FOCUS Chronic heart failure

Echocardiography
David Prior
Jennifer Coller in heart failure
A guide for general practice
Heart failure is the inability of the heart to provide
Background sufficient cardiac output for the body’s needs without
Echocardiography is an essential investigation in
an increase in filling pressures. Heart failure can be
patients with suspected heart failure. An echocardiogram
difficult to diagnose as the symptoms and signs can be
provides assessment of cardiac chamber size and
structure, ventricular function, valvular function and key nonspecific – it is important to confirm a clinical diagnosis
haemodynamic parameters. by demonstrating cardiac dysfunction.

Objective
All major heart failure guidelines, including the Australian
This article explains the principles of echocardiography
guidelines developed by the National Heart Foundation and
and how general practitioners can use echocardiograms to
Cardiac Society of Australia & New Zealand, recommend
manage patients with heart failure.
echocardiography as an essential first line investigation in the
Discussion evaluation of suspected heart failure.1 Retrospective studies
Echocardiography can provide diagnostic information suggest that patients with a clinical diagnosis of heart failure who
about the cause of heart failure, and may indicate what
have had an echocardiogram have a better outcome than those
further investigations are required and what therapy
who have not, presumably due to more appropriate evidence based
is indicated. It may also provide important prognostic
management.2 This article will discuss why assessment of cardiac
information. It can be used for noninvasive quantitative
monitoring. Identification of impaired systolic function is structure and function is critical in evaluating heart failure, the
important as there is evidence based therapy which can specific information gained from an echocardiogram and how to
improve prognosis in this condition. interpret an echocardiogram report. It will concentrate on the use
of transthoracic echocardiography as this is typically the first line
Keywords: heart diseases; heart failure;
investigation with transoesophageal echocardiography reserved for
echocardiography
specific situations.
In Australia, ischaemic heart disease accounts for about 50%
of patients with heart failure.1 Other common causes include
hypertension and dilated cardiomyopathy. Underlying valvular heart
disease and pericardial disease are less common but important
as they may be amenable to surgical treatment. Less common but
identifiable by echocardiogram are hypertrophic cardiomyopathy, a
cause of left heart failure and pulmonary hypertension, a cause of
right heart failure (Table 1).
Previously left ventricular failure was considered a disease
of reduced left ventricular systolic function. However, recent
studies suggest up to 50% occur in the setting of a normal ejection
fraction, particularly in the elderly. This is thought to be partly
due to impaired cardiac filling, with similar symptoms to systolic
dysfunction. Traditionally called diastolic heart failure, evidence for
subtle abnormalities of systolic contraction means ‘heart failure
with normal ejection fraction’ (HFNEF) is the preferred term.

904 Reprinted from Australian Family Physician Vol. 39, No. 12, december 2010
 Table 1. Important causes of heart failure with reduced and A B
normal ejection fraction

