Echocardiography in the management of pulmonary embolism

Echocardiography is not recommended as a routine imaging test to diagnose suspected pulmonary embolism. However, it is useful for identifying patients with pulmonary embolism who may have a poor prognosis. It can be used for rapid and accurate risk assessment. Moderate or severe right ventricular hypokinesis, per-sistent pulmonary hypertension, a patent foramen ovale, and free-floating right-heart thrombus are echocardiographic markers that identify patients at risk for death or recurrent thromboembolism. Such patients warrant consideration for thrombolysis or embolec-tomy. Serial imaging of right ventricular function can help physi-cians monitor the effect of treatment and judge whether the se-lected management strategy is successful. Further research will clarify and define more precisely the utility and limitations of echocardiography in the management of pulmonary embolism. Ann Intern Med. 2002;136:691-700. www.annals.org For author affiliation and current address, see end of text. Patients with acute pulmonary embolism are under-going echocardiography with increasing frequency (1). Because the use of echocardiography in these pa-tients is burgeoning, I provide my perspective on the utility of this test in bedside management. I do not recommend echocardiography as a routine imaging test to diagnose suspected pulmonary embolism because most patients with pulmonary embolism have normal echocardiograms. Nevertheless, among patients who undergo echocardiography for suspected left-heart failure, the imaging of a normal left ventricle and di-lated, hypokinetic right ventricle may serendipitously suggest the diagnosis of pulmonary embolism. In addi-tion, echocardiography is useful for diagnosis in hemo-dynamically unstable patients with unexplained dysp-nea, syncope, or right-heart failure. Transesophageal echocardiography is best reserved for critically ill pa-tients in whom the cause of cardiovascular instability remains uncertain