)قالوا سبحانك ال علم لنا إال ما علمتنا

إنك أنت العليم الحكيم (

صدق الله العظيم

ECHO IN THE CORONARY INTENSIVE CARE UNIT: DOES IT REALLY IMPACT PATIENT

MANAGEMENT? Thesis

Submitted in Partial Fulfillment for Master Degree in Cardiology.

ByDR.Amr Ahmed Alshamy.

Attention has been drawn to the limitations of the physical examination for the detection of cardiovascular abnormalities that can be present in critically ill patient without being clinically recognized.

Even in the presence of invasive monitoring, significant cardiovascular pathologies may be missed. Precise evaluation of these pathologies is crucial in CCU specially in critically ill patient (Bossone et al., 2005).

TTE is helpful in establishing the clinical diagnosis, in excluding certain clinical suspicions and in determining what therapy should be given (Poelaert et al., 1998).

Because of its rapid, accurate and repetitive image acquisition, TTE can play a key role in the diagnosis and evaluation of patients admitted with acute chest pain in the ICCU (Orme et al., 2009).

The role of TTE is well known in establishing the diagnosis, location, and extent of MI, in diagnosing its mechanical complications and in providing prognostic information (Horowitz et al., 1992).

TTE can be the preferred initial diagnostic modality when the history, physical examination, and routine laboratory tests can not identify the cause of dyspnea (Vannan, 2009).

TTE in the CCU is not only useful for analyzing cardiac anatomy and function in critically ill patients, but it can also be used in evaluating and monitoring the hemodynamics (Royse et al., 2006).

TTE can be of great help for adequately assessing preload and volume status which important for proper management of critically ill patients (Michard, 2011).

TTE is crucial in CCU specially in hemodynamically unstable patients for:

Assessment of left ventricular function and diagnosis of significant RV dysfunction for guiding resuscitation , informing decisions management and providing information about prognosis (Royse et al., 2006).

The objective of this study is to determine the impact of (TTE) on management decisions and treatment strategies in patient admitted to ICCU due to any cardiovascular problem.

Study designBetween January 2010 and October 2010, 100 consecutive patients of either sex in Prince Sultan of Cardiac Center in Saudi Arabia were included in a single arm study aiming to assess the role of TTE in the patients management who were admitted in CCU under variety of clinical settings.

According to significance of TTE finding in decision making, the patients were divided into two groups:Group I, the patients in whom TTE was inconclusive. Group II, the patients in whom TTE was highly significant in changing management plan.

Methods All patients were subjected to:

1-Full medical history and physical examination.2-TTE has done using all possible views to assess:a. LV diastolic and systolic functions.b. Wall motion abnormalities.c. RV systolic pressure using tricuspid velocity.d. Valve disease and its severity.e. Presence of intra-cardiac mass.f. Pericardial effusion and tamponade.3-Assessment of new intervention within 48 hours

and change of the management.

CASE NO. (6)A 16 years old female admitted in CCU with high fever, cough, and fatigue. A systolic murmur along the left sternal border was noted during a routine physical examination.TTE (2-D mode) showed hyperechogenic mass in the apical side of RV (1) and in IVS (2).According to TTE finding, (Cardiac MRI) was planned then possible surgical resection of intracardiac mass.

Table(1):Demographic and baseline characteristics:VariablesNumberPercent

Age Mean value55.58 Standard Deviation15.939 

SexMale6060Female4040

Cause of admissionChest pain2929Congestive symptoms2525

Syncope1515Embolic symptoms1515

Shock1616

Different co-morbidities

DM2626HTN2121CRF1414

Smoking2525Respiratory Diseases55

Cerebrovascular Insuff.44

Figure(1): Demographic data according to sex:

Figure(2): Demographic data according cause of admission

INDICATION OF TTE

LVFValve lesion

RVSPEffusio

nMas

sTota

lX2p

Group I (-ve)555552514.9

<0.01

Group II (+ve)

402055575

Total4525101010100

Table(2): Role of echo according to indication of echo in both groups

Table(3): Role of echo according to echo findings:ECHO

FINDINGS

NORMAL

LIMITED

 LVD

Valve L

MassPH

P. EFF.

ADHOC

MTotal

X2p

Group I -ve

1510000000025

80<0.001

GroupII +ve

5030205552375

Total201030205552310

0

Change in Manageme

nt Plan

NO change

Coronary

interven

Valve surger

y

Further procedure

Further

image

Altered medica

tion

Total

X2p

Group I (-ve)

250000025100

<0.001

Group II(+ve)

0231510111675

Total252315101116100Figure(5): change in management plan in both groups

Table(4): change in management plan in both groups

Table(5): Significance of echo according to age

 NMeanStd. Deviationtp

Group I2554.5215.0450.4>0.05

Group II7555.9316.309

Figure(6): Echo significance according to age

53.5

54

54.5

55

55.5

56

No Yes

54.52

55.93

 Group IGroup IITotal

X2pNo.%No.%No.%

male2080.0%4053.3%6060.0%

5.6<0.05

female520.0%3546.7%4040.0%

Total25100.0%75100.0%100100.0

%

Table(6):Significance of echo according to sex

Figure(7): Echo significance according to sex

TTE plays fundamental role in decision making and modification in the treatment strategy in patients who were admitted in CCU.

The management plan was changed in 75 out of 100 patients in our study.

TTE prompts an additional specific investigations in those patients that have important influence in their management.

All CCU should be provided by portable echocardiography machines and every intensivist should have some formal training in echocardiography.

TTE should be done as early as possible and can be repeated for further evaluation which really impact in patient management.

Supportive data for the etiologies of hypotension and shock can be obtained rapidly with TTE.

TEE probe should be available in CCU however this increases the cost of the machine and requires experienced physicians in this field.