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Echocardiography for Acute Coronary Syndrome


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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

DR.Dr. Amiliana Mardiani Soesanto, SpJP (K), FIHA. 3rd Pekanbaru Cardiology Update, August 24th 2013. Pangeran Hotel, Pekanbaru. Learn more at

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  • 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
  • 6. Regional Wall Motion Assessment
  • 7. 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
  • 8. 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.
  • 9. 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 .
  • 10. 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
  • 11. Evaluation other causes of cardiac chest pain • Aortic Disection • Valvular Heart Disease (Aortic Stenosis, Aortic Regurgitation) • Pericarditis • Myocarditis • Pulmonary Embolism • Takotasubo (stress induced cardiomyopathy)
  • 12. Other causes of Chest Pain in ER
  • 13. Takotsubo Stress induced cardiomyopathy Apical ballooning cardiomyopathy
  • 14. 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
  • 15. Mechanical Complication of MI
  • 16. 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.
  • 17. Echocardiography Improves Risk Stratification Eur J Echocardiogr 2004; 5: 142-8
  • 18. 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
  • 19. Ultrasound Lung Comets
  • 20. Appropriatness Echocardiography for Risk Stratification
  • 21. 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