Reduced ejection fraction Normal ejection fraction

• Coronary artery disease • Hypertension
• Hypertension • Coronary artery disease
• Dilated cardiomyopathy • Valvular heart disease C D
– idiopathic • Hypertrophic cardiomyopathy
– familial • Restrictive cardiomyopathy
– toxic (drugs, alcohol) • Infiltrative cardiomyopathy
– metabolic (thyroid abnormalities) – amyloidosis
– myocarditis – iron deposition
Figure 1. Common two dimensional
– peripartum • Constrictive pericarditis echocardiographic views of the heart.
• Valvular heart disease A) Parasternal long axis view; B) Para-
sternal short axis view; C) Apical four
chamber view; D) Subcostal view
Principles of clinical cardiac LV = left ventricle, LA = left atrium, RV
ultrasound = right ventricle, RA = right atrium, MV
= mitral valve, AO = aorta, Li = liver
Echocardiography uses ultrasound in the 2–7 MHz range to provide
detailed information about the structure and function of the heart. Assessment
Ultrasound machines have become smaller, more portable and with
improved image quality, permitting easier use within the community. Left ventricular systolic function
The major ultrasound modalities used are M-mode, two dimensional One of the critical pieces of information to be gained from an
(Figure 1) spectral Doppler and colour Doppler echocardiography echocardiogram is whether left ventricular systolic function is normal
(Figure 2). Using traditional ‘grey scale’ two dimensional ultrasound, or reduced (Figure 3). When systolic function is reduced, proven heart
cardiac chambers and major blood vessels can be measured. Left failure therapies such as angiotensin converting enzyme inhibitors
ventricular wall thickness and mass can be estimated to document (ACEIs) and beta blockers improve cardiac symptoms and prognosis.1
the presence of left ventricular hypertrophy. Function of the left and The degree of reduction in systolic function provides prognostic
right ventricles and motion of cardiac valves may be assessed in information – lower left ventricular ejection fraction (LVEF) is
real time. The integration of Doppler ultrasound techniques allows associated with worse prognosis. The degree of systolic dysfunction
additional information from estimation of blood flow velocities within can determine additional therapies – for example, an implantable
the heart. Doppler ultrasound relies on the shift in sound frequency defibrillator (AICD) is recommended if the LVEF is below 35%.3 In
that occurs when a sound wave is reflected from a moving object, contrast, the evidence for treatment in HFNEF where LVEF is normal
such as a red blood cell, and provides information about the direction is unclear and no specific pharmacologic therapy has been shown to
and velocity of blood flow. improve mortality, although candesartan may reduce hospitalisations.4
Doppler ultrasound can be used to make quantitative The pattern of diastolic filling contributes to the severity of symptoms
haemodynamic measurements such as cardiac stroke volume and in heart failure in both systolic heart failure and HFNEF and provides
output, and to quantify the severity of valvular lesions. Doppler incremental prognostic information5 as discussed below.
echocardiography may be used to estimate intracardiac pressures Systolic function may be assessed using a number of methods.
such as the pulmonary artery systolic pressure (which can become LVEF is the most widely used quantitative measure of systolic
elevated in response to heart failure). Colour Doppler, in which blood function, and measures what fraction of the left ventricular diastolic
flow velocities are represented on a two dimensional image by blood volume is ejected during each cardiac cycle. The normal LVEF
different colours, can be useful to demonstrate patterns of flow and is 50–70% and a LVEF below 50% reflects reduced systolic function.
is particularly useful for valvular regurgitation (Figure 2). Current practice uses two dimensional measurement to calculate LVEF
Windows available for ultrasound evaluation of the heart within with the Simpson’s Biplane method; tracing the endocardial border at
the thorax are limited and vary between individuals. Air within the end diastole and end systole to estimate left ventricle (LV) volumes and
lungs conducts ultrasound poorly, ribs may obscure views of the LVEF. If adequate tracing of the endocardium is impossible, a visually
heart and body habitus can affect the quality of images. However, estimated LVEF may be reported, although the accuracy is highly
echocardiography should still be ordered as image quality is often operator dependent. Three dimensional echocardiography provides
adequate for assessment, or may be enhanced with intravenous more reproducible quantification of LVEF but is not available on all
contrast agents. echocardiographs.

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 FOCUS Echocardiography in heart failure – a guide for general practice

