Transthoracic echocardiography: what it can reveal about the heart as part of a cardiovascular check-up
Assessing cardiovascular health does not always mean looking for an obvious condition. In many cases, the question is broader – and also more useful: how well is the heart functioning today?
Blood pressure, blood tests, an electrocardiogram and the assessment of risk factors provide essential information. But there is one aspect that can only be understood by observing the heart directly in action: the structure of its chambers, how the heart muscle contracts, how it relaxes between one beat and the next, how the valves function, and how blood flows through it.
Transthoracic echocardiography provides this information in a non-invasive, radiation-free and real-time manner. Using a probe placed on the chest, it employs ultrasound to generate dynamic images of the heart as it beats. It is not a static photograph. It is an examination that allows both structure and function to be observed simultaneously.
That is why it plays a key role in clinical practice and can also be valuable in certain preventive cardiovascular assessments, provided there is a medical indication and a specific question to be answered.
As Dr Angélica María Romero Daza, head of the Advanced Cardiac Imaging Unit at the Publio Cordón Memorial Hospital, explains, “in a cardiovascular assessment, transthoracic echocardiography can help answer very specific questions: how the heart is functioning, how its chambers are behaving, whether the valves are working properly, or whether there are any findings that need to be interpreted within the patient’s clinical context”.
Its value, she adds, “lies not in producing yet another image, but in integrating that information with the patient’s medical history, symptoms, risk factors and the aim of the assessment”.
What is a transthoracic echocardiogram?
Transthoracic echocardiography is, essentially, an ultrasound scan of the heart. Just as an abdominal ultrasound allows us to view internal organs, echocardiography uses ultrasound to visualise the heart. The difference is that the heart is an organ in constant motion. Therefore, the test not only allows us to see its shape, but also to analyse how it contracts, how it relaxes, how its valves open and close, and how blood flows between its chambers.
The term ‘transthoracic’ indicates that the examination is carried out from the surface of the chest. The probe is placed on different points of the chest to obtain images from various angles. From there, the specialist can observe the atria, ventricles, valves, great vessels and various parameters of cardiac function.
This combination is particularly valuable because the heart is understood not only in terms of its anatomy, but also in terms of how it functions. A chamber may be dilated, a wall may be thicker than expected, a valve may not open or close properly, or blood flow may show signs of high pressure, overload or functional impairment.
The guidelines from the American Society of Echocardiography and the European Association of Cardiovascular Imaging describe echocardiography as a systematic examination, with standardised measurements of the cardiac chambers, ventricular function and other essential parameters to ensure that the results are comparable and clinically useful. This document updated the normal values for the four cardiac chambers and incorporated parameters such as three-dimensional echocardiography and myocardial deformation in specific contexts.
How it is performed and what the patient experiences
From the patient’s perspective, it is usually a simple and well-tolerated examination. It is typically carried out with the patient lying down, usually on their left side. This position brings the heart closer to the chest wall and facilitates imaging.
The specialist applies a small amount of gel to the chest and moves the probe over different areas of the chest. During the examination, they may ask the patient to change position slightly, to breathe in a particular way, or to hold their breath for a few seconds to improve image quality. At times, sounds related to blood flow may be heard; these form part of the Doppler analysis and do not, in themselves, indicate any problem.
The test does not use radiation, does not require anaesthesia and, in general, does not require any complex preparation. In most cases, the patient can resume their normal activities afterwards, unless the doctor advises otherwise based on the clinical context.
However, just because the test is comfortable for the patient does not mean it is a routine procedure. The quality of the examination depends on obtaining good acoustic windows, selecting the appropriate planes, taking accurate measurements and, above all, interpreting the findings within the context of the patient’s medical history.
“Patients generally tolerate the examination well,” says Dr Romero, “but for the specialist, it is not a routine test. The quality of the information depends on obtaining good imaging windows, selecting the appropriate measurements and interpreting the findings using clinical judgement.”
What the specialist looks for during an echocardiogram
During a transthoracic echocardiogram, the specialist examines the heart from different angles. They do not simply ‘check if the heart is fine’, but rather build up a structured understanding of its anatomy and function.
