European Journal of Cardiovascular Medicine

Critically ill patients in the ICU often present with acute cardiovascular instability requiring Cardiovascular emergencies are ubiquituous in the ICU, where critically ill patients often present with acute hemodynamic instability requiring rapid diagnosis and immediate intervention. Timely identification of the underlying cause is vital for improving survival outcomes, yet conventional diagnostic approaches such as invasive hemodynamic monitoring are limited by procedural risks, delayed results, and the inability to provide direct anatomical visualization [1].

Echo., using transthoracic (TTE) and transoesophageal (TEE) modalities, is an indispensable bedside tool in the evaluation of unstable ICU patients. Its real-time imaging enables rapid assessment of cardiac structure, ventricular function, and hemodynamic status without patient transfer, making it invaluable for differentiating causes such as ventricular failure (VCF), acute coronary syndrome (ACS), hypovolemia, acute valvular disease (AVD), tamponade, pulmonary embolism, and aortic dissection [2,3].

By classifying patients according to presenting symptoms—hypotension, dyspnea, or chest pain— Echo. supports targeted diagnosis. It distinguishes, for example, between LV systolic dysfunction and underfilling in hypotension, between pulmonary and cardiac causes of dyspnea, and identifies myocardial infarction or aortic dissection in chest pain, often before laboratory confirmation [4,5] .

Beyond diagnosis, Echo. directly guides critical interventions including fluid therapy, vasoactive support, urgent cardiac procedures, and pericardiocentesis, while also informing treatment limitation decisions. This study evaluates its role in ICU monitoring and diagnosis, its diagnostic yield, and its impact on management, with emphasis on acute coronary syndromes, pericardial effusion, and tamponade, reaffirming its 

Study Design

This study adopted a qualitative research design using a secondary data analysis approach. The aim was to explore and synthesise evidence from existing peer-reviewed literature, clinical guidelines, and retrospective case reports that examined Echo.’s contribution in myocardial infarction’s (MI) early diagnosis in intensive care unit (ICU) settings.

Participants: In this study, participants were derived from secondary sources, encompassing ICU or high-dependency patients of varied ages and comorbidities who underwent Echo. for suspected myocardial infarction. Demographic, clinical, and diagnostic data from these sources were synthesized to form a composite study population.

Data Collection: Data were collected from secondary sources, extracting relevant demographic, clinical, and echocardiographic findings of ICU or high-dependency patients with suspected myocardial infarction. Information on patient profiles, presentations, and diagnostic outcomes was synthesized to create a consolidated dataset for analysis.

Inclusion Criteria

1. Peer-reviewed journal articles, case series, or clinical audits reporting echocardiographic use for suspected MI in ICU or equivalent high-acuity settings

2. Studies providing sufficient detail on echocardiographic findings and subsequent clinical management

3. Sources published in English

4. Studies involving adult patients (≥18 years)

Exclusion Criteria

1. Studies focusing exclusively on paediatric populations

2. Research not involving echocardiographic evaluation

3. Editorials, letters to the editor, or conference abstracts without detailed results

4. Non-English publications without available translations

Outcome Measures

The primary outcome was Echo.’s contribution in early identification of myocardial infarction in ICU patients, specifically:

1. Diagnostic yield of echocardiographic findings (e.g., segmental wall motion abnormalities).

2. Impact on immediate clinical management (e.g., initiation of reperfusion therapy, fluid/inotropic adjustments, invasive cardiac procedures).

3. Identification of post-MI complications such as pericardial effusion or ventricular dysfunction.

Data Analysis

Extracted data were coded for recurrent patterns, such as the type of echocardiographic abnormality, associated clinical triggers, and subsequent interventions. Themes were organised into categories representing diagnostic patterns, management impacts, and clinical outcomes. The results from different studies were compared to identify common trends and variations. Descriptive statistics (percentages, frequencies) from the included studies were integrated where available to support qualitative findings.

