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Myocardial deformation by strain echocardiography identifies patients with acute coronary syndrome and non-diagnostic ECG presenting in a chest pain unit: a prospective study of diagnostic accuracy

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Abstract

Objective

Clinical assessment often cannot risk stratify patients hospitalized with chest pain and non-diagnostic electrocardiography (ECG) or myocardial enzymes. An inappropriate admission of patients with non-cardiac chest pain is an enormous cost factor.

Methods

2315 patients who presented in the chest pain unit (CPU) with symptoms suggestive of acute coronary syndrome (ACS) were screened. All patients with relevant changes in ECG or myocardial enzymes were excluded. 268 consecutive patients (mean 58 ± 7 years, 88 men) were prospectively included and underwent echocardiography for left ventricular ejection fraction (LVEF), wall motion score index (WMSI) and strain parameter and a coronary angiography (CA) within 2 ± 1 days after admission.

Results

Anatomically obstructive coronary artery disease (CAD) (≥70 % diameter stenosis) was present in 110 patients (41 %). The incremental value of LVEF, WMSI, and strain parameters to relevant clinical variables was determined in nested Cox models. Baseline clinical data associated with relevant CAD were age [hazard ratio (HR) 1.31, p = 0.03], arterial hypertension (HR 1.39, p = 0.03) and diabetes (HR 1.46, p = 0.001). The addition of endocardial global circumferential strain (GCS) (HR 1.57, p < 0.001) caused the greatest increment in model power (χ 2 = 43.4, p < 0.001). Optimal cut-off value was calculated as -21.7 % for GCS (sensitivity 87 %, specificity 76 %) to differentiate between these patients.

Conclusions

In patients with suspected ACS but without ECG changes or myocardial enzyme abnormalities, myocardial deformation imaging can identify patients at risk. This approach may be applied to improve decision guidance at the CPU for fast discharge of patients with non-cardiac chest pain or prompt cardiological allocation of patients with CAD.

Clinical trial registration

NCT 02357641.

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Abbreviations

ACS:

Acute coronary syndrome

AUC:

Area under the curve

CA:

Coronary angiography

CAD:

Coronary artery disease

CI:

Confidence interval

CPU:

Chest pain unit

CK:

Creatine kinase

CT:

Coronary computer tomography

ECG:

Electrocardiography

LVEF:

Left ventