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Role of Echocardiography in Acute Chest
Pain Syndromes in the Era of
Multimodality Imaging
Ernesto E Salcedo, MD
Professor of Medicine university of Colorado Denver
Director of Echocardiography University of Colorado Hospital
Main causes of chest pain that pose an
immediate threat to life
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Acute coronary syndrome
Acute Aortic Syndromes
Pulmonary embolism
Tension pneumothorax
Pericardial tamponade
Mediastinitis (eg, Esophageal rupture)
To Admit or Not to Admit
• Patients with acute
myocardial infarction
who are mistakenly
discharged from the
emergency department
have short-term
mortality rates of about
25 percent, at least
twice what would be
expected if they were
admitted
Lee TH NEJM 2000
• The admission of a
patient with chest pain
who is at low risk for
acute myocardial
infarction costs an
average of $5,000 at
many institutions and
can lead to unnecessary
tests and procedures,
with their attendant
costs and complications
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Nuclear Stress Test
Courtesy Dr. J Maloo, University of Colorado Denver
Stress Echocardiogram
bod-ron 00012589
Left Ventricular Segmental Wall Motion Analysis
Lang R J Am Soc Echocardiogr 2005;18:1440-1463.
Segmental LV Wall Analysis
Hutchison SJ 2009 Complications of Myocardial Infarction
Regional Wall Motion Abnormalities
Parametric Imaging- Dyssynchrony
Methods: RT3DE (Philips) and CMR (Siemens) images were obtained from 31 patients and
analysed by using prototype software to semiautomatically calculate indices of regional left
ventricular function, which were compared between RT3DE and CMR (linear regression,
Bland–Altman). Additionally, CMR images were reviewed by an expert, whose RWM grades
were used as a reference for automated classification of segments as normal or abnormal
from RT3DE and from CMR images. For each modality, normal regional ejection fraction (REF)
values were obtained from 15 patients with normal wall motion. In the remaining 16 patients,
REFs were compared with thresholds that were derived from patients with normal wall
motion and
optimised using receiver operating characteristic analysis.
Nesser HJ Heart 2007;93;572-578
Segmental Wall Motion Analysis
3D Echo vs. CMR
Nesser HJ Heart 2007;93;572-578
Coronary CT Angiography
Courtesy Dr. J Maloo, University of Colorado Denver
Sf-rca8/08
sten-42yo2052273
8-8
2052273
CT Angiogram
Patent SVG to LAD
Courtesy Dr. J Maloo, University of Colorado Denver
KJ-CABG-06-11
Case ACS_139
CT Angiogram Patent STENT LAD
Courtesy Dr. J Maloo, University of Colorado Denver
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3D LV Size and function
Full
Volume
Live 3D
LV Shell
and
Segments
Multiplane
reconstruction
LV Volumes and EF by 3D Echo
Dorosz J….Salcedo E JACCC 2012 in press
Meta-analysis of Echo vs. CMRI LV Volume and EF
Dorosz J….Salcedo E JACCC 2012 in press
Comparison of end-diastolic volume (mL), end-systolic volume (mL) and
ejection fraction (%) measured by magnetic resonance
imaging and echo measures
Accuracy
Narrowing of the
Limits of agreement
With each additional
modality
2D
3D
Jenkins C. European Heart Journal (2009) 30, 98–106
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Apical Akinesis at Rest
No New Segmental Wall motion Abnormalities
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Global Ischemia
Courtesy Dr. J Maloo, University of Colorado Denver
Fesseh_F-dit-1520317
Inferior Scar Anterior Ischemia
Inferior Scar Anterior Ischemia
ACUTE AORTIC SYNDROMES
Aortic Dissection Classification
Classic
Aortic Dissection
Ulceration
Intramural
Hematoma
Discrete Dissection
From Svensson LG, Circulation 99: 1331–6, 1999
Iatrogenic Dissection
European Heart Journal (2001) 22, 1642–1681
Echocardiography in Aortic Dissection
• Transesophageal echocardiography in addition to
transthoracic echocardiography can be used for
decision making in the emergency room or even
operating theatre in acute aortic dissection with
high accuracy.
• Pitfalls have to be taken into account.
• The high resolution enables the diagnosis also of
intramural hematoma, plaque ulceration, as well
as traumatic aortic injury. When more spatial
resolution is necessary, CT or MRI are used in
addition.
European Heart Journal (2001) 22, 1642–1681
Arch aneurysm with dissection flap.
Jacobs AK Circulation. 2010;121:1544-1579
Artifact mimicking dissection.
Jacobs AK Circulation. 2010;121:1544-1579
Conclusions: TTE is a useful imaging modality for the diagnosis of acute type A aortic dissection.
It cannot be used as the sole screening technique for detecting AAAS, but in patients with
optimal image quality and clear-cut diagnosis of AAAS should proceed to the operative room,
whereas in patients with negative or indeterminate studies, other imaging techniques are
needed to refine the diagnosis.
Am Heart J 2012;163:112-8
Conclusions
• Echocardiography plays a central role in the
management of acute chest pain syndromes.
• Transthoracic echocardiography provides
critical information for the diagnosis and risk
stratification of patients with suspected or
known ACS.
• TEE and to a lesser degree TTE are key imaging
tools in the diagnosis and management of
Acute Aortic Syndromes.
[email protected]