First, they examine the heart chambers. The atria receive the blood and the ventricles pump it out: the right ventricle to the lungs and the left ventricle to the rest of the body. An echocardiogram allows the specialist to assess whether these chambers are of an appropriate size, whether there is any dilation, whether the walls are of the expected thickness, and whether there are any signs of overload.
It then analyses pumping function. One of the best-known parameters is the left ventricular ejection fraction, which estimates the proportion of blood the ventricle expels with each beat. However, echocardiography is not limited to this single figure. A heart may have a preserved ejection fraction and yet still exhibit abnormalities in relaxation, increased filling pressures or signs of overload that require medical interpretation.
The mobility of the heart muscle is also assessed. The specialist observes whether all regions of the heart contract in a coordinated manner or whether any area moves less than expected. This information may be relevant in various clinical contexts, particularly where there are symptoms, a history of, or suspected cardiovascular disease.
Another key focus is the valves. The heart valves act as doors that open and close to direct the blood in the correct direction. Echocardiography allows us to assess whether a valve opens properly, whether it is narrowed, whether it does not close properly, or whether it allows some blood to flow backwards. These findings may be mild and require only monitoring, or they may be of greater significance depending on their severity, progression and clinical context.
As Dr Romero explains, “in echocardiography, we do not interpret a single piece of data. We take into account measurements, movement, blood flow and the clinical context. Two patients may have similar readings, yet these may have different clinical implications depending on their age, medical history, symptoms, physical activity and the reason for the assessment”.
Dr Angélica Romero Daza explaining her transthoracic echocardiography results to a patient
What Doppler means and why it is important
Doppler is a fundamental part of echocardiography. Put simply, whilst the echocardiographic image allows us to see the anatomy of the heart, Doppler helps us to understand how blood flows through that anatomy.
Doppler analyses the direction and speed of blood flow. Thanks to this tool, the specialist can study how blood passes through the valves, whether there is any narrowing, whether there is reverse blood flow, whether certain velocities are higher than expected, or whether certain data suggest changes in pressures within the heart.
This information is particularly useful for assessing valves, diastolic function, filling pressures and certain flow patterns. For this reason, a comprehensive echocardiogram is not limited to producing clear images of the heart. It must incorporate anatomical measurements, muscle movement, ventricular function and blood flow analysis.
The European NORRE project — Normal Reference Ranges for Echocardiography — provided reference values for Doppler parameters used in the assessment of cardiac physiology. In one of their analyses, the researchers showed that these values can vary with age and highlighted the importance of using specific reference ranges, particularly when assessing systolic function, diastolic function and left ventricular filling pressures.
What it can contribute to a cardiovascular assessment
As part of a cardiovascular assessment, echocardiography can provide information that other tests do not show in the same level of detail. It allows us to assess, for example, whether the left ventricle is of an appropriate size and has preserved pumping function. It also helps to analyse whether the atria are dilated, whether there is thickening of the heart muscle, whether the valves are narrowed or leaking, or whether there are indirect signs of elevated pressure in certain chambers.
This information may be relevant in people with symptoms such as shortness of breath, chest pain, palpitations, reduced physical capacity, dizziness or excessive tiredness. It may also be of interest when a murmur is detected during a clinical examination, when there is a family history of cardiovascular disease, or when risk factors such as high blood pressure, diabetes, high cholesterol, smoking or previous cardiovascular disease are present.
In the 2024 European guidelines on chronic coronary syndromes, resting echocardiography forms part of the specialist cardiological assessment in people with suspected chronic coronary artery disease, particularly to rule out left ventricular dysfunction and valvular disease before proceeding to other diagnostic tests. This recommendation does not mean that everyone needs an echocardiogram, but it does confirm its role as a tool for structural and functional assessment within certain clinical contexts.
As Dr Romero points out, “there is no one-size-fits-all answer for all patients. The right question is not whether everyone needs an echocardiogram, but what we want to find out and what decision that information can help guide.”
