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Almost every cardiac patient and a large share of breathless respiratory patients arrive with an echocardiogram already done. The report is dense, largely numerical, and rarely explained. This guide covers what each measurement means, the handful that genuinely change physiotherapy, and the single most important caveat — that ejection fraction correlates poorly with how breathless a patient is or how far they can walk.
The four studies
| Study | What it adds |
|---|---|
| Transthoracic (TTE) | The standard study — probe on the chest wall, 30–45 minutes, no preparation. Answers almost every question below. |
| Transoesophageal (TOE) | Probe in the oesophagus under sedation, fasted. Far better views of the valves, the left atrial appendage and prosthetic material — used for endocarditis, before cardioversion, and intra-operatively. |
| Stress echo | Imaging during exercise or dobutamine. Detects inducible ischaemia, and unmasks valve or filling abnormalities that are normal at rest — the study that most often explains exertional symptoms with a normal resting echo. |
| Contrast / bubble study | Agitated saline or contrast agent to improve endocardial definition, or to detect a right-to-left shunt such as a patent foramen ovale. |
Left ventricular function
Ejection fraction is the fraction of end-diastolic volume ejected per beat, and it is the number everyone quotes. It classifies heart failure phenotype — reduced (≤40%), mildly reduced (41–49%) and preserved (≥50%) — which in turn determines drug therapy.1,2
Global longitudinal strain (GLS) appears on many modern reports and detects impaired contractility while EF is still normal — it is more sensitive than EF, and is used to catch cardiotoxicity during cancer therapy. A normal EF with an abnormal GLS is an early abnormality, not a normal study.
Regional wall motion abnormalities localise previous infarction. A named territory (“anteroseptal hypokinesis”) maps onto a coronary artery and usually to a documented event.
Diastolic function — where HFpEF lives
Reported as grade I–III diastolic dysfunction, derived from mitral inflow velocities (E and A), tissue Doppler (e′), the E/e′ ratio, left atrial volume index and tricuspid regurgitant velocity.3
A raised E/e′ with an enlarged left atrium indicates elevated filling pressures — the mechanism behind exertional breathlessness in heart failure with preserved ejection fraction. This matters because those patients look normal on the headline EF and are frequently told their heart is fine. They are also the group in whom exercise training produces the clearest gains in quality of life.
The right heart — the part respiratory physiotherapy should read first
Right ventricular function is systematically under-read, and it is the side that matters in chronic lung disease.4
| Measure | Threshold | Meaning |
|---|---|---|
| TAPSE | <17 mm suggests RV systolic dysfunction4 | Simple, reproducible, on almost every report |
| RV S′ | <9.5 cm/s abnormal4 | Tissue Doppler measure of RV contraction |
| Peak TR velocity | >2.8 m/s intermediate; >3.4 m/s high probability of pulmonary hypertension5 | The screening signal — echo estimates probability, right heart catheterisation confirms |
| RV size and septal motion | Dilated RV, flattened septum | Pressure or volume overload — look for the cause |
An echo cannot diagnose pulmonary hypertension; it assigns a probability that triggers further assessment.5 A patient with COPD or interstitial disease whose exercise tolerance has fallen out of proportion to their spirometry, with a raised TR velocity and a dilated RV, is a different clinical problem from deconditioning — see pulmonary hypertension.
Valves
Each valve is reported for stenosis and regurgitation, graded mild to severe. The one with the clearest implications for exercise prescription is aortic stenosis: severe disease is defined by a peak velocity ≥4.0 m/s, mean gradient ≥40 mmHg or valve area ≤1.0 cm².6
Regurgitant lesions are usually better tolerated and less restrictive, but severe mitral or aortic regurgitation with LV dilatation warrants checking what the cardiologist has advised before progressing load.
Pericardium and other findings
- Pericardial effusion — size, and whether there is tamponade physiology. A patient with breathlessness and a new effusion needs review before exercise.
- Intracardiac thrombus, particularly LV apical thrombus after anterior infarction — check anticoagulation status.
- Vegetations in suspected endocarditis; a negative TTE does not exclude it, which is why TOE follows.
- Shunts — patent foramen ovale or atrial septal defect, sometimes the explanation for unexplained hypoxaemia.
What limits an echo
Image quality depends on acoustic windows, and they are poor in exactly the patients respiratory services see most: hyperinflated lungs, obesity, chest wall deformity, and post-operative dressings and drains. A report qualified as “suboptimal windows” deserves less weight, and may be why a contrast study or cardiac MRI followed. Doppler measurements are also load-dependent — volume status, blood pressure and rhythm at the time of the study all affect them, so an echo performed during an acute admission may not represent the patient's stable state.
What to tell the patient
- A transthoracic echo is painless, takes 30–45 minutes, involves gel and lying on the left side, and uses no radiation.
- They may be asked to hold their breath briefly and to roll — useful to know for the breathless or the post-operative patient.
- A TOE requires fasting and sedation, with someone to take them home.
- Results usually go to the referrer rather than being given at the time.
What this means for physiotherapy
- Read TAPSE and TR velocity before you read ejection fraction in a respiratory patient — the right heart is the side your disease affects.
- Never set exercise intensity from EF alone. It does not predict capacity, and the functional test does.
- Check for severe aortic stenosis before prescribing high-intensity or heavy resistance work.
- A normal EF with diastolic dysfunction and a big left atrium is HFpEF — a real diagnosis, and one that responds to training.
- Note the date and the clinical context: an echo taken during decompensation is not the patient in front of you six weeks later.
References & evidence base
- McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42(36):3599–3726.
- Bozkurt B, Coats AJS, Tsutsui H, et al. Universal definition and classification of heart failure. Eur J Heart Fail. 2021;23(3):352–380.
- Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. J Am Soc Echocardiogr. 2016;29(4):277–314.
- Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults. J Am Soc Echocardiogr. 2010;23(7):685–713.
- Humbert M, Kovacs G, Hoeper MM, et al. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J. 2022;43(38):3618–3731.
- Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease. Circulation. 2021;143(5):e72–e227.
Further reading
- Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the ASE and EACVI. J Am Soc Echocardiogr. 2015;28(1):1–39.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.
Corrections: If something on this page is wrong, out of date or unclear, we want to know. Email reception@inspireclinic.au with the page name and what you believe is incorrect. Substantive corrections are made promptly, and the guide’s version and last-updated date are changed to reflect it.