adjunct tool to wall motion score index for diagnosis and/or prognosis of acute coronary disease IIa B High risk unstable angina or acute myocardial infarction III C * No recurrence of angina, no signs of heart failure, no abnormalities on the initial/serial electrocardiogram and normal troponin; &typical angina pain with electrocardiogram change or functional test, in the presence of normal coronary angiography. requesting the examination for evaluation of patients with chest pain with a confirmed diagnosis of myocardial ischemia (ACS/AMI), since TTE should not delay the immediate onset of treatment. 176,177,180 On the other hand, in the screening of symptomatic patients suspected of having coronary artery disease in the emergency room, recent evidence indicates the potential usefulness of GLS calculated by 2D speckle tracking. In the absence of preexisting structural heart disease, previous infarction or left bundle branch block, GLS (when < 16.5%) may complement existing diagnostic algorithms and act as an early adjunct marker of ischemia. 183 5.2.2. Stress Echocardiography The evidence of a new alteration of the segmental contractility at rest or its appearance before the induction of stress (exercise or pharmacological) suggests ischemic etiology. 184 Stress echocardiography is an independent predictor of cardiovascular death, of additional value to the other methods and can avoid coronary angiography. 175,179 Its use may be recommended for risk stratification of patients in chest pain units (Table 34), especially when the electrocardiogram does not define the diagnosis and the exercise test is submaximal, non-feasible or inconclusive. 179 Traditionally, stress echocardiography is performed after 24 hours of chest pain relief in low to moderate risk patients with no evident ischemic changes on the electrocardiogram and normal cardiac enzymes. 5.2.3. Contrast Echocardiography This echocardiographic modality allows the immediate and simultaneous access of LV segmental contraction and myocardial perfusion. 179,180 In patients with acute chest pain and non-diagnostic electrocardiogram, the use of contrast echocardiography increases sensitivity for the diagnosis of 162