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ECHO 2013 / Echocardiography in Acute Coronary Syndromes Management and Risk Assessment

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Echocardiography 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