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Ischemic heart disease

  • Role of echo in patients with acute chest pain, presented by D Tsiapras (Athens, GR)  
  • Complications of acute myocardial infarction, presented by L Halmai (Szeged, HU)  
  • Stress echo protocols and techniques, presented by B Beleslin (Belgrade, RS)  
  • Doppler coronary flow reserve, presented by G Athanassopoulos (Pireas, GR)


1. Role of echo in patients with acute chest pain. /D Tsiapras
2-4% of patients with acute coronary syndromes have inadverted discharges based on troponin/ECG. Due to earlier appearance in ischemic cascade of wall motion abnormalities, echo might contribute to eliminate them. In this setting, contrast echo or strain analysis might be of interest, although when used inappropriately it might result in false diagnosis.
Predischarge evaluation with stress echo should be applied in cases with negative troponin.

Echo also has a pivotal role in aortic dissection for flap, extension of dissection and complications (aortic regurgitation, pericardial effusion). Pulmonary embolism has been reported in about 15% of patients with chest pain. The combination of an acceleration time of right ventricular ejection <60 msec and peak transtricuspid gradient<60 mmHg  with the Mc Connel sign (increased apical with decreased basal right ventricular thickening) contribute to make the diagnosis.

2. Complications of acute myocardial infarction. /L Halmai
Post-MI septal rupture (0.2% of myocardial infarctions-GUSTO 1 trial) has 24% mortality in 72 hours and 75%-90% in 30 days. Ischemic mitral regurgitation (MR) occurs in 25% of MI (mostly transient). Severe MR (PISA effective orifice area>0.2 cm2, regurgitant volume>30 ml, tenting area >2.5cm2) doubles the 1-year mortality. Papillary muscle rupture (1-5% of MI’s) usually concerns the posteromedial one (single vessel blood supply). It contributes to 5% of MI mortality and has a 90% mortality rate during the first week. Free wall rupture is subacute in 25% of cases and contributes to the 25% of MI mortality. Right ventricular infarction occurs in 30% of inferior MI and necessitates specific treatment to avoid early cardiogenic shock. Echo is the method of choice to guide early drainage in cases of pericardial tamponade (even with small amount of fluid in rapid accumulation).

3. Stress echo protocols and techniques. /B Beleslin
Several pharmacological stressors can be used which act differently (1: increase in coronary blood supply:dobutamine: inotropy-chronotropy via a1/b1 adrenergic receptors; 2: reduce blood supply: dipyridamole/adenosine vasodilation of arterioles-A2 receptors). Treadmill or bicycle ergometry may be used. All protocols provide excellent diagnostic accuracy at a low cost and lack of biohazards. Detailed analysis of test outcome (workload, heart rate, onset /recovery of ischemia, vessels involved) provides risk stratification. Contrast agents can be used to improve image quality when at least 2 segments are not visualized. Dedicated protocols for aortic stenosis and mitral regurgitation might also be applied.

4. Doppler coronary flow reserve./G Athanassopoulos
Noninvasive coronary velocity reserve (CVR) is feasible in almost all distal left anterior descending arteries and in at least 50% of cases for right coronary /circumflex artery with current echo machines. Use of either bolus or continuous infusion of adenosine (140mg/kg/min) is feasible without major complications. Microvascular coronary disease (diabetes, left ventricular hypertrophy, syndrome X) might reduce CVR value (range from 3 to 2). CVR> 2 reassures patency of the epicardial vessel with a clear lumen diameter >50% and contributes to the risk stratification in chronic coronary artery disease in conjunction to the stress echo outcome.

 The evaluation of CVR is supported by current ESC guidelines for revascularization. CVR contributes also to risk stratification of both dilated and hypertrophic cardiomyopathy.

Conclusion:

 

There is a need for more extensive use of transthoracic echo in the emergency department especially in cases with acute coronary syndromes. Evolving technologies for better evaluation of left ventricular mechanics (strain analysis) might be of added clinical value. Early detection of mechanical complications of acute myocardial infarction is crucial to improve early and late outcome. Evolving functional mitral regurgitation post-myocardial infarction (MI) must be identified promptly. The broad spectrum of stress echo protocols should be applied in a more extensive manner in clinical practice. There is a great amount of evidence in order to secure risk stratification strategies in coronary artery disease. Clinical judgment and prudency should be exercised for individual patient tailoring of the protocol. The evaluation of coronary velocity reserve should be incorporated in stress echo protocols. It provides accurate information both for vessel patency as well as contributes to risk stratification in chronic coronary artery disease. It has excellent feasibility in post-revascularization follow-up more specifically the left anterior descending artery

References


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Ischemic heart disease

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

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