What it can help to guide or detect
A transthoracic echocardiogram can help guide the investigation of a wide range of conditions. One of the most common is a heart murmur. A murmur is a sound that a doctor can hear with a stethoscope and which, in some cases, is related to the flow of blood through a valve. Echocardiography allows us to assess whether there is a valvular abnormality and how significant it is.
It can also provide information in people with long-standing high blood pressure. When blood pressure remains high for years, the heart may adapt by thickening its walls or altering the way it relaxes. Echocardiography allows us to observe whether there are signs of such adaptation and whether they are clinically significant.
In patients experiencing shortness of breath, excessive tiredness or a loss of functional capacity, the test can help assess whether there is ventricular dysfunction, a valvular abnormality, chamber dilation or indirect evidence of high blood pressure. In people with palpitations or abnormalities detected on an electrocardiogram, it can provide information on the baseline cardiac structure.
It can also be useful in the follow-up of known conditions, such as valvular heart disease, cardiomyopathies or certain abnormalities in ventricular function. In these cases, it not only helps with diagnosis but also with assessing progression, stability and the need for further monitoring.
What can be considered normal – and why it is not always that simple
One of the challenges of echocardiography is defining what is considered normal. The heart does not have the same dimensions in everyone. Age, sex, body surface area, blood pressure, physical activity and certain medical histories can influence certain measurements.
That is why cardiovascular medicine has developed reference values based on large-scale studies and standardised protocols. The NORRE project, spearheaded by the European Association of Cardiovascular Imaging, was designed to establish contemporary ranges of normal values in echocardiography. One of its studies analysed the quantification of cardiac chambers in 734 healthy volunteers from 22 institutions and demonstrated the importance of adjusting certain measurements according to body size, age and sex.
This evidence helps to explain something important for patients: an echocardiogram is not simply a set of numbers. A result may be normal for one person but require attention in another. A mild finding may have no clinically relevant significance, whilst another, seemingly minor finding, may become significant if accompanied by symptoms, medical history or risk factors.
Therefore, a normal echocardiogram can provide reassurance, but it is no substitute for a comprehensive cardiovascular assessment if symptoms are present or there is a high risk. Conversely, an isolated finding should not cause alarm without proper medical interpretation.
The specialist makes an important clarification here: “A normal echocardiogram provides reassurance, but it is no substitute for a comprehensive cardiovascular assessment if symptoms or relevant risk factors are present. Conversely, an isolated finding should not cause alarm without a proper clinical interpretation.”
What an echocardiogram cannot answer
A thorough explanation must also clarify the test’s limitations. Transthoracic echocardiography allows for the assessment of structure, function, valves and blood flow, but it does not answer all cardiovascular questions.
For example, it does not allow direct visualisation of the coronary arteries with the level of detail provided by a coronary CT scan or catheterisation. It can reveal indirect consequences of certain problems, such as abnormalities in heart muscle movement or changes in ventricular function, but it does not replace other tests when the clinical aim is to examine the heart’s arteries in detail.
Nor does it replace a comprehensive medical assessment. Its results must be interpreted in conjunction with the patient’s medical history, physical examination, blood pressure, electrocardiogram, blood tests and other investigations where necessary.
This point is particularly important in the context of medical check-ups: the value of a test lies not in carrying it out in isolation, but in understanding why it is requested, what question it answers and how that information will be used.
Echocardiography and cardiovascular medical check-ups
As part of a cardiovascular medical check-up, transthoracic echocardiography can provide a different perspective to that offered by other tests. Whilst a blood test provides information on metabolic markers and an electrocardiogram records electrical activity at a specific moment, echocardiography offers direct information on the structure and mechanical function of the heart.
It may be of particular interest to people who wish to know how their heart is functioning today, even if they are not consulting a doctor because of any obvious symptoms. In these cases, its value lies not in ‘having yet another test’, but in assessing whether the chambers are of an appropriate size, whether pumping function is preserved, whether the valves are working correctly, or whether there are signs of overload that should be interpreted as part of a medical assessment.
It can also provide information for people with high blood pressure, a family history of heart disease, heart murmurs, abnormalities detected in other tests, subtle symptoms, regular participation in sport, or a desire to make significant lifestyle changes.
