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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

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Echocardiography for Acute Coronary Syndrome

  1. 1. Echocardiography for Acute Coronary Syndrome Amiliana Mardiani Soesanto,MD Non Invasive Division Dept.Cardiology and Vascular Medicine/ National Cardiovascular Center Harapan Kita
  2. 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. 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. 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. 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. 6. Regional Wall Motion Assessment
  7. 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. 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. 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. 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. 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. 12. Other causes of Chest Pain in ER
  13. 13. Takotsubo Stress induced cardiomyopathy Apical ballooning cardiomyopathy
  14. 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. 15. Mechanical Complication of MI
  16. 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. 17. Echocardiography Improves Risk Stratification Eur J Echocardiogr 2004; 5: 142-8
  18. 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. 19. Ultrasound Lung Comets
  20. 20. Appropriatness Echocardiography for Risk Stratification
  21. 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