Final acs

Echc based diagnostic InEchc based diagnostic In
Acute coronary syndromeAcute coronary syndrome
Faisal Alatawi, MDFaisal Alatawi, MD
Consultant cardiologist PSCCConsultant cardiologist PSCC
ACS symposium
2-3December 2006

AAcutecute CCoranaryoranary SSyndromyndrom
((ACSACS((
Millions of patients ( USA 6( each yearMillions of patients ( USA 6( each year
present to Emergency Departmentspresent to Emergency Departments
( ED( with chest pain suggestive of( ED( with chest pain suggestive of
ACSACS
MinorityMinority ultimately are diagnosed withultimately are diagnosed with
myocardial ischemia or infarctionmyocardial ischemia or infarction..
-CDC/NCHS, 1997,
-Lewis WR, et al Curr Opin Cardiol 1999

ACSACS
Approximately 5% of thoseApproximately 5% of those
with acute myocardialwith acute myocardial
infarction (AMI ( areinfarction (AMI ( are
mistakenly dischargedmistakenly discharged
from the EDfrom the ED
-Goldman L,, et al:. Engl J Med 1988
-McCarthy BD, et al: Ann Emerg Med 1993-

Early diagnosis &treatment ofEarly diagnosis &treatment of
myocardial infarction improvesmyocardial infarction improves
–rate of coronary arterial patency,rate of coronary arterial patency,
–myocardial salvagemyocardial salvage
–patient survivalpatient survival
–finances of the health care.finances of the health care.
-GUSTO trials N Engl J Med
-TIMI Engl J Med 1996
ACSACS

AMI diagnosisAMI diagnosis
HistoryHistory
ECGECG
Serum cardiac enzymeSerum cardiac enzyme
levelslevels

Cardiac EnzymesCardiac Enzymes
sensitive andsensitive and
specific test.specific test.
serum cardiacserum cardiac
en-zyme takesen-zyme takes
timetime
delay startingdelay starting
appropriateappropriate
treatment.treatment.
Ck-Mb
TMyo

Thrombolytic therapyThrombolytic therapy
Chest pain withChest pain with
–11.. ST segment elevation > 0.1 mVST segment elevation > 0.1 mV
in at least two contiguous leadsin at least two contiguous leads
Nah.pptNah.ppt,,
–22. N. New or presumably newew or presumably new
bundle branch blockbundle branch block LBBB.pptLBBB.ppt
–33.. ST segment depression inST segment depression in
thoracic leadsthoracic leads V1-V3V1-V3 QarQar..pptppt

ECG: limitationECG: limitation
ST- elevationST- elevation
– 30-40% of AMI30-40% of AMI
– PericarditisPericarditis
– Aneurysm formationAneurysm formation
– LBBBLBBB

AcuteAcute myocardialmyocardial
ischemiaischemia PhysiologyPhysiology

•Myocardial blood flow can be
diminished even in the
presence of normal wall motion
•An akinetic segment
does not necessarily
imply a lack of
myocardial capillary
blood flow
Rest Stress
Diastolic
Dysfunction
Echo
Doppler
Regional
Systolic
Dysfunction
Echo, gated
nuclear,
MRI
ECG
Changes
ECG
tracing
Chest Pain
Patient
history
Ischemic Cascade
Ischemia
(Flow mismatch)
Nuclear,
Pet,
MCE,
MRI
Cardiac
enzymes
Labs
-Tennant R, Wiggers CJ:. Am J Physiol 1935.

Acute ischemia PhysiologyAcute ischemia Physiology
Systolic regional wall motion detected bySystolic regional wall motion detected by
echocardiography occurs at early stageechocardiography occurs at early stage
of ischemia.of ischemia.
This raised the interest in the use ofThis raised the interest in the use of
echocardiographyechocardiography
– in the diagnosisin the diagnosis
– defining the coronary territory involveddefining the coronary territory involved
– prognosis of acute coronary syndromesprognosis of acute coronary syndromes
-Tennant R, Wiggers CJ:. Am J Physiol 1935.

