Clinical Investigation
Significance of Native and Allograft CAD
Early Assessment of Strain Echocardiography Can Accurately Exclude Significant Coronary Artery Stenosis in Suspected Non–ST-Segment Elevation Acute Coronary Syndrome

https://doi.org/10.1016/j.echo.2014.01.019Get rights and content

Background

Many patients with suspected non–ST-segment elevation acute coronary syndrome (NSTE-ACS) do not have significant coronary artery disease. The current diagnostic approach of repeated electrocardiography and cardiac biomarker assessment requires observation for >6 to 12 hours. This strategy places a heavy burden on hospital facilities. The objective of this study was to investigate whether myocardial strain assessment by echocardiography could exclude significant coronary artery stenosis in patients presenting with suspected NSTE-ACS.

Methods

Sixty-four patients presenting to the emergency department with suspected NSTE-ACS without known coronary artery disease, inconclusive electrocardiographic findings, and normal cardiac biomarkers at arrival were enrolled. Twelve-lead electrocardiography, troponin T assay, and echocardiography were performed at arrival, and all patients underwent coronary angiography. Significant coronary stenosis was defined as >50% luminal narrowing. Global myocardial peak systolic longitudinal strain was measured using speckle-tracking echocardiography. Left ventricular ejection fraction and wall motion score index were calculated.

Results

No significant stenosis in any coronary artery was found in 35 patients (55%). Global peak systolic longitudinal strain was superior to conventional echocardiographic parameters in distinguishing patients with and without significant coronary artery stenosis (area under the curve, 0.87). Sensitivity and specificity were calculated as 0.93 and 0.78, respectively, and positive predictive value and negative predictive value as 0.74 and 0.92, respectively. Feasibility of the strain measurements was excellent, with 97% of segments analyzed.

Conclusions

Myocardial strain by echocardiography may facilitate the exclusion of significant coronary artery stenosis among patients presenting with suspected NSTE-ACS with inconclusive electrocardiographic findings and normal cardiac biomarkers.

Section snippets

Study Population

Sixty-four patients with suspected NSTE-ACS without known coronary artery disease, inconclusive ECG findings, and normal cardiac biomarkers at admission were enrolled at Sørlandet Hospital Arendal. Patients admitted with suspected NSTE-ACS were enrolled if the following criteria were met: (1) acute anginal pain lasting >10 min, (2) episode of chest pain within the past 3 days, and (3) indication for coronary angiography according to current guidelines.9 Exclusion criteria were: (1) age < 18

Clinical and Angiographic Data

Of the 64 patients who had normal initial cTnT and inconclusive ECG findings, 35 (55%) did not have significant coronary artery stenosis and 29 (45%) had significant coronary artery stenosis by coronary angiography. Baseline and clinical data for patients with and without significant coronary artery stenosis are presented in Table 1. Time from onset of symptoms to arrival in the ER, time from arrival in the ER to echocardiographic examination, and time from arrival in the ER to coronary

Discussion

To our knowledge, this study is the first to evaluate myocardial strain by speckle-tracking as an early method to identify patients without significant coronary artery stenosis in a population with suspected NSTE-ACS with inconclusive ECG findings and normal initial cardiac biomarkers.

Earlier echocardiographic studies focused on how to detect patients with coronary disease.14 In contrast, this study was designed to describe how an accurate assessment of myocardial strain might exclude

Conclusions

The present study demonstrates that myocardial strain by speckle-tracking may be superior to conventional echocardiographic parameters in excluding significant coronary artery stenosis in patients with suspected NSTE-ACS, inconclusive ECG findings, and normal cardiac biomarkers. A combined strategy with electrocardiography, a single set of cardiac proteins, and measurement of myocardial strain by speckle-tracking echocardiography may aid clinicians in excluding significant coronary artery

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    This study was funded by the Norwegian Health Association, South-Eastern Norway Regional Health Authority, and Sørlandet Hospital (Arendal, Norway).

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