A B A B characterised by a restrictive filling pattern,

with an elevated E/A wave ratio (typically
>2.0), and occurs in the setting of markedly
reduced LV compliance and markedly
elevated LA pressure. This pattern points to
an adverse prognosis largely independent of
the underlying LVEF.6
C D Several other parameters also
suggest elevated LV filling pressures,
including LA enlargement in response to
Figure 2. Secondary mitral regur- chronically elevated LV filling pressures,
gitation in dilated cardiomyopathy
demonstrated using colour Doppler.
and abnormalities of tissue Doppler
A) Coloured jet of mitral regurgitation imaging. In the setting of diastolic or
into the LA. The mitral regurgitation; systolic dysfunction, LV filling pressures
Figure 3. Possible causes of heart
(B) occurs because LV enlargement can be approximated using a ratio of the
failure on echocardiography. A) Dilated
restricts the mitral leaflets from clos-
cardiomyopathy with dilation of all E wave and the early diastolic motion of
ing completely during systole (C)
cardiac chambers (2.5 cm markers on the mitral annulus (the E’ wave, Figure 4).
left). Left ventricular ejection fraction
The E/E’ ratio increases with increasing
is reduced; B) Hypertrophic cardio-
Segmental (or regional) variation in wall myopathy with normal left ventricular LA pressure and an E/E’ ratio >15 makes
thickening is suggestive of underlying coronary cavity size, but marked hypertrophy elevated LA pressure highly likely.7 Elevated
artery disease, and areas of thinning are of the anteroseptum (AS) which is filling pressures leads to dyspnoea from
commonly seen at the site of previous myocardial asymmetric compared to the posterior pulmonary congestion.
wall (PW), LVEF is preserved; C) The
infarction (Figure 3). Further evaluation including
stress echocardiography or coronary angiography
inferior wall (arrows) is thinned and Valvular disease
bright due to scarring from previous
may be indicated. More global dysfunction infarction. LVEF is reduced; D) Marked Valvular heart disease is an important
should prompt a search for other causes of a increase in left ventricular wall thick- correctable cause of heart failure and may
ness due to infiltration with amyloid
dilated cardiomyopathy (Table 1). The detection be a cause or consequence of abnormal
protein in cardiac amyloidosis. The LA
of mural thrombus within the LV in the setting of and RA are enlarged and LVEF may be ventricular function. Structural information
regional or global systolic dysfunction is a strong normal or reduced about the four cardiac valves from two
indication for anticoagulation. dimensional imaging includes thickening,
calcification, restriction or redundancy
Left ventricular diastolic function of valve leaflets. Doppler ultrasound is the predominant method to
Filling of the LV during diastole is a critical component of cardiac assess the severity of valve disease. Spectral Doppler, which assesses
function independent of LVEF. It is influenced by left atrial (LA) the direction and velocities of blood flow, can be used to quantify the
pressure which drives filling and active LV relaxation which provides severity of valvular stenosis or regurgitation. Blood travelling through
suction into the ventricle. In sinus rhythm, inflow through the mitral a narrowed orifice, such as a stenotic aortic valve, must increase in
valve occurs in two phases; an early phase producing an E wave on velocity to maintain constant forward flow. The increase in blood velocity
Doppler examination and an atrial filling phase producing an A wave across the valve is used to calculate the pressure gradient across the
(Figure 4). Normally, the E wave is larger than the A wave so that their valve, and the valve area. Colour flow imaging, by displaying patterns
ratio is >1.0. An impaired relaxation pattern is a mild form of diastolic of blood flow superimposed on the normal grey scale image, aids in
dysfunction. It indicates an abnormality of active, energy dependent localising sites of turbulent flow or regurgitation (Figure 2). In the context
LV relaxation and is associated with a decreased E/A wave ratio of left ventricular enlargement or systolic dysfunction, quantitative
(<1.0). However, this is a common finding in people over the age of 60 evaluation of valvular pathology is important to establish whether
years due to age related reduction in LV relaxation. chronic volume or pressure overload may be a contributing factor.
The amplitude of the E wave is largely dependent on the efficiency
of LV relaxation and the LA pressure. As relaxation worsens and LA
Other cardiac findings associated with
heart failure
pressure increases, a ‘pseudonormal’ pattern occurs, characterised
by an E/A wave ratio between 1.0 and 2.0. This pattern can be Atrial fibrillation commonly coexists with heart failure.
differentiated from a normal diastolic filling pattern by the addition Echocardiography may identify underlying cardiac structural and
of tissue Doppler imaging, which directly measures the reduced functional abnormalities that may predispose to atrial fibrillation.
relaxation of the myocardium. Severe diastolic dysfunction is Transthoracic echocardiography does not identify or exclude LA

