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

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

7. Regional Wall Motion Assessment

8. 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

9. 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.

10. 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
.

11. 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

12. Evaluation other causes of
cardiac chest pain
• Aortic Disection
• Valvular Heart Disease (Aortic Stenosis, Aortic Regurgitation)
• Pericarditis
• Myocarditis
• Pulmonary Embolism
• Takotasubo (stress induced cardiomyopathy)

13. Other causes of Chest Pain in ER

14. Takotsubo
Stress induced
cardiomyopathy
Apical ballooning
cardiomyopathy

15. 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

16. Mechanical Complication of MI

19. 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.

20. Echocardiography Improves Risk Stratification
Eur J Echocardiogr 2004; 5: 142-8

21. 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

22. Ultrasound Lung Comets

24. Appropriatness Echocardiography
for Risk Stratification

25. 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