Echocardiography is useful in the diagnosis and management of acute myocardial infarction (AMI) for several reasons: 1. It can detect regional wall motion abnormalities (RWMAs) that occur prior to ECG changes during a coronary occlusion, aiding early diagnosis. 2. It is recommended to evaluate ventricular function, detect mechanical complications like thrombus, and stratify risk in patients with confirmed AMI. 3. RWMAs seen on echocardiography localize the area of infarction and correspond to the coronary artery territory. Complications like ventricular septal defects and mitral regurgitation can also be identified.

1. May 8, 20181
Role of Echocardiography in
Acute Myocardial Infraction
Dr. Rakesh Kumar
MBBS, MD
DNB cardiology resident
Sunshine hospital

2. INTRODUCION
May 8, 20182
The echocardiography has become an established and
standard tool in the evaluation and management of the
patients with acute myocardial infraction
Role : Diagnosis , location , extent of MI , ventricular function ,
prognostic information , mechanical complications and risk
stratification

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• Two series of patients evaluated during transient coronary
artery occlusions induced by angioplasty
• Sev. Ischemia / infraction produces echo changes (RWMA)
that can be visualized within seconds of coronary artery
occlusion 12 +/- 5 and 19+/- 8 seconds in
(Hauser AM et.al 1985 , Wohgelernter D et.al 1986 )
• echo changes occurs prior to the onset of ECG changes and
symptoms

5. INDICATIONS
May 8, 20185
• To aid in the diagnosis in patients with suspected MI
(initial evaluation in suspected ACS in ED)
• In all patients with confirmed acute MI to evaluate
regional segmental abnormality ,ven. Function,
mechanical complications
• Mainly useful when clinical history and ECG are not
helpful

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Recommendations for Echocardiography in the
Diagnosis of Acute Myocardial Ischemic Syndromes
Class I
1. Diagnosis of suspected acute ischemia or infarction not evident by
standard means.
2. Measurement of baseline LV function.
3. Evaluation of patients with inferior myocardial infarction and clinical
evidence suggesting possible RV infarction.
4. Assessment of mechanical complications and mural thrombus.
Class II
Identification of location/severity of disease in patients
with ongoing ischemia.
Class III
Diagnosis of acute myocardial infarction already evident
by standard means.

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Myocardial Ischemia/Infarction With TTE
• Acute chest pain with suspected MI and nondiagnostic ECG
when a resting echocardiogram can be performed during pain
• Evaluation of a patient without chest pain but with other
features of an ischemic equivalent or laboratory markers
indicative of ongoing MI
• Suspected complication of myocardial ischemia/infarction,
including but not limited to acute mitral regurgitation,
ventricular septal defect, free-wall rupture/tamponade, shock,
….rt ventricular involvement, HF, or thrombus

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10. Diagnosis
May 8, 201810
• Segmental LV wall motion abnormalities are characteristic of
myocardial infarction
• The RWMAs develop reflect a localized decrease in the
amplitude and the rate of myocardial contraction as well as a
blunted degree of myocardial thickening and local
remodeling

11. RWMA INDEX
May 8, 201811
The severity of contractile dysfunction is, accordingly, scored
visually in each segment as
1 for normal contraction or hyperkinesia,
2 for hypokinesia (50-60% block)
3 for akinesia (>80% block)
4 for dyskinesia and
5 for aneurysmal segments
the global wall motion score is thereafter calculated by
averaging the readings in all the segments.
A normal LV has a wall motion score index of 1
a wall motion score index of 1.1–1.9 can predict a small infarct
size, index equal to or greater than 2.0 can predict the
occurrence of complications.

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Although there Is variability in branching pattern
LAD lesion WMA s – Anterior , A/S(base and mid levels), most of
apex
RCA lesion WMAs – inferior, I/S (base and mid levels)
Lcx lesions WMAs- lateral (base and mid levels)
Dominant – inferolateral segment (RCA or Lcx)
ANTERIOLATERAL CAN BE DUE TO LAD/LCX

15. False positive of RWMAs
May 8, 201815
• Transient myocardial ischemia (stunned myocardium)
• Chronic ischemia (hibernating myocardium)
• Non ischemic cardiomyopathy, TAKOTSUBO cardiomyopathy
• Myocarditis
Other cardiac causes include
• LBBB, RV Pacing, Intrinsic conduction abnormalities, post
operative changes, RV overload - in these cases wall
thickening is preserved

16. Residual ischemia in AMI
May 8, 201816
Patients with acute MI who are not taken to the cath lab within 48
hrs, and who are candidates for PCI, should be considered for
stress testing to evaluate for residual ischemia.
The 2003 ACC/AHA/ASE task force and
The 2011 ACC/AHA/ASE appropriateness criteria classified as
appropriate the use of stress echocardiography within three
months of MI to evaluate the presence/extent of inducible
ischemia for individuals who are hemodynamically stable, without
recurrent chest pain symptoms or signs of heart failure, or who
have not had coronary angiography since the AMI .

