The evaluation and management of patients who arrive at the emergency department with acute symptoms and/or worrying clinical condition is a daily challenge. Careful history taking—when it is possible—and clinical examination remain the mandatory first steps. It is of the utmost importance to obtain a timely accurate diagnosis and to immediately stratify the risk to the patient’s life. Therefore, choice of the correct investigation is essential. Among the possible tools, imaging modalities are frequently required. Echocardiography is the most versatile method. It is non-invasive, can be performed at the bedside, provides rapid results, and avoids contrast injection and exposure of the patient to radiation. Echocardiography is now available in most emergency rooms, allowing immediate, standard transthoracic examination by an emergency department physician. For some indications and some ultrasonic modalities, specialised and trained physicians or sonographers are necessary for performance and interpretation.

This article focuses on the clinical information that can be obtained from echocardiography according to the most frequent presentations suggesting a cardiovascular emergency.

ACUTE CHEST PAIN: SUSPICION OF ACUTE CORONARY SYNDROME

Patients with acute chest pain account for a notable proportion (20–30%) of medical admissions to the emergency department.1 Acute coronary syndromes can be easily identified in the presence of typical chest pain and a diagnostic ECG, and confirmed by serial changes in cardiac enzymes. However, a vast majority of patients have atypical chest pain and/or normal or non-diagnostic ECG; early determination of serum troponin frequently is negative. Marginal elevations of troponin in this clinical setting result in uncertainty. To avoid unnecessary prolonged hospital observation (which is costly) and mistaken discharge (with the associated potential for litigation), rapid cost effective and accurate risk stratification is important. Numerous alternative strategies are possible (table 1).

Echocardiography can be performed only at rest, conventionally or with implementation of an ultrasound contrast agent. Echocardiography can also be coupled with …