ABC | Volume 113, Nº1, July 2019

Statement Position Statement on Indications of Echocardiography in Adults – 2019 Arq Bras Cardiol. 2019; 113(1):135-181 ACS (Table 35).180,185 Patients with normal perfusion and myocardial function at rest have good prognosis, while the presence of perfusion defects at rest identifies a subgroup at high risk for ACS. 185 5.3. Chronic Coronary Artery Disease 5.3.1. Transthoracic Echocardiography TTE, while providing important information on segmental contractility when performed at the time of acute chest pain, is limited in the investigation of patients with chronic coronary disease. 175 Two situations of indication should be valued: the first one when there is a need for a differential diagnosis of chest pain with non-ischemic causes, such as pericarditis, valvular diseases (such as aortic stenosis) or cardiomyopathies that may occur with chest pain; the second is based on the knowledge of global left ventricular function as a prognostic factor in stable patients with chronic coronary disease (Table 36). 175 5.3.2. Stress Echocardiography Stress echocardiography is a useful investigative method for both suspected patients and those with an established diagnosis of stable coronary disease (Table 37). The method offers good accuracy in the ischemic investigation of patients from moderate to high risk, with a slight predominance of specificity compared to other non-invasive imaging methods, such as myocardial scintigraphy. 179,184,186,187 The stress-induced modality, whether physical, with treadmill or bicycle, or pharmacological, with dobutamine sensitized with atropine or even with dipyridamole, does not significantly change the diagnostic performance of the test. 179 In general, Table 35 – Recommendations of contrast echocardiography in acute coronary syndrome Recommendation Class of recommendation Level of evidence Use of echocardiographic contrast for better definition of the endocardial border and to access left ventricular structure/function when two or more adjacent segments are not visible in the standard resting or stress tests I B Assessment of patients with acute chest pain and non-diagnostic electrocardiogram IIb B Assessment of myocardial perfusion in all types of ACS III C Routine use of echocardiographic contrast in all patients with chest pain and suspected CAD III C ACS: acute coronary syndrome; CAD: coronary artery disease. Table 36 – Recommendations of transthoracic echocardiography in chronic coronary disease Recommendation Class of recommendation Level of evidence Differential diagnosis of precordial pain I B Initial assessment of left ventricular function as a prognostic indicator, even in patients with no evidence of heart failure I B Assessment of left ventricular function when there is evidence of heart failure or change in clinical status I B Periodic reassessment of stable patients without clinical change III C in the investigation of stable coronary disease, stress echocardiography should be indicated for those patients with limited exercise performance, either by functional class or by non-interpretable electrocardiogram, such as in the presence of left bundle branch block. 188 Thus, the method should not be considered as a substitute for the ergometric test. However, if available, it can be used as the first examination in the investigation of selected patients, with intermediate or high pretest probability. Furthermore, in the investigation of the risk of chronic coronary disease, it can be used as a sequential method to others such as coronary tomography, when the calcium score shows levels above 400. 184,186 Another important clinical situation for indication of stress echocardiography is the preoperative evaluation of patients undergoing intermediate-risk surgery. 179,187,189 Even in this situation, the method can be used but it should not generally replace the exercise test when this is possible. However, in vascular surgeries, where there are one or more risk factors, the investigation may start from the echocardiographic examination under stress. 184 Situations in which there is a need for the topographical definition of ischemia, such as those of a functional significance investigation of already known lesions, also induce the image examination under stress, which may be the echocardiography. However, the availability of the method in the region of medical practice and the technical ability and experience of the echocardiography laboratory for individualized application of the levels of recommendation suggested here should be considered. 5.3.3. Contrast Echocardiography The use of echocardiographic contrast agents consisting of microbubbles capable of overcoming the pulmonary barrier and remaining intact has become a powerful 163