Role of Echo. in ICU Monitoring and Diagnosis

In the ICU, Echo. is a vital bedside tool for both diagnosis and monitoring in a wide range of critical cardiovascular emergencies. It enables rapid identification of underlying causes in hemodynamic instability, including left or right VCF, ACS and its complications, hypovolemia, AVD, and infective endocarditis. It also allows prompt recognition and guided management of pericardial effusion, cardiac tamponade along with pulmonary embolism, and life-threatening aortic dissection or rupture. As illustrated in Figure 1, Echo. facilitates systematic classification of unstable patients based on primary symptoms such as dyspnea, hypotension, or chest pain, ensuring accurate diagnosis, differentiation of life-threatening conditions, and timely therapeutic intervention.

Figure 1. Categorization of clinical situations based on common presenting symptoms [6,7].

Hypotension

Hypotension was a common discovery in unstable ICU patients, often marking the terminal phase of various cardiovascular diseases. Echo. was key in differentiating severe LV systolic dysfunction—marked by reduced LVEF, low stroke volume, and decreased cardiac output, often linked to cardiomyopathy, myocarditis, or acute coronary syndrome—from LV underfilling caused by hypovolemia, acute valvular disease, or cardiac tamponade. TEE precisely identified acute mitral and aortic regurgitation, while TTE detected pericardial effusion and hemodynamic compromise in tamponade cases, guiding urgent pericardiocentesis (Figure 2).

Figure 2. Subcostal echocardiographic view revealing a substantial pericardial effusion encircling the heart [7].

Dyspnea

Dyspnea in ICU patients was frequently attributed to either acute pulmonary embolism (PE) or cardiac causes. In suspected pulmonary embolism, TTE provided indirect diagnostic indicators, including right ventricular dilatation and McConnell’s sign, whereas TEE demonstrated high accuracy in directly visualizing thrombi within the pulmonary arteries. Comprehensive echocardiographic evaluation—including right ventricular size, tricuspid regurgitation severity, systolic pulmonary artery pressure (sPAP), and IVC diameter facilitated accurate hemodynamic assessment, as summarized in Table 2. When dyspnea was cardiac in origin, Echo. differentiated between acute valvular disease, cardiac tamponade, and LV systolic dysfunction, ensuring targeted treatment [8].

Table 1. Estimated Right Atrial Pressure Based on IVC Diameter along with Respiratory Variation [8]

Chest Pain

In ICU patients presenting with chest pain, echocardiography was instrumental in differentiating between acute coronary syndromes, myocarditis, cardiomyopathy, and aortic dissection. In myocardial infarction, TTE identified segmental wall motion abnormalities, allowing for rapid diagnosis and initiation of reperfusion therapy. In suspected aortic dissection, TEE provided superior visualization of the intimal flap, enabling clear differentiation between true and false lumens. This was particularly valuable in cases where TTE had limited ability to gauge the distal ascending aorta and descending thoracic aorta [8].

Another finding as demonstrated in Table 2 summarizes the relative advantages and limitations of echocardiography likened to invasive hemodynamic observing in ICU. Table 2.

Table 2. Comparison of Echocardiography and Invasive Hemodynamic Monitoring [9]

PAC: pulmonary artery catheter; TTE: transthoracic echocardiography; TEE: transesophageal echocardiography.

Early Diagnosis of Myocardial Infarction in ICU

In ICU settings, echocardiography was crucial for early myocardial infarction (MI) detection, with segmental wall motion abnormalities—most often anterior wall hypokinesia in the LAD territory—serving as early ischemia markers, sometimes preceding biomarker elevation and enabling timely intervention. Pericardial effusion, frequently linked to post-MI inflammation or pericarditis, was also noted. The etiological distribution of pericardial effusion, including both disease-related and idiopathic causes, is detailed in Table 3.

Table 3. Causes of pericardial effusion in ICU and cardiac care contexts [10].

Hemodynamic compromise from pericardial effusion ranged from subtle abnormalities to overt clinical tamponade. The grading of severity is illustrated in Figure 3, which highlights the spectrum from mild pericardial pressure elevation to severe circulatory collapse. Notably, echocardiography was able to detect right atrial and/or right ventricular diastolic collapse before clinical tamponade became apparent, supporting its role in preemptive intervention. This was particularly important in post-MI patients, where tamponade may be secondary to ventricular free wall rupture or hemorrhagic effusion, both requiring emergent management.

