ECHO 2013 / Echocardiography in Acute Coronary Syndromes Management and Risk Assessment
.pdfEchocardiography in Acute Coronary Syndromes: management + risk assessment
Michael H. Picard, M.D.
Massachusetts General Hospital
Harvard Medical School
Disclosure
• none
Echocardiography in ACS:
should we image ? SOMETIMES
•Uninterpretable or non diagnostic ECG
–LBBB
–Nonspecific ST T wave changes
•Negative or borderline biomarkers
•Confusing presentation - Differential diagnosis
–Ischemia
–Infarction
–Aortic dissection
–Pericarditis
–Myocarditis
–Pulmonary embolism
–Other: Takotsubo, Noncardiac etiologies
Roles for echo in ACS
•Diagnosis
•Decision making
–Regional function
•Location and extent of dysfunction
–Global function
•Hypotension – is it due to hypovolemia or poor LV function ?
•Need for IABP, etc
•Prognosis
–Early
•Regional LV function
–size of LV dysfunction
•Global LV function
–Late
•Stress echo
–Inducible ischemia, additional therapies, return to work,
• Assessing complications
Roles for echo in ACS
•Diagnosis
–Excellent negative predictive value
–WMA
•15-20% of thickness
•does not discriminate acute vs. chronic
•Ischemia (reversible) vs. MI (necrosis)
Is this an inferior MI ?
“Pseudodyskinesis”
Abnormal outward motion but normal thickening
Role of Hand held echo in diagnosis of ACS
Weston et al; Am Heart J 2004;148:1096-101
•150 pts with sx of ACS, non-diagnostic ECG and negative biomarkers
•30 day f/u for cardiac events
•Normal HHE
–2.5% risk of cardiac event
•Abnormal HHE
–20% risk of cardiac event
•91% negative predictive value
Stress echo in dx of ACS
Jeetley et al, Eur J Echo 2006;7:155-64 and Eur Hrt J 2007 Jan 16, 2007
•Clinical symptoms of ACS, non diagnostic ECG, negative troponin
•12% significant CAD on coronary angio
•Stress ECG
–Sens 56%
–Spec 33%
•Exercise echo
–Sens 84%
–Specificity 77%
•Stress echo classified more as low risk (accurately), fewer intermediate risk and thus lower cost of care since less additional testing
Do biomarkers replace the need for echo in acute MI ?
•Biomarkers at present do not replace cardiac imaging
–Complementary
–Synergistic
•Rule in by troponin is easy
•Rule out requires at least an 8 hour wait