Echocardiography for ED TriageEchocardiography for ED Triage
• 180 pt presented to ED with180 pt presented to ED with
symptoms suggesting AMIsymptoms suggesting AMI
• 2-D Echo performed2-D Echo performed
• ED Drs admitted 140 pt andED Drs admitted 140 pt and
dismissed 40 pt, based ondismissed 40 pt, based on
standard clinical and ECG findingsstandard clinical and ECG findings
Sabia: Circulation 84:3(Suppl I), 9/91Sabia: Circulation 84:3(Suppl I), 9/91

2-D Echo for Cardiac Patients in the ED2-D Echo for Cardiac Patients in the ED
Sabia: Circulation 84:3(Suppl I), 9/91Sabia: Circulation 84:3(Suppl I), 9/91
180 pt180 pt
169 (94%) had adequate 2-DE169 (94%) had adequate 2-DE
2 (4%) AMI2 (4%) AMI 0 (0%) AMI0 (0%) AMI 27 (31%) AMI27 (31%) AMI
60 (36%)60 (36%)
No regional orNo regional or
global LVglobal LV
dysfunctiondysfunction
87 (51%)87 (51%)
RWMA with orRWMA with or
Without globalWithout global
LV dysfunctionLV dysfunction
22 (13%)22 (13%)
GlobalGlobal
dysfunctiondysfunction
without RWMAwithout RWMA

30 patients had enzyme-confirmed MI30 patients had enzyme-confirmed MI
• Typical (STTypical (ST↑↑)) 9 pt (9 pt (sensitivity, 30%(,sensitivity, 30%(,
• Normal ECGNormal ECG 3 pt3 pt
• Obscured ECG (LBBB, etc)Obscured ECG (LBBB, etc) 8 pt8 pt
• Nonspecific changesNonspecific changes 10 pt10 pt
Sabia: Circulation 84(Suppl I), 9/91Sabia: Circulation 84(Suppl I), 9/91

All had regional abnormalities on ED 2DEAll had regional abnormalities on ED 2DE
Only 4 had STOnly 4 had ST↑↑ on ED ECGon ED ECG
40 pt dismissed from ER40 pt dismissed from ER
• 2 had AMI2 had AMI
• 1 had MI complication1 had MI complication
29/30 MI pt had adequate 2DE29/30 MI pt had adequate 2DE
• 27 had RWMAs27 had RWMAs (sensitivity, 90%).(sensitivity, 90%).
• 2 had no RWMAs2 had no RWMAs
13/30 MI pt had early complications13/30 MI pt had early complications
Sabia: Circulation 84(Suppl I), 9/91Sabia: Circulation 84(Suppl I), 9/91
• 3 cardiogenic shock3 cardiogenic shock
• 4 life-threatening arrhythmias4 life-threatening arrhythmias
• 8 post-MI angina (4 underwent CABGs)8 post-MI angina (4 underwent CABGs)

.Sabia P,, et al:. Circulation 1991.
Possible AMI
ST elevationST elevation
Non ST elevationNon ST elevation
2DE2DE
2DE2DE
adequetadequet
2DE2DE::
in adequatein adequate
ECG ,CEECG ,CE
No RWMANo RWMA
RWMARWMA
HomeCCU

If this scenario is applied to the set ofIf this scenario is applied to the set of
study patients,study patients,
– CCU reduced by 25%,CCU reduced by 25%,
– hospital stay reduced by 23%,hospital stay reduced by 23%,
– total cost is 24% lower.total cost is 24% lower.
Under this scenarioUnder this scenario
– two patients with small AMI and notwo patients with small AMI and no
complications would be sent home.complications would be sent home.
.Sabia P,, et al:. Circulation 1991.

Heart ER ProgramHeart ER Program
1010 patients over 32 months1010 patients over 32 months
Gibler WB, et al:. Ann Emerg Med 1995

1010Symptoms of acute coronary syndrome
known CAD, Heamo.
unstable, Significant
ST abnormalities, UA
9-hr evaluation program
Serial CK-MB( 0,3,6,9 hr)
Continuous 12-lead ECG
monitoring
9-hr evaluation program
Serial CK-MB( 0,3,6,9 hr)
Continuous 12-lead ECG
monitoring
2D Echo2D Echo
Graded exercise
testing
Graded exercise
testing
Discharge
Admission
Significant ST abnormalities ,CK-
MB elevation , heamod
sunstable, signific,arrhy
Normal
No
Normal
abnormal
abnormal
yes
829829))82.1%82.1%((
15353))15.1%15.1%((
Yes No

Heart ER ProgramHeart ER Program
The authors concluded that theThe authors concluded that the
""Heart ER ProgramHeart ER Program" provides an" provides an
effective approach for evaluationeffective approach for evaluation
ofof low- to moderate-risklow- to moderate-risk patientspatients
with possible acute coronarywith possible acute coronary
syndrome in the emergencysyndrome in the emergency
department.department.