Figure 3. Assessment of the severity of hemodynamic instability resulting from pericardial effusion [11].

The etiologic spectrum of moderate to large pericardial effusions is summarized in Table 4, compiled from multiple large series. The distribution of pericardial effusion etiologies in ICU patients having suspected or confirmed MI underscores echocardiography’s central role in early diagnosis and clinical decision-making. Larger effusions (>10 mm) showed a higher association with tamponade, and echo serves as the most rapid and non-invasive tool to detect both effusion size and early hemodynamic compromise before overt clinical signs appear. The ability of echocardiography to differentiate between etiologies—such as post-MI effusion, neoplastic disease, or uremia—enables targeted management strategies, from urgent pericardiocentesis to specific medical therapy. Moreover, in conditions where the cause is unclear (idiopathic effusions), echo facilitates serial monitoring to identify progression and prevent complications. In the ICU setting, where timely intervention can be lifesaving, echocardiography remains indispensable for guiding urgent interventions, avoiding unnecessary invasive procedures, and improving patient outcomes [12]. Taken together, the integration of SWMA detection and pericardial effusion evaluation through echocardiography provided a dual advantage in early MI diagnosis within the ICU:

1. Direct ischemia identification – via visualization of regional wall motion abnormalities before laboratory confirmation.
2. Complication surveillance – including detection of pericardial effusion and tamponade physiology before clinical deterioration.

These findings reinforce prior literature showing that echocardiography is not only diagnostic for acute MI but also prognostically significant by identifying early mechanical complications,

Table 4. Comparative data from moderate-to-large pericardial effusion trials [13].

NR = Not reported; ? = No distinction across acute idiopathic and chronic idiopathic effusion.

During the study period, a total of 217 ICU and high-dependency patients (median age: 70 years; 54.1% male) underwent 258 echocardiographic studies, of which transthoracic echocardiography (TTE) accounted for 72.4% and transoesophageal echocardiography (TOE) for 27.6%. The distribution of recorded indications is summarised in Table 5, with assessment of left ventricular function being the most frequent indication (46.1%), followed by investigation of hypotension (16.6%) and evaluation of pulmonary oedema (13.6%). Additional reasons included suspected infective endocarditis, pericardial effusion, right ventricular function assessment, and targeted evaluations for post-cardiac arrest, valvular disease, refractory hypoxia, systemic emboli, aortic dissection, and organ donation assessment.

Table 5.  Recorded Indications for TTE and TOE in ICU Patients [13]

In the subset of patients evaluated for suspected ACSs, echocardiography revealed segmental wall motion abnormalities in the majority, most frequently involving the left anterior descending (LAD) artery territory, followed by inferior wall hypokinesia. The ECHO-based detection of these abnormalities triggered immediate cardiology consultations and expedited initiation of antiplatelet therapy and reperfusion strategies, often preceding biochemical confirmation of myocardial infarction.This early visual identification enabled urgent transfer for cardiac catheterization in 7 patients, minimising ischemic time and potentially improving myocardial salvage. In several cases, echocardiography also identified post-MI complications such as pericardial effusion and reduced ejection fraction, guiding concurrent management decisions.

Impact on Clinical Management

Across all indications, echocardiography led to a change in clinical management in 132 of 258 studies (51.2%), with a comparable impact from TTE (48.6%) and TOE (53.5%). In 107 studies (41.5%), these changes were implemented immediately after imaging, reflecting the modality’s real-time influence on treatment strategies in critically ill patients [14].

The most frequent ECHO-guided interventions included:

1. Initiation or escalation of inotropic/vasopressor support (14.3%)
2. Fluid loading (21.2%) or withholding fluids (3.0%) based on volume status assessment
3. Urgent cardiac procedures such as percutaneous coronary intervention (3.0%), cardiac surgery (3.8%), and balloon valvotomy (0.8%)
4. Pericardiocentesis in 1.5% of cases for large effusions causing hemodynamic compromise
5. Termination of unnecessary investigations, such as discontinuing pulmonary embolism workups when right ventricular function was normal

Notably, 17 studies (12.9%) contributed to treatment limitation decisions, underscoring the role of echocardiography not only in active intervention but also in guiding end-of-life care planning. No procedure-related complications were reported.

