Background: The Echocardiography Laboratory at the Rivers State University Teaching Hospital (RSUTH) serves a wide demographic from Port Harcourt and surrounding regions. As cardiovascular diseases rise in prevalence across Sub-Saharan Africa, periodic audits provide essential insight into evolving disease patterns and service demands. This study aimed to evaluate the clinical indications and echocardiographic diagnoses over a one-year period to inform practice improvement, strategic planning, and cardiovascular investment. Methods: A retrospective, descriptive cross-sectional study was conducted using data from December 2022 to December 2023. Transthoracic echocardiographic reports were reviewed for demographic details, clinical indications, anthropometric data, and echocardiographic findings. Ethical clearance was obtained from the ethics committee of the Rivers State University Teaching Hospital. Data was collected on Excel spreadsheet and analysis was performed using SPSS version 25. Results: A total of 830 echocardiograms were analyzed, comprising 471 females (56.75%) and 359 males (43.25%), with a mean age of 55.7 ± 15.6 years and mean BMI of 29.2 ± 6.8 kg/m². The most common indications for echocardiography were hypertension (36.7%), heart failure (14.7%), and chest pain syndromes (8.8%). Hypertensive heart disease was the most frequent echocardiographic diagnosis (43.6%), followed by valvular heart disease (11.1%), ischemic heart disease (10.0%), and cardiomyopathies (8.2%). Congenital heart diseases, mainly septal defects, accounted for 2.7% of cases. Isolated right heart strain was seen in 5.6%, and 18.7% had normal echocardiographic findings. Conclusion: Hypertensive heart disease remains the dominant cardiac pathology in our setting. This audit highlights the diagnostic utility of echocardiography and the need for sustained investment in cardiovascular diagnostics and workforce training in Nigeria.