Stress EchocardiographyStress Echocardiography
Echocardiography imaging may be used inEchocardiography imaging may be used in
conjunction with exercise or pharmacologicconjunction with exercise or pharmacologic
stress to assess for ischemia, depending onstress to assess for ischemia, depending on
the patient's ability to perform adequatethe patient's ability to perform adequate
exerciseexercise
Studies have demonstrated the safety ofStudies have demonstrated the safety of
stress testing ifstress testing if AMIAMI are ruled out afterare ruled out after
several hours of observation.several hours of observation.

Trippi et al reported a clinical trial usingTrippi et al reported a clinical trial using
dobutamine stress echocardiography (DSE)dobutamine stress echocardiography (DSE)
for evaluation of pts presenting with CP to EDfor evaluation of pts presenting with CP to ED
to determine who can be safely dischargedto determine who can be safely discharged
from the ED.from the ED.
The Echo images were digitized forThe Echo images were digitized for
electronic transmission according to theirelectronic transmission according to their
teleechocardiography protocolteleechocardiography protocol
Trippi JA, et al:J Am Coll Cardiol 1997

163 pts with negative results on initial163 pts with negative results on initial
ECGs and blood studiesECGs and blood studies
If the resting echo was normal, DSEIf the resting echo was normal, DSE
was performed by a trained nurse,was performed by a trained nurse,
with images again transmitted to thewith images again transmitted to the
cardiologist.cardiologist.

The test was completed within an averageThe test was completed within an average
of 5.4 hours after ED adm.of 5.4 hours after ED adm.
Using clinical follow-up data and car-diacUsing clinical follow-up data and car-diac
catheterization as the gold standard, thecatheterization as the gold standard, the
authors determinedauthors determined
– Sensitivity 89.5%,Sensitivity 89.5%,
– Specificity 88.9%,Specificity 88.9%,
– Negative predictive value 98.5%.Negative predictive value 98.5%.

Technical Aspects ofTechnical Aspects of
EchocardiographyEchocardiography
image Acquisition in the EDimage Acquisition in the ED
Echo study of pts with CP in EDEcho study of pts with CP in ED
should concentrate global and RWMshould concentrate global and RWM
valvualr lesiosn ,screen for othervalvualr lesiosn ,screen for other
possible nonischemic causes of chestpossible nonischemic causes of chest
pain suchpain such NON ACSNON ACS CP.pptCP.ppt
AMI complicationsAMI complications MIMI complications.pptcomplications.ppt

A well-trained sonographer orA well-trained sonographer or
echo-cardiographer is essentialecho-cardiographer is essential
Avoid wasting valuable time withAvoid wasting valuable time with
unnecessaryunnecessary
patient positioning, use ofpatient positioning, use of
appropriate transducers, andappropriate transducers, and
adjust-ment of machine settingsadjust-ment of machine settings

Transducer frequency selectionTransducer frequency selection
( body )( body )
Colorization of two-dimensionalColorization of two-dimensional
echocardiographic imagesechocardiographic images
Echo contrast have also been used toEcho contrast have also been used to
enhance visualization of theenhance visualization of the
endocardialendocardial

InterpretationInterpretation
The accurate interp ofThe accurate interp of
RWMA requires an expertRWMA requires an expert
wall thickening and Systolicwall thickening and Systolic
endocardial motion areendocardial motion are
evaluated for allevaluated for all
mayocardial segments.mayocardial segments.

Coronary Artery AnatomyCoronary Artery Anatomy
LV Segment DistributionLV Segment Distribution
LMCLMC
CXCX
OMOM
DD
LADLAD
PDPD
RMRM
RCRC
BasalBasal
MidMid
ApicalApical
RVRV
ASAS AA
LALA
ILILII
ISIS
AA
ALAL
ILILII
ISIS
ASAS
RVRV
RVRV
AA
LL
II
SS
1717
1818
1919
11
22
3344
55
66
77
88
991010
1111
1212
1616
1313
1414
1515
2020
2121
2222
2323
2424

Each segment is classified asEach segment is classified as
– HyperkineticHyperkinetic =0=0
– Normal=1Normal=1
– Hypokinetic=2Hypokinetic=2
– Akinetic =3Akinetic =3
– Dyskinetic=4Dyskinetic=4
– Aneurysmal=5Aneurysmal=5
WMSI =Sum of wall motion score/NumberWMSI =Sum of wall motion score/Number
of visualized segmentsof visualized segments

