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 43 – Recommendations of the echocardiography in pericardial diseases Recommendation Class of recommendation Level of evidence Clinical suspicion of pericardial effusion I C Serial studies for evaluation of recurrent stroke I C Assessment after radiotherapy (five years in patients at high risk for cardiotoxicity and ten years in others) I C Suspicion of constrictive pericarditis, early detection of constriction or differential diagnosis with restriction I B Suspected cardiac tamponade (chest trauma, cardiac surgery, iatrogenic perforation in cardiac catheterization or electrophysiological study, rupture of the ventricular wall after myocardial infarction and aortic dissection) I C Suspected pericardial cyst, pericardial mass or pericardial agenesis I C Monitoring of pericardiocentesis I B Serial studies to assess the effect of treatment on stroke IIa C Routine examination for small effusions in hemodynamically stable patients III C Investigation of pericardial thickening without repercussion III C 10. Systemic Diseases 10.1. Introduction The indication of echocardiography in systemic diseases depends on the prevalence of associated heart disease, the characteristics peculiar to cardiac involvement in each situation and the clinical suspicion of cardiac involvement. 235 For example, examination is mandatory in individuals with systemic diseases potentially causing restrictive cardiomyopathy that show signs and symptoms of heart failure in clinical evolution. Some systemic diseases for which the indication of the examination should be considered are as follows. 10.2. Chronic Renal Failure Morphophysiological changes in LV (such as hypertrophy, dilatation, systolic and diastolic dysfunction) are common in patients with end-stage renal disease and predict a worse prognosis. 236-238 International guidelines recommend TTE for all dialysis patients one to three months after the initiation of renal replacement therapy and at three-year intervals thereafter, despite the symptoms. 239 10.3. Amyloidosis It is a common cause of restrictive cardiomyopathy and may be familial (transthyretin) or nonfamiliar (primary or light chain). Cardiac involvement due to amyloid deposition may lead to some suggestive echocardiographic findings: thickening and increased echogenicity (“granular” appearance) of the LV walls (especially in the absence of arterial hypertension), biatrial dilatation, thickening of the valves and interatrial septum, diastolic dysfunction (grade II and III), small pericardial effusion, prominent decrease in longitudinal strain in the basal and mid LV segments (“sparing” the apical segments), and later systolic dysfunction with LVEF. 240 10.4. Sarcoidosis It is important to investigate the presence of cardiac involvement in sarcoidosis (granulomatous disease of unknown origin), as this is a potentially fatal condition. Among the various echocardiographic findings that may be found, we have: dilated cardiomyopathy, restrictive cardiomyopathy, segmental contractility alterations that do not obey the classic coronary territorial distribution, basal septum akinesia, inferolateral aneurysm and abnormal thickness of the septum (thickening or thinning). 241 10.5. Neoplasias The echocardiography can detect silent pericardial metastases in some types of neoplasia (such as breast and lung) and monitor the cardiotoxic effect of chemotherapeutic agents. 242 10.6. Autoimmune Diseases The test may diagnose lupus-associated cardiac manifestations, such as pericardial effusion and sterile vegetations, systemic sclerosis, such as pulmonary hypertension, or rheumatoid arthritis, such as valve abnormalities. 235 11. Diseases of The Aorta, Pulmonary Artery and Veins 11.1. Aorta The evaluation of the aorta is routine in the TTE, since it allows to examine some of its segments, mainly the aortic root and the proximal portion of the ascending aorta, affected in numerous affections. The root of the aorta is formed by the aortic ring, the sinuses of Valsalva and the synotubular junction. The descending aorta and the proximal abdominal aorta can be evaluated at the suprasternal and subxiphoid sections, respectively. 154,243 However, the TTE should be considered a screening test, with limitations, since it does 168