906 Reprinted from Australian Family Physician Vol. 39, No. 12, december 2010
 Echocardiography in heart failure – a guide for general practice FOCUS

valve structure and function and other important findings such as

Mitral inflow Septal annular motion
(pulsed wave Doppler) (tissue Doppler imaging) pericardial abnormalities. A summary of the clinically important findings
will be provided with an interpretation in the context of the indication
provided on the request form. It is important that the request contains
sufficient clinical details to allow the echocardiographer to conduct and
report the study to ensure the clinical question is addressed.
A ‘technically difficult study’ usually means that the patient was
obese, had lung disease or was unable to cooperate fully so that some
aspects of the examination may be unclear or unanswered. If a finding on
a technically difficult examination does not fit with the clinical picture, it
is useful to discuss this with the reporting clinician.
Normal Impaired Pseudo- Restrictive After ensuring the report concerns the correct patient, begin reading
relaxation normal (severe
(mild dysfunction) (moderate dysfunction with from the end summary to ensure the key clinical question has been
↑↑ LAP)
dysfunction with
↑ LAP)
answered. However, do not to stop here; go back to the body of the
Mitral
report to check it supports the conclusions. If the left ventricle is reported
valve
inflow
as enlarged, the chamber dimensions on M-mode should be greater than
the normal range, allowing for patient size. If left ventricular hypertrophy
Septal
annular is reported, the left ventricular wall thicknesses (septal and posterior)
motion
or left ventricular mass will be above the normal range. Left ventricular
No symptoms Symptoms with
exertion Symptoms at rest or with exertion systolic function will usually be quantified by fractional shortening
(M-mode) or LVEF, and impaired systolic function is a key clinical finding
Figure 4. Patterns of diastolic dysfunction. The Doppler
pattern of the mitral inflow and mitral annular motion are
Name: Patient name DOB: 10/12/1950 Date: 08/10/2010
used to grade the severity of diastolic dysfunction, to
M-mode measurements 2-D measurements
provide an estimate of left atrial pressure and to indicate LV diastolic diam: 6.7 cm (N<5.7) LVEF: 35% (N>50)
LV systolic diam: 5.2 cm LVEF method: Biplane Simpson’s
how likely diastolic function abnormalities are likely to Septum: 1.1 cm (N<1.1)
Posterior wall: 1.0 cm (N<1.1) LA area: 26 cm² (N≤20)
cause symptoms Fractional shortening: 22% (N>26) LAVI: 40 mL/m² (N<29)
Left atrium: 4.8 cm (N<4.0) RA area: 23 cm² (N<18)
E = early diastolic filling wave, A = atrial filling wave, Aortic root: 3.2 cm (N<3.6)

E’ = early mitral annular motion, A’ = mitral annular Doppler measurements

Doppler velocity(m/sec) Valve gradients (mmHg)
motion due to atrial filling, LAP = left atrial pressure, S = Peak Normal Peak Mean
Aortic: 1.0 (1.0-1.7)
systolic mitral annular motion Pulmonary:
Tricuspid:
0.7 (0.6-0.9)
(0.3-0.7)
Mitral: E = 0.9 A = 0.3 (0.6-1.3)
Mitral decel time: 140 msec

thrombus in most cases because the left atrium is a structure in the MV area: cm² RV pressure: 33 mmHg + RA
AR half time: msec RVSP: 43 mmHg (N<36)
far (low resolution) field of the echocardiogram. Echocardiography is AoV area: cm² E/E’ septal: 16

able to identify other conditions which give rise to symptoms and signs Indication: ? heart failure
ECG: Sinus rhythm

of heart failure. The presence of a pericardial effusion can be seen on Left ventricle: Mildly dilated left ventricle with moderate systolic dysfunction. The pattern is
segmental with thinning and akinesis of all apical segments. No mural thrombus evident. The
ultrasound and echocardiography can be used to assess the severity estimated LVEF = 35 ± 5%. Restrictive diastolic filling and an E/E’ of 16 indicate elevated filling
pressures
Right ventricle: Normal right ventricular size and function
of the associated haemodynamic disturbance. The more chronic entity Left atrium: Mildly dilated left atrium
Right atrium: Mildly dilated right atrium. The inferior vena cava is not dilated
of constrictive pericarditis has characteristic echo features. In the Aortic valve: Normal trileaflet aortic valve which opens widely. No aortic regurgitation
Mitral valve: The mitral valve leaflets are normal, however posterior leaflet closure is restricted
by LV dilation. There is moderate mitral regurgitation which is directed posteriorly
context of right heart failure, echocardiography can identify pulmonary Pulmonary valve: Normal pulmonary valve with trivial regurgitation
Tricuspid valve: Normal tricuspid leaflets with trivial regurgitation

hypertension (secondary to pulmonary arterial disease or chronic lung There is mild pulmonary hypertension with an estimated RV systolic pressure of 43 mmHg