However, its use in health check-ups should avoid two extremes: trivialising it as a routine test for everyone, or reserving it exclusively for patients with known disease. The right approach lies in personalised indication.
In the words of Dr Romero, “in prevention, a test makes sense when it answers a specific question and when its result can be incorporated into a personalised medical recommendation”.
That is the key to rigorous preventive medicine: not accumulating tests, but selecting those that can provide useful information for making better decisions.
What happens if a finding is detected
When an echocardiogram reveals an abnormality, the next step depends on its nature and the patient’s clinical context. In some cases, regular follow-up is sufficient. In others, it may be necessary to adjust treatment or supplement the investigation with blood tests, a stress test, heart rhythm monitoring, cardiac MRI, coronary CT scan or other specific tests.
A common example is the finding of mild valvular abnormalities. These do not always indicate significant disease or require intervention. However, they may need to be monitored if they progress or are accompanied by symptoms. A similar situation applies to minor chamber enlargement, signs of ventricular hypertrophy or abnormalities in the heart’s relaxation: their significance depends on the patient’s age, blood pressure, symptoms and other clinical data.
Echocardiography, therefore, should not be viewed as a test that provides isolated answers, but rather as a tool that helps guide clinical decision-making.
An image that gains value when interpreted
Transthoracic echocardiography allows the heart to be observed directly, dynamically and non-invasively. It shows how its walls move, how its valves open and close, how blood circulates and how its chambers behave during each heartbeat.
But its value lies not merely in obtaining images. It lies in interpreting what those images mean for a specific individual.
At the Publio Cordón Memorial Hospital, echocardiography is seen as part of a personalised cardiovascular assessment, in which technology and medical expertise must work together. The image provides data; clinical judgement gives it meaning.
Observing the heart can also be a form of prevention when that observation answers a well-formulated medical question. Because knowing how the heart is functioning today can help in making more accurate decisions regarding follow-up, treatment, physical activity and cardiovascular care.
The information contained in this article is for informational purposes only and is not a substitute for a personalised medical assessment or individual recommendations for diagnostic tests.
Frequently asked questions about transthoracic echocardiography
Does a transthoracic echocardiogram hurt?
No. It is a non-invasive test and is generally well tolerated. The patient lies down whilst the specialist moves a probe over different areas of the chest using a gel. You may feel slight pressure on your chest at times, which is necessary to obtain better images, but this is not usually painful.
Is any preparation required?
In most cases, no complex preparation is required. It is not usually necessary to fast or stop taking any medication, unless the medical team advises otherwise due to the clinical context. It may be helpful to bring any previous cardiology reports, electrocardiograms, recent blood test results or results from other tests, if available.
What can an echocardiogram detect?
An echocardiogram allows the size of the heart chambers, the thickness of the walls, pumping function, the heart’s relaxation, valve function and blood flow (using Doppler) to be assessed. It can help guide the investigation of heart murmurs, valvular heart disease, chamber enlargement, hypertrophy, abnormalities in ventricular function, signs of overload, or findings related to high blood pressure or other cardiovascular diseases.
Does a normal echocardiogram rule out any heart problems?
Not necessarily. A normal echocardiogram can provide reassuring information about cardiac structure and function, but it does not rule out all cardiovascular problems. For example, it does not directly examine the coronary arteries in the same detail as a coronary CT scan or a cardiac catheterisation, nor does it replace a comprehensive assessment of symptoms, risk factors, an electrocardiogram, blood tests or other investigations where these are indicated.
Does it make sense to have one as part of a preventive medical check-up?
It may be appropriate when there is a specific medical concern. In a cardiovascular check-up, an echocardiogram can provide direct information on how the heart is functioning today: whether the chambers are of an appropriate size, whether pumping function is preserved, whether the valves are working correctly, or whether there are signs of overload. It should not be seen as a mandatory test for everyone, but rather as a useful tool when the doctor considers that it can provide relevant information as part of a personalised assessment.
The information in this article is provided for general awareness and does not replace an individualised medical assessment.