WMSI has been found to correlate to theWMSI has been found to correlate to the
infarct size on clinicopathologic studies*∞infarct size on clinicopathologic studies*∞
and to perfusion Size on single photonand to perfusion Size on single photon
emission computed tomography SPECT)emission computed tomography SPECT)
imaging.imaging. ∞∞
-**Shen WK, Edwards WD, et al: Am J Cardiol 1991
-∞∞Oh JK, et al:. Am Heart J 1996

Several clips can beSeveral clips can be
acquired ,satisfactoryacquired ,satisfactory
one selected forone selected for
comparative display.comparative display.
Comparison of restComparison of rest
and stress imagesand stress images
from each view isfrom each view is
facilitated by the usefacilitated by the use
of side-by-side quad-of side-by-side quad-
screenscreen

Left Ventricular Wall Motion ScoreLeft Ventricular Wall Motion Score
Index with Acute Myocardial InfarctionIndex with Acute Myocardial Infarction
• 61 consecutive pt with AMI61 consecutive pt with AMI
• Admitted within 24 hr ofAdmitted within 24 hr of
onset of chest painonset of chest pain
• Echo performed withinEcho performed within
12 hr of CCU admit12 hr of CCU admit
Nishimura RA: JACC 4 (6), 12/84Nishimura RA: JACC 4 (6), 12/84

Acute Myocardial InfarctionAcute Myocardial Infarction
LV Wall Motion Score IndexLV Wall Motion Score Index
Nishimura RA: JACC 4(6), 12/84Nishimura RA: JACC 4(6), 12/84
VT/VFVT/VF 1.81.8±±0.60.6 2.42.4±±0.50.5
DeathDeath 1.81.8±±0.60.6 2.52.5±±0.50.5
ComplicationComplication NoNo YesYes
CHFCHF 1.61.6±±0.50.5 2.42.4±±0.50.5

2-D Echo During Acute MI2-D Echo During Acute MI
Killip class & WMSIKillip class & WMSI
Initial KillipInitial Killip
I (47 pt)I (47 pt)
II-IV (14 pt)II-IV (14 pt)
Final KillipFinal Killip
I (37 pt)I (37 pt)
(WMSI)(WMSI)
(1.6(1.6±±0.5)0.5)
(2.4(2.4±±0.4)0.4)
II-IV (24 pt)II-IV (24 pt)
(2.4(2.4±±0.6)0.6)
Nishimura RA: JACC 4(6), 12/84Nishimura RA: JACC 4(6), 12/84

AssessmentAssessment of theof the NeedNeed forfor
UrgentUrgent CoronaryCoronary AngiographyAngiography
Normal global and regional wall motionNormal global and regional wall motion
may conservative approach, with latermay conservative approach, with later
stress testing to rule out significantstress testing to rule out significant
coronary artery disease.coronary artery disease.
The finding of a new wall motionThe finding of a new wall motion
abnormality, however, may prompt moreabnormality, however, may prompt more
urgent coronary angiography and interven-urgent coronary angiography and interven-
tiontion

RiskRisk Stratification andStratification and AnalysisAnalysis
ofof LongLong-Term-Term ClinicalClinical OutcomeOutcome
GUSTO-IIb-the 30-day ,death or MIGUSTO-IIb-the 30-day ,death or MI
– 5.5% in patients with T-wave inversion,5.5% in patients with T-wave inversion,
– 9.4% in patients with ST-segment elevation,9.4% in patients with ST-segment elevation,
– 10.5% in patients with ST-segment10.5% in patients with ST-segment
depression,depression,
– and 12.4% in patients with ST-segmentand 12.4% in patients with ST-segment
elevation and depressionelevation and depression (P <(P < .001)..001).
– creatine kinase level is also associated withcreatine kinase level is also associated with
greater risk of death and reinfarction, as isgreater risk of death and reinfarction, as is
elevation in serum troponin levels.elevation in serum troponin levels.
Savonitto et al:. JAMA 1999

A number of studies have demonstratedA number of studies have demonstrated
the incremental utility ofthe incremental utility of
echocardiography, beyond clinicalechocardiography, beyond clinical
assessment and electrocardiography, inassessment and electrocardiography, in
predicting clinical outcome of patients withpredicting clinical outcome of patients with
acute chest pain.acute chest pain.
Fleischmann, et al:. Am J Cardiol 1997
Kontos et. Ann Emerg

In a prospective , 466 pts with acuteIn a prospective , 466 pts with acute
CP, Echo predictors complicationsCP, Echo predictors complications
2DEcho &Doppler ,21 hours of2DEcho &Doppler ,21 hours of
presentationpresentation
global biventricular functionglobal biventricular function
regional wall motion,regional wall motion,
valvular diseasevalvular disease
Kontos et. Ann Emerg

The composite complications endThe composite complications end
point includedpoint included
–significant recurrent myocardialsignificant recurrent myocardial
ischemiaischemia
– heart failure,heart failure,
–or arrhythmia.or arrhythmia.

