© 2004 by European Society of Cardiology
Copyright © 2004, The European Society of Cardiology
Role of echocardiography in acute coronary syndromes
Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
m.simoons{at}erasmusmc.nl
* Corresponding author. Erasmus Medical Center, Thoraxcenter, Department of Cardiology, Dr. Molewaterplein 40, Room H560, 3015 CD Rotterdam, Netherlands. Tel. +31-10-463-3938; fax: +31-10-463-5258.
Please see page 132 for the article by Hagendorff et al. (doi: 10.1016/S1525-2167(03)00055-6) and page 142 for the article by Hickman et al. (doi: 10.1016/S1525-2167(03)00077-5 to which this editorial pertains.
Acute coronary syndromes are caused by a sudden complete or partial obstruction of an epicardial coronary artery, often with distal embolisation of thrombotic material. The resulting reduced tissue perfusion and subsequent abnormalities of wall thickening or wall motion may be visualised by echocardiography. The reports by Hickman et al.1 and Hagendorff et al.2 in this issue of the European Journal of Echocardiography demonstrate that such visualisation by echocardiography can be improved by contrast echocardiography and harmonic imaging. The studies are relatively small, and consequently lack power to demonstrate the added value of echocardiography in addition to clinical characteristics, electrocardiography, including multilead ischemia monitoring and biochemical markers of myocardial necrosis, inflammation and cardiac dysfunction. Yet, the authors convincingly demonstrate that successful imaging of wall motion and perfusion is feasible in the majority of the patients with acute coronary syndromes. The question should be asked why such imaging would be important to improve our understanding (research) or patient management (practice). The former is self-evident. Careful precise characterisation of myocardial perfusion and wall motion in selected patients will certainly help to improve the understanding of the pathophysiology of acute coronary syndromes. For example, these patterns may help to document, understand and perhaps treat the no reflow phenomenon, absence of adequate tissue perfusion in spite of patent epicardial coronary arteries.
Whether these methods have an immediate clinical value will depend on the strategy for management of patients with acute coronary syndromes followed in a specific hospital. Indeed, different diagnostic and therapeutic strategies may be envisaged.
First, physicians may choose to perform immediate coronary angiography in all patients with persistent ST segment elevation, and immediate or early coronary angiography in all other patients with a suspected acute coronary syndrome. In addition to medical therapy (antiplatelet agents, anticoagulants, beta blockers, ACE inhibitors and statins) revascularisation may then be offered to those patients with significant coronary lesions. Nowadays, in most patients such revascularisation will be by percutaneous techniques, immediately following angiography. If such aggressive strategy is adopted, there will be little need for extensive echocardiographic examinations.
The recommended strategy is to perform immediate angiography and percutaneous coronary revascularisation in patients with acute coronary syndromes and persistent ST segment elevation, as well as in high risk patients without ST segment elevation, characterised by on going or recurrent ischemia, myocardial necrosis (elevated cardiac troponin levels) or diabetes. According to this strategy, low risk patients should be further evaluated by non-invasive methods to assess whether they have coronary artery disease, and whether they are at risk for subsequent events. In these patients risk assessment can be done by "classical exercise testing", stress echocardiography or exercise/stress perfusion imaging with radioisotopes, and ECG ischemia monitoring. Improved methods for assessment of myocardial wall motion, wall thickening, or perfusion1,2 should be applied to optimise imaging by echocardiography in these tests.
A specific group of patients, with a high risk for mortality, are those patients with bundlebranch block, other intraventricular conduction defects or pacemaker rhythm, which complicate the interpretation of the electrocardiogram. Such patients are often not treated appropriately, and have a poor outcome as documented by the Euro Heart Survey Acute Coronary Syndromes. In such patients immediate angiography may be performed. An alternative is immediate echocardiographic evaluation to assess the presence of impaired myocardial perfusion, or impaired wall motion. An invasive procedure might than be offered to those patients exhibiting such abnormalities.
Nevertheless, knowledge of the success of a PCI in acute STEMI for future recovery of contractile response will be an area where perfusion and wall motion by echocardiography will be of clinical importance.
A final strategy might be to assess the presence/absence of coronary artery disease by immediate multislice computer tomography. Such strategy is being considered, but has not yet been widely implemented.
At present, echocardiography is useful and widely used for assessment of cardiac function after an acute coronary syndrome, and for assessment of myocardial ischemia during stress. Optimal detection of all segments of both ventricles is required for complete evaluation of a patient. Contrast echocardiography and harmonic imaging should be applied widely to optimise echocardiographic imaging in these patients.
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- Hickman M., Swinburn J.M.A., Senior R. Wall thickening assessment with tissue harmonic echocardiography results in improved risk stratification for patients with non-ST-segment elevation acute chest pain. Eur J Echocardiography (2004) 5(2):142–148.[CrossRef]
- Hagendorff A., Goeckritz A., Pfeiffer D., Becher H. Myocardial contrast echocardiography demonstrates myocardial hypoperfusion in the LAD territory in patients with acute chest pain at rest—a prospective study using power Doppler harmonic imaging with intravenous bolus application. Eur J Echocardiography (2004) 5(2):132–141.[CrossRef]
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Related articles in Eur J Echocardiogr:
- Myocardial contrast echocardiography demonstrates myocardial hypoperfusion in the LAD territory in patients with acute chest pain at rest—a prospective study using power Doppler harmonic imaging with intravenous bolus application
- A Hagendorff, A Goeckritz, D Pfeiffer, and H Becher
Eur J Echocardiogr 2004 5: 132-141.[Abstract] [FREE Full Text] - Wall thickening assessment with tissue harmonic echocardiography results in improved risk stratification for patients with non-ST-segment elevation acute chest pain
- M. Hickman, J.M.A. Swinburn, and R. Senior
Eur J Echocardiogr 2004 5: 142-148.[Abstract] [FREE Full Text]
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