Conclusion
disease). The right ventricular systolic pressure (RVSP) can be estimated 1. Mildly dilated LV with moderate segmental systolic dysfunction. The presence of apical infarction
is suggestive of underlying coronary disease
2. Mild biatrial enlargement with features of elevated LA pressure
by Doppler echocardiography, as can the effect of the elevated RVSP on 3. Moderate functional MR due to LV enlargement
4. Mild pulmonary hypertension
the structure and function of the right ventricle.
Cardiologist

Interpreting an echocardiogram report

Figure 5. Sample echocardiography report including
Despite the existence of guidelines for structured echocardiography
normal values for important parameters
reporting, reports come in many formats.8 Most provide quantification N = normal value, LV = left ventricular, LVEF = left
of cardiac chamber size and function, key Doppler parameters of valve ventricular ejection fraction, LA = left atrium, LAVI =
function and important haemodynamic parameters, often in tabular left atrial volume index, RA = right atrium, MV = mitral
valve, RV = right ventricular, RVSP = right ventricular
format. Figure 5 provides a sample echocardiogram report which also
systolic pressure, AR = aortic regurgitation, AoV =
includes normal values. There is generally an interpretation of cardiac aortic valve
chamber structure and ventricular function, both systolic and diastolic,

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 FOCUS Echocardiography in heart failure – a guide for general practice

in heart failure. Left ventricular diastolic function will often be graded. symptoms at rest are unusual in mild diastolic dysfunction prompting
It is uncommon to have clinically significant diastolic dysfunction consideration of other causes for dyspnoea. Mild diastolic dysfunction may
without concomitant left atrial enlargement; a ‘barometer’ of long term be associated with symptoms during activity and may require exercise
trends in left atrial pressure. If diastolic function is abnormal but the testing to unmask them.9 Similarly, mild valvular lesions are usually
left atrium is not enlarged consider other causes for the symptoms. asymptomatic and should not be regarded as the cause of dyspnoea.
Sometimes there is no demonstrated specific cause for left
ventricular systolic dysfunction. However, regional wall thinning,
How frequently should echocardiography
be repeated?
hypokinesis or akinesis are strongly suggestive of underlying coronary
artery disease. When present, the degree of valvular dysfunction is Transthoracic echocardiography is mandatory in the initial assessment
usually quantified and the mechanism of dysfunction is determined if of suspected heart failure. Evidence suggests routine annual
possible. Important supporting parameters are typically included such as echocardiography is inappropriate to monitor heart failure or mild
valve gradient or valve area for aortic and mitral stenosis. In the context stenotic or regurgitant value lesions unless symptoms or signs
of significant mitral or tricuspid regurgitation the report should specify change.10 If there is a significant change in the severity of symptoms,
whether this is due to a valve leaflet problem or is secondary to chamber re-assessment of systolic, diastolic or valvular function is appropriate
dilation (often seen with cardiomyopathies). and moderate and severe lesions may require more frequent evaluation.
Routine assessment can be useful to measure the effect of changes
Correlation of echocardiogram findings in therapy on cardiac structure and function.
with symptoms
While an echocardiogram provides assessment of cardiac structure and Summary
function, consider whether abnormal findings identified on the study Transthoracic echocardiography is recommended in all cases of
are the cause of the patient’s symptoms. Symptoms of heart failure can suspected heart failure to confirm the clinical diagnosis, identify the
occur at any LVEF and their severity correlates best with the degree of any aeitiology and guide further investigation and therapy. Figure 6 shows
associated diastolic dysfunction rather than the LVEF. However, significant a useful diagnostic algorithm in suspected heart failure. Important

Suspected chronic heart failure

Echocardiogram

LVEF reduced LVEF normal

Global Segmental LVH or LA

Valvular disease Normal LA size
dysfunction dysfunction enlargement

Cardiomyopathy ? Coronary
? HF–NEF
evaluation artery disease

Assess diastolic filling

Abnormal Normal

Treat for heart failure with Consider other

Valvular disease HF–NEF
reduced LVEF diagnoses

Figure 6. Diagnostic algorithm using echocardiography in suspected heart failure.

