![Triage of Patients with Chest Pain
[ discharge or not ? ]
• In patients with symptoms suggestive ACS [>30 min chest pain, < 6 hrs
onset, and abnormal ECG –non ST elevation]
– TTE (tissue harmonic imaging) : 97 % NPV, 24% PPV
– TTE (tissue harmonic imaging) : 92% sensitivity, 48% specificity
Eur J Echocardiogr 2004; 5: 142-8
• False positive
– transient myocardial ischemia, chronic ischemia (hibernating
myocardium), or myocardial scar, myocarditis, nonischemic
cardiomyopathy or other conditions not associated with coronary
occlusion.](https://image.slidesharecdn.com/echoforacs-130827214827-phpapp01/85/Echocardiography-for-Acute-Coronary-Syndrome-9-320.jpg)
![Triage of Patients with Chest Pain
[ discharge or not ? ]
• Normal systolic function at rest reassuring, but NOT exclude the
diagnosis of ACS
• Evaluation of wall thickening by TTE is appropriate in patients with ACS,
but NOT a diagnostic initial testing
JACC 2007 ; 50:187-204
• Subendocarial infarction : no RWMA echo alone can be false negative
.](https://image.slidesharecdn.com/echoforacs-130827214827-phpapp01/85/Echocardiography-for-Acute-Coronary-Syndrome-10-320.jpg)
Echocardiography for Acute Coronary Syndrome
- 1. Echocardiography for Acute Coronary Syndrome Amiliana Mardiani Soesanto,MD Non Invasive Division Dept.Cardiology and Vascular Medicine/ National Cardiovascular Center Harapan Kita
- 2. Introduction • Acute Coronary Syndrome : is a serious condition, without proper management, the outcome will be poor. • Early detection and accurate diagnostic is of important to improve the outcome. • ACS could presents with atypical symptom, lack of specific ECG changes, and negative cardiac biomarkers. • Accurate assessment of chest pain in the emergency department requires a thorough knowledge of the differential diagnosis and appropriate use of diagnostic tools.
- 3. Echocardiography in Acute Coronary Syndrome • Diagnosis – Initial triage – confirming the diagnosis – rule out the differential diagnosis • Detecting Complication • Management Strategy : early revascularization / intervention, IABP • Risk Stratification
- 4. Ischemic Cascade A sequence of pathophysiologic events caused by coronary artery disease. Nuclear imaging probes an earlier event (hypo-perfusion) in the ischemic cascade than stress echocardiography does (systolic dysfunction). Eur Heart J 2003 ; 24 (9) 789-800 Regional Wall Motion Abnormality
- 5. Regional Wall Motion Abnormality (RWMA) • Wall thickening , assessed in 16/17 segments Wall Motion Index • RWMA are characteristic of myocardial ischemia and infarction. • Subjective, sometimes difficult to assess due to suboptimal echo window tissue harmonic imaging, contrast echocardiography and myocardial contract echo • Their location correlates well with the distribution of CAD and pathological evidence of infarction
- 7. Regional Wall Motion Assessment
- 8. Initial Emergency Departement Triage • Suspected ACS confirming the diagnosis – non diagnostic ECG ; non specific ST-T changes – atypical chest pain ; Non ACS (?), ACS in DM/geriatric (?) • Chest pain but unclear ACS rule out differential diagnosis – evaluating other cause of chest pain • the greatest advantage : when the clinical history and ECG findings are non-diagnostic
- 9. Triage of Patients with Chest Pain [ discharge or not ? ] • In patients with symptoms suggestive ACS [>30 min chest pain, < 6 hrs onset, and abnormal ECG –non ST elevation] – TTE (tissue harmonic imaging) : 97 % NPV, 24% PPV – TTE (tissue harmonic imaging) : 92% sensitivity, 48% specificity Eur J Echocardiogr 2004; 5: 142-8 • False positive – transient myocardial ischemia, chronic ischemia (hibernating myocardium), or myocardial scar, myocarditis, nonischemic cardiomyopathy or other conditions not associated with coronary occlusion.
- 10. Triage of Patients with Chest Pain [ discharge or not ? ] • Normal systolic function at rest reassuring, but NOT exclude the diagnosis of ACS • Evaluation of wall thickening by TTE is appropriate in patients with ACS, but NOT a diagnostic initial testing JACC 2007 ; 50:187-204 • Subendocarial infarction : no RWMA echo alone can be false negative .
- 11. Algorhythm of Chest Pain Assessment in ER Chest pain Non specific ECG changes normal cardiac biomarkers Resting TTE Normal DSE Within 5-6 hrs Positive Negative Sensitivity 89.5% Specificity 89 % NPP 98.5% Otto C. In The Practice of Clinical Echocardiography 2012 Cardiac event : 4% Cardiac event : 30% JAMA 1999;281:707-713 Ann Emerg Med 2001;38:42-48 JACC 2003;41:596
- 12. Evaluation other causes of cardiac chest pain • Aortic Disection • Valvular Heart Disease (Aortic Stenosis, Aortic Regurgitation) • Pericarditis • Myocarditis • Pulmonary Embolism • Takotasubo (stress induced cardiomyopathy)
- 13. Other causes of Chest Pain in ER
- 15. Detecting complications • Un-explained haemodynamic deterioration immediately evaluated. • TTE and TOE are complementary – TTE (experienced echocardiographer) immediate diagnosis – TOE for critically ill patients (difficult image acquisition) • Complication : – Ruptur ventricular septum, - M.Papilaris ruptur, – Ruptur free wall, - Dresler Syndrom, – Apical aneurysm + thrombus - RV infarction Heart 2002;88:419–425
- 16. Mechanical Complication of MI
- 19. Risk stratification and analysis of long term clinical outcome Post ACS risk stratification – LV assessment before coronary angiography – Relevant if conservative management is planned Higher risk patients post ACS • persistent wall motion abnormalities ; more severe chronic ischemia and are at higher risk of adverse events. Am J Cardiol 2000;86 (suppl 4A):43G–5G. • Assist decision making if the appropriateness of reperfusion is uncertain, by demonstrating the localization and extent of wall motion abnormality. • not obviously high risk ; without clinical evidence of LV dysfunction will have significant wall motion abnormalities. Am J Cardiol 2000;86(suppl 4A):43G–5G • extensive regional detect early LV remodelling and other complications, and affect subsequent medical management.
- 20. Echocardiography Improves Risk Stratification Eur J Echocardiogr 2004; 5: 142-8
- 21. In ACS, effective risk stratification can be acheaved by simple echo and chest ultrasound It is comparable with TIMI and GRACE score Am J Cardiol 2010; 106 : 1709-1716 EF : Ejection Fraction TAPSE : Tricuspid Annular Plane Systolic Excursion ULCs : Ultrasound Lung Comets Echo score
- 24. Appropriatness Echocardiography for Risk Stratification
- 25. Take home messages • Echocardiography can be used to rapidly detect the presence of RWMA resulting from acute infarction / ischemia , stratify patients into high- or low-risk categories, diagnose important complications, and predicts the prognosis. • Echocardiography for diagnosis of myocardial infarction is most helpful in patients with a high clinical suspicion but a normal or non-diagnostic ECG