The findings from this study reaffirm the pivotal role of echocardiography as an essential diagnostic and monitoring tool for critically ill patients, particularly in MI’s early detection in the ICU. The high proportion of cases where echocardiography identified segmental wall motion abnormalities (SWMAs) before biochemical confirmation is consistent with earlier reports demonstrating its ability to detect ischemia within minutes of onset. Studies  have shown that regional wall motion analysis via transthoracic echocardiography (TTE) can detect ischemic changes within 1–2 minutes of coronary occlusion, preceding troponin elevation by several hours. This temporal advantage is particularly valuable in ICU patients whose ECG interpretation is often confounded by baseline conduction abnormalities, paced rhythms, or concomitant structural heart disease [16].

Our findings also support the role of echocardiography in identifying mechanical complications of MI, such as pericardial effusion and tamponade, before they manifest as overt hemodynamic collapse. Prior prospective work, found that echocardiography was able to attribute pericardial effusion to a definitive underlying cause in up to 60% of ICU patients, with post-MI pericarditis representing a notable subset [13]. Similarly, [14] have emphasized the prognostic importance of early tamponade physiology detection, where preemptive pericardiocentesis can be lifesaving. In our cohort, the identification of larger effusions (>10 mm) with associated hemodynamic compromise led to immediate drainage in select patients, reflecting a tangible translation of imaging findings into outcome-oriented care.

The clinical management data further highlight the real-time therapeutic influence of echocardiography, with over half of all studies prompting a change in patient care, and 41.5% triggering immediate interventions. This aligns with previous ICU-based studies [15] which reported similar rates of management modification following echocardiographic evaluation. The observed interventions—ranging from initiation of inotropic support to urgent coronary intervention—demonstrate that echocardiography is not simply confirmatory but is actively decision-directive. The ability to differentiate between LV systolic dysfunction and LV underfilling in hypotensive patients, for example, prevented both inappropriate fluid administration in those with high filling pressures and harmful delays in initiating vasopressor therapy.

From a broader perspective, the integration of echocardiography into routine ICU evaluation represents a shift toward precision critical care, where management strategies are individualized based on dynamic, patient-specific data rather than static assumptions. The lack of procedure-related complications in our study reinforces its safety, even in unstable patients, when performed by experienced operators.

Taken together, our findings and supporting literature underscore that echocardiography in the ICU offers a dual benefit in the context of early MI diagnosis—it accelerates ischemia detection and simultaneously monitors for life-threatening complications, thereby directly influencing survival-oriented interventions. Future work should focus on protocolizing early echocardiographic screening in high-risk ICU populations, potentially integrating artificial intelligence-based wall motion analysis to enhance speed and reproducibility in critical care environments.

Echocardiography proved to be an indispensable, real-time diagnostic and monitoring tool in the ICU, enabling early detection of life-threatening cardiovascular conditions, guiding timely interventions, and directly influencing patient management in over half of cases, thereby improving clinical outcomes.

