Chapter 17: Stress echocardiography in the emergency department

In patients with chest pain, a resting, limited echocardiographic examination (even with a handheld imaging device) may provide invaluable information: a recent-onset regional wall motion abnormality of ischemic origin is frequently obvious when electrocardiographic changes are absent and cardiac enzymes (including high-sensitivity troponin) are not yet abnormal.
The resting echocardiogram can document or raise suspicion of important nonischemic causes of chest pain, including pericardial effusion, pulmonary embolism, and acute aortic dissection.
When resting echocardiography, electrocardiogram, and serial enzyme assay findings are negative and myocardial infarction has been ruled out, stress echo can be performed in patients with intermediate (30–60%) pretest probability, even at bedside, for risk stratification. If it is positive, hospital admission (in view of ischemia-driven angiography and revascularization in the presence of more extensive ischemia) is warranted. If it is negative with a comprehensive protocol (ideally including assessment of heart rate reserve and coronary flow velocity reserve), the patient can be safely discharged with very low probability of adverse outcome in the short-to medium-term follow-up.
Acutely symptomatic patients should never be tested in the ED setting.

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