In univariate analysis, the followingIn univariate analysis, the following
variables predicted complications:variables predicted complications:
– LVD (LVD (OROR, 2.9 ), 2.9 )
– RVF (RVF (OROR, 2.7), 2.7)
– LV enddiastolic dimension OR, 1.6/cm;LV enddiastolic dimension OR, 1.6/cm;
– LV endsystolic dimension (OR, 1.4/cmLV endsystolic dimension (OR, 1.4/cm
– Wall motion index (Wall motion index (OR, 3.0; 95% CI, 1.84.8OR, 3.0; 95% CI, 1.84.8).).

In a companion study involvingIn a companion study involving
448 pts, the longterm survival of448 pts, the longterm survival of
these pts was examined.these pts was examined.
The followup period wasThe followup period was 3547M3547M

NoNo
LVDLVD

LimitationsLimitations RegionalRegional ContractileContractile
FunctionFunction to Evaluateto Evaluate IschemiaIschemia
Between episodes of cardiac ischemia,Between episodes of cardiac ischemia,
– the patient's wall motion may be completely normal.the patient's wall motion may be completely normal.
– Stress testing should be considered after myocardialStress testing should be considered after myocardial
infarction is ruled out.infarction is ruled out.
Preexisting LVDPreexisting LVD
In adequate visualization of endocardial bordersIn adequate visualization of endocardial borders
obesity, deformity, chest trauma, thoracic surgeryobesity, deformity, chest trauma, thoracic surgery
time constraints imposed for rapid diagnosis andtime constraints imposed for rapid diagnosis and
institution of therapy.institution of therapy.

LimitationsLimitations RegionalRegional ContractileContractile
FunctionFunction to Evaluateto Evaluate IschemiaIschemia
Personnel AvailabilityPersonnel Availability
One approach to deal with this problem is to trainOne approach to deal with this problem is to train
emergency department personnel to performemergency department personnel to perform
echocardiograms. .echocardiograms. .
– An obstacle to successful implementation of thisAn obstacle to successful implementation of this
approach is the difficulty in gaining and maintainingapproach is the difficulty in gaining and maintaining
sufficient experience in performing echocardiographicsufficient experience in performing echocardiographic
studies ,Shift .studies ,Shift .
This logistical problem may be partially solvedThis logistical problem may be partially solved
with the advent of digital teleechocardiographywith the advent of digital teleechocardiography
systems.systems.

Future DevelopmentsFuture Developments
Myocardial ContrastMyocardial Contrast
The use of echocThe use of echoc
contrast tocontrast to
evaluateevaluate
myocardialmyocardial
perfusion is rapidlyperfusion is rapidly
developingdeveloping
Stunning
Hibernation
Ischemia
Viability

Myocardial Contrast EchoMyocardial Contrast Echo
Rinkevich which reported a landmark
study , 1017pts
Reginal function ( RF) by contrast Echo
98% adequate
Myocardial Perfusion 96% adequate .

Their 2 year followup
>1000 patients found
evidence for MCE to
assess patients
presenting to their ED
with CP .
RF is the best
predictor of both short
and longterm
cardiovascular
endpoints
Myocardial Contrast EchoMyocardial Contrast Echo
Diana Rankevich , etal Eur Heart journal 2005

Future DevelopmentsFuture Developments
Other Echo modalitiesOther Echo modalities
Doppler tissue imagingDoppler tissue imaging
Strain & strain rateStrain & strain rate
Color kinesis, for assessment of regionalColor kinesis, for assessment of regional
wall motionwall motion

Diagnosis, exclude causes of chest painDiagnosis, exclude causes of chest pain
– Aortic dissectionAortic dissection
– Pericarditis (with effusion)Pericarditis (with effusion)
– Aortic stenosisAortic stenosis
– Hypertrophic cardiomyopathyHypertrophic cardiomyopathy
Vascular territory involved ( direct revasc)Vascular territory involved ( direct revasc)
Area of myocardium at risk ( strtifica)Area of myocardium at risk ( strtifica)
Global ventricular function ( strtifica)Global ventricular function ( strtifica)
AMI complications (urge surg)AMI complications (urge surg)
Echo inEcho in ACSACS

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