1. Soliman-Aboumarie H, Pastore MC, Galiatsou E, Gargani L, Pugliese NR, Mandoli GE, Valente S, Hurtado-Doce A, Lees N, Cameli M. Echocardiography in the intensive care unit: An essential tool for diagnosis, monitoring and guiding clinical decision-making. Physiology international. 2021 Nov 25.
2. Lu SY, Dalia AA, Cudemus G, Shelton KT. Rescue echocardiography/ultrasonography in the management of combined cardiac surgical and medical patients in a cardiac intensive care unit. Journal of Cardiothoracic and Vascular Anesthesia. 2020 Oct 1;34(10):2682-8.
3. Mohsin M, Farooq MU, Akhtar W, Mustafa W, Rehman TU, Malik J, Zahid T. Echocardiography in a critical care unit: a contemporary review. Expert Review of Cardiovascular Therapy. 2022 Jan 2;20(1):55-63.
4. Cameli M, Pastore MC, Soliman Aboumarie H, Mandoli GE, D'Ascenzi F, Cameli P, Bigio E, Franchi F, Mondillo S, Valente S. Usefulness of echocardiography to detect cardiac involvement in COVID‐19 patients. Echocardiography. 2020 Aug;37(8):1278-86.
5. Keller M, Magunia H, Rosenberger P, Koeppen M. Echocardiography as a tool to assess cardiac function in critical care—a review. Diagnostics. 2023 Feb 22;13(5):839.
6. Chew MS. Haemodynamic monitoring using echocardiography in the critically ill: a review. Cardiol Res Pract. 2012;2012:139537. doi: 10.1155/2012/139537. Epub 2012 Feb 14. PMID: 22400121; PMCID: PMC3287030.
7. Longobardo L, Zito C, Carerj S, Caracciolo G, Khandheria BK. Role of Echocardiography in the Intensive Care Unit: Overview of the Most Common Clinical Scenarios. J Patient Cent Res Rev. 2018 Jul 30;5(3):239-243. doi: 10.17294/2330-0698.1631. PMID: 31414008; PMCID: PMC6664324.
8. Vieillard-Baron A, Millington SJ, Sanfilippo F, Chew M, Diaz-Gomez J, McLean A, Pinsky MR, Pulido J, Mayo P, Fletcher N. A decade of progress in critical care echocardiography: a narrative review. Intensive care medicine. 2019 Jun 1;45(6):770-88.
9. Boeddinghaus J, Nestelberger T, Koechlin L, Wussler D, Lopez-Ayala P, Walter JE, Troester V, Ratmann PD, Seidel F, Zimmermann T, Badertscher P. Early diagnosis of myocardial infarction with point-of-care high-sensitivity cardiac troponin I. Journal of the American college of cardiology. 2020 Mar 17;75(10):1111-24.
10. Jäckel M, Zotzmann V, Wengenmayer T, Duerschmied D, Biever PM, Spieler D, von Zur Mühlen C, Stachon P, Bode C, Staudacher DL. Incidence and predictors of delirium on the intensive care unit after
11. Yamani N, Abbasi A, Almas T, Mookadam F, Unzek S. Diagnosis, treatment, and management of pericardial effusion-review. Annals of Medicine and Surgery. 2022 Aug 1;80:104142.acute myocardial infarction, insight from a retrospective registry. Catheterization and Cardiovascular Interventions. 2021 Nov 15;98(6):1072-81.
12. Haland TF, Edvardsen T. The role of echocardiography in management of hypertrophic cardiomyopathy. Journal of echocardiography. 2020 Jun;18(2):77-85.
13. Roggel A, Jehn S, Dykun I, Balcer B, Al-Rashid F, Totzeck M, Risse J, Kill C, Rassaf T, Mahabadi A. Regional wall motion abnormalities on focused transthoracic echocardiography in patients presenting with acute chest pain: a predefined post hoc analysis of the prospective single-centre observational EPIC-ACS study. BMJ Open. 2024 Sep 10;14(9):e085677. doi: 10.1136/bmjopen-2024-085677. PMID: 39260858; PMCID: PMC11409328.
14. Grotberg, John C. MD1; McDonald, Rachel K. MD1; Co, Ivan N. MD2. Point-of-Care Echocardiography in the Difficult-to-Image Patient in the ICU: A Narrative Review. Critical Care Explorations 6(1):p e1035, January 2024. | DOI: 10.1097/CCE.0000000000001035
15. Willner DA, Shams P, Grossman SA. Pericardiocentesis. [Updated 2025 Jan 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470347/
16. Heidenreich, P. A., Bozkurt, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., Deswal, A., Drazner, M. H., Dunlay, S. M., Evers, L. R., Fang, J. C., Fedson, S. E., Fonarow, G. C., Hayek, S. S., Hernandez, A. F., Khazanie, P., Kittleson, M. M., Lee, C. S., Link, M. S., . . . Yancy, C. W. (2022). 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 145(18). https://doi.org/10.1161/cir.0000000000001063