LVEF = left ventricular ejection fraction, LVH = left ventricular hypertrophy, LA = left atrium,
HF-NEF = heart failure with normal ejection fraction

908 Reprinted from Australian Family Physician Vol. 39, No. 12, december 2010
 Echocardiography in heart failure – a guide for general practice FOCUS

findings include the presence or absence of left ventricular systolic

dysfunction, the presence and severity of valvular dysfunction and
key haemodynamic features such as diastolic filling patterns and
pulmonary artery pressure.

Authors
David Prior MBBS, PhD, FRACP, is Director of Non-invasive Cardiac
Imaging, Department of Cardiology, St Vincent’s Hospital, Melbourne,
Victoria. david.prior@svhm.org.au
Jennifer Coller MBBS, FRACP, is Research Fellow, Department of
Cardiology, St Vincent’s Hospital, Melbourne, Victoria.

Conflict of interest: none declared.

References
1. Krum H, Jelinek MV, Stewart S, et al. Guidelines for the prevention, detection
and management of people with chronic heart failure in Australia 2006. Med J
Aust 2006;185:549–57.
2. Senni M, Rodeheffer RJ, Tribouilloy CM, et al. Use of echocardiography in the
management of congestive heart failure in the community. J Am Coll Cardiol
1999;33:164–70.
3. Bardy GH, Lee KL, Mark DB, et al. Amiodarone or an implantable cardioverter-
defibrillator for congestive heart failure. N Engl J Med 2005;352:225–37.
4. Yusuf S, Pfeffer MA, Swedberg K, et al. Effects of candesartan in patients
with chronic heart failure and preserved left-ventricular ejection fraction: the
CHARM-Preserved Trial. Lancet 2003;362:777–81.
5. Redfield MM, Jacobsen SJ, Burnett JC Jr, Mahoney DW, Bailey KR,
Rodeheffer RJ. Burden of systolic and diastolic ventricular dysfunction in
the community: appreciating the scope of the heart failure epidemic. JAMA
2003;289:194–202.
6. MeRGE collaborators. Independence of restrictive filling pattern and LV ejec-
tion fraction with mortality in heart failure: an individual patient meta-analysis.
Eur J Heart Fail 2008;10:786–92.
7. Ommen SR, Nishimura RA, Appleton CP et al. Clinical utility of Doppler echo-
cardiography and tissue Doppler imaging in the estimation of left ventricular
filling pressures Circulation 2000;102:1788–94.
8. Gardin JM, Adams DB, Douglas PS, et al. Recommendations for a stand-
ardized report for adult transthoracic echocardiography: a report from the
American Society of Echocardiography’s Nomenclature and Standards
Committee and Task Force for a Standardized Echocardiography Report. J Am
Soc Echocardiogr 2002;15:275–90.
9. Burgess MI, Jenkins C, Sharman JE, Marwick TH. Diastolic stress echocar-
diography: hemodynamic validation and clinical significance of estimation of
ventricular filling pressure with exercise. J Am Coll Cardiol 2006;47:1891–900.
10. TTE/TEE Appropriateness Criteria Writing Group, Douglas PS, Khandheria
B, et al. ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 appropriateness
criteria for transthoracic and transesophageal echocardiography: a report of
the American College of Cardiology Foundation Quality Strategic Directions
Committee Appropriateness Criteria Working Group, American Society of
Echocardiography, American College of Emergency Physicians, American
Society of Nuclear Cardiology, Society for Cardiovascular Angiography and
Interventions, Society of Cardiovascular Computed Tomography, and the
Society for Cardiovascular Magnetic Resonance. Endorsed by the American
College of Chest Physicians and the Society of Critical Care Medicine. J Am
Soc Echocardiogr 2007;20:787–805.

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