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19. LV SYTOLIC FUNCTION
May 8, 201819
IN PATEINTS WITH AMI WITH RWMA
BIPLANE SIMPSON S METHOD IS ACURATE TO CALCULATE
EF
EF = (EDV-ESV)/EDV X 100

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21. Mechanical changes
May 8, 201821
• Patients who suffered acute MI are subjected to a broad
range of potential life threatening complications
• Can range from cardiogenic shock to mechanical
complications
1. Left ventricular thrombus
2. Ventricular septal rupture
3. Free wall rupture
4. LV aneurysm and pseudo aneurysm
5. Papillary muscle rupture
6. Right ventricular infraction
7. Pericardial effusion
8. Infract expansion

22. LV thrombus
May 8, 201822
• 1.5% to 3.% Left ventricular mural thrombus
• The risk of lv thrombus varies with size and location of mi
• GISSI-3 DATABASE revealed that 5.1% of patients treated
with fibrinolytic developed LVT
• Anterior mi 11.5% > other MI 2.3%
• m/c Site of LVT is LV apex
• Apical window is the best view
• Multiple studies revealed that Contrast echo has more
sensitivity than non contrast echo

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25. LV Free Wall Rupture
May 8, 201825
• It is the second leading cause mortality
• The incidence 6% (the shock trail registry) but accounts for
15% in hospital mortality after acute MI
• lv free wall rupture most frequently presents as a
catastrophic event EMD electro mechanical dissociation
due to cardiac tamponade
• Enlarging pericardial effusion with echo dense structures in
patients with hemodynamic compromise accounts 98%
specific for free wall rupture

26. Ventricular free wall rupture
May 8, 201826

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28. Aneurysm and Pseudoaneurysm
May 8, 201828
• LV apical aneurysm may develop secondary to myocardial
scar and thinning of myocardium with subsequent LV
expansion
• Pseudo aneurysm occurs when rupture develops over time or
incomplete perforation
• PA remain somewhat contained within a limited segment of
the pericardium
• m/c in inferolateral or infer posterior walls
• connects with lv cavity with neck frequently contains
thrombus to and fro blood flow through the site of rupture

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31. Ventricular Septal Rupture
May 8, 201831
• Uncommon , less than 1% acute mi
• Post infraction VSR more common in 2% to 5% with
cardiogenic shock ( 3.9% the SHOCK TRIAL registry , ran.
Shock trail)
• Can occur in both ant. And non ant. MI
• Apical VSR in ant. MI
• Posteriobasal VSR in inferior MI

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33. Acute mitral regurgitation and
papillary muscle rupture
May 8, 201833
Mitral regurgitation is common among patients with an acute
MI its prevalence 50%
Pathophysiology of Acute MR in AMI
1. Dilatation of the mitral annulus secondary to the LV
dilatation
2. Papillary muscle displacement or dysfunction due to
proximity of the insertion of pm to infracted area
3. Papillary muscle rupture /CT rupture

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• Papillary muscle rupture Is rare but life
threatening complication
• i = 1-3% of acute MI mortality is 80% with
medical therapy alone
• Posteromedial (single supply) is most common
than anterolateral (dual supply)
•
• Flail mitral leaflet with free moving papillary
muscle head, eccentric MR

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36. Right Ventricular Infraction
May 8, 201836
The 2003 ACC/AHA /ASE taskforce gave class I recommendation and
2011 appropriate criteria for echo - to the use the echo for inferior
wall mi and clinical evidence RV infraction
Echo finding
1. Enlargement of right ventricle with or without segmental wall motion
abnormality (systolic paradoxical VS motion)
2. Decrease decent of right ventricular base
3. Plethora of the inferior vena cava diameter decreased by 50%
4. Reduced RVEF
5. Impaired TAPSE
6. Tissue Doppler systolic velocity
20% have PFO right to left shunt (agitated saline)

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