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DR.Dr. Amiliana Mardiani Soesanto, SpJP (K), FIHA. 3rd Pekanbaru Cardiology Update, August 24th 2013. Pangeran Hotel, Pekanbaru. Learn more at PerkiPekanbaru.com
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Echocardiography for Acute Coronary Syndrome
Amiliana Mardiani Soesanto,MD Non Invasive Division
Dept.Cardiology and Vascular Medicine/ National Cardiovascular Center
Harapan Kita
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.
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
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
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
Regional Wall Motion Assessment
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
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.
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
.
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
Evaluation other causes of cardiac chest pain
• Aortic Disection
• Valvular Heart Disease (Aortic Stenosis, Aortic Regurgitation)
• Pericarditis
• Myocarditis
• Pulmonary Embolism
• Takotasubo (stress induced cardiomyopathy)
Other causes of Chest Pain in ER
Takotsubo
Stress induced cardiomyopathy
Apical ballooning cardiomyopathy
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
Mechanical Complication of MI
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.
Echocardiography Improves Risk Stratification
Eur J Echocardiogr 2004; 5: 142-8
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
Ultrasound Lung Comets
Appropriatness Echocardiography for Risk Stratification
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