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