Echocardiography in ischemic heart disease

1. DR. BHARGAV KIRAN. G
PG- 1ST YEAR
ECHOCARDIOGRAPHY
IN ISCHEMIC HEART DISEASE:
CLINICAL UTILITY

2. ECHOCARDIOGRAPHY
 It is the sonogram of heart which is used
as standard two dimensional, three
dimensional and doppler ultrasound to
create images of the heart.
 It is one of the most used diagnostic
technique in cardiology to R/O diseases
like ischemic heart disease, valvular heart
diseases etc.,
 Most important clinical utility is early
diagnosis which helps in early reperfusion

3. ROLE OF ECHO IN ACUTE MI
 Diagnosis.
 Detection of any other associated
defect.
 Triage in chest pain units.
 Assessment of complications.
 Assessment of haemodynamic status.
 Post MI risk stratification/prognosis.
 Assessing effectiveness/change of
therapy.
 Evaluation of myocardial viability.

4. Role contd
 The two earliest changes noted after a coronary
occlusion are:
o The defect in systolic thickening of the affected
segment. RWMA can vary from hypokinesia to
dyskinesia depending onn the systolic
thickening and pattern of motion of the affecting
segment and severity and extent of RWMA
depends on:
o Degree of coronary obstruction,
o Lesion length, eccentricity, number of sequential
lesions.
o Duration of coronary obstruction.
o Amount of transmural versus non transmural

5. CLINICAL IMPLICATIONS IN
DIAGNOSIS
 Normal LV wall motion in the presence of normal
ECG and without chest pain doesnot exclude
IHD.
 No RWMA in presence of chest pain virtually
excludes IHD.
 Conversely presence of RWMA in presence of
typical and atypical chest pain is almost
diagnostic of IHD.
 In the absence of ischemia or injury at the time of
examination, echo can be normal even in the
presence of triple vessel disease.
 Similarly in unstable angina, the duration of

6. UTILITY IN EVALUATION OF CHEST
PAIN AT THE EMERGENCY
DEPARTMENT
 Advantages:
-Bed side
-Portable
-Immediate diagnosis
-

7. Differentiating acute recent and old infarct:
In acute MI, overall wall thickness is normal
though there is decreased systolic thickening
with RWMA and there is enzyme rise.
In old infarct, there is marked thinning of
segments, increased echogenicity due to
fibrosis and scarring, presence of aneurysm if
any and absence of enzyme rise.
-To look for aortic dissection, pulmonary
thromboembolism, pericardial tamponade,
HOCM.

8. Who should undergo early ECHO?
 Doubtful diagnosis/ Early detection – with
abnormalities in systolic thickening and RWMA
 Hypotension – Cardiac or non-cardiac
RWMA and LV dysfunction in cardiac cause.
 Heart failure
 Unexplained dyspnoea
 Chest pain with LBBB

9. Who should undergo second ECHO?
 Change in clinical status- insight for incipient
failure, extension of ischemic process, diastolic
abnormalities like reversible restrictive physiology,
development of new complications.
 Recurrence of chest pain – reocclusion of infarct-
related artery, pericarditis, ischemia at a distance.
 Restrictive filling pattern in first ECHO (increased
LV filling pressure) – to guide management.

10. ASSESSMENT OF
COMPLICATIONS.
 LV THROMBUS:
 Appears as non homogenous distinct
echocardiography mass in LV cavity, margins distinct
from underlying endocardium located adjacent to an
area of RWMA.
 Nidus for the formation of LVT is a large infarction
especially anterior, presence of significant RWMA, an
LVEF usually below 40%.
 Possibility of LVT should be considered if an akinetic
or dyskinetic segment which is normally thin
and scarred due to myocardial damage,
appeared thickened.

11.  LV Aneurysm:-
 It is related to transmural infarction and is a
consequence of infarct expansion.
 Echocardiographically there is myocardial
thinning with bulging dyskinetic motion in both
systole and diastole.
 LV Pseudoaneurysm:-
 Due to a contained subacute rupture of a
small portion of the free wall of LV which is
spontaneously sealed and contained by
adherent pericardium. On color flow mapping,
there is to and fro blood flow between LV and
aneurysm.

12.  Ventricular septal rupture:-
 Occurs commonly in transmural infarction, an extensive
infarction in both LAD and right coronary artery
occlusion.
 Occurs at any point of the septum from the base to
apex depending upon the coronary artery involvement.
 Colour flow mapping aids in detection of flow from LV to
RV.

13.  Acute mitral regurgitation:-
 The partial or complete rupture leads to flial mitral valve
and mitral regurgitation.
 Two basic mechanisms of AMR are
 Partial or complete rupture of papillary muscles
 Papillary muscle dysfunction.(less serious).
 Typical 2d-echo findings include a flial mitral leaflet with
often a mobile mass seen attached to chordae and
prolapsing in left atrium during systole.
 Mortality is very high if left untreated.
 50% of patients die within one day of rupture and about
90% of patients within a week without surgical therapy.

14.  Chronic ischemic cardiomyopathy:-
 It is defined as chronic LV dysfunction due to sequelae
of diffuse coronary artery disease.
 There is typically RWMA- mostly akinesia or
dyskinesia.
 It is not possible to separate an ischemic from non
ischemic dilated cardiomyopathy.
 Clues to the former include patient age, presence of
cardiac risk factors, clinical history of previuos ischemic
events and as mentioned earlier presence of RWMA,
presence of an area of dense scar.

15. UTILITY IN ASSESSING VIABILITY IN
IHD
 Myocardial stunning :
‘Stuns but does not kill’
Produced by acute ischemic insults of short duration with
no infarction with normal resting coronary flow.
Spontaneously recovers within few hours to weeks.
Subsets:
-Reperfusion following AMI
-Exercise induced severe ischemia
-Unstable coronary syndromes
-After revascularization therapy

16.  Hibernating myocardium:
 There is a critically stenosed coronary artery leading to
chronic depression of myocardial function.
 Myocardial segments are dysfunctional but alive.
 There is a complete or partial functional recovery after
revascularisation.
 Delay in revascularisation leads to irreversible damage.

17. POST ACUTE MI RISK
STRATIFICATION/ PROGNOSIS
 Predictors of adverse prognosis as assessed by
echo are :
 Degree of wall motion abnormality and hence the
systolic function.
 Infarct extension.
 Infarct expansion and degree of LV dilatation.
 More than mild valvular regurgitation.
 Right ventricular function.
 LA volume index more than 40ml square.
 Diastolic dysfunction variables especially
pseudonormal or restrictive mitral inflow pattern
indicative of elevated film pressure.

18. Echo for guiding therapy.
 Thrombolytic therapy cannot be embark based on
RWMA on echocardiography as they can be
found both in STEMI and NSTEMI.
 If primary angioplasty facilities are not present,
then based on echocardiography findings,
supportive measures like aspirin, high dose
statin, NTG, beta blockers or ACE inhibitors can
be initiated.

19.  Some therapeutic measures include:
 Assessment of LV dysfunction or degree of LV expansion
guides treatment with ACE inhibitors and specific beta
blockers.
 Persistent LV dysfunction with viability will need
revascularisation procedure.
 Doppler parameters of reversible restrictive physiology
helps in guiding therapy with diuretics and vasodilators.
 ECHO demonstrates that occasional patients with
hypotension despite treatment with dopamine or
dobutamine develop significant left ventricular outflow
tract gradients due to dopamine exacerbated dynamic
LVOT narrowing.

20. Role of new technologies.
 Newer techniques like three dimensional echo,
MCE, speckle tracking echocardiography have
emerged as excellent techniques for the
diagnosis of IHD especially in its early stage.
 3D- echo is useful in detecting various
complications, quantification of LV chamber
volumes, function and mass.
 MCE detects myocardial perfusion defect in its
early stages.
 Speckle tracking echo is advanced form of
quantitative tissue doppler imaging, is valuable in
objective and quantitative evaluation of global
and regional myocardial function. They help in
assessing reperfusion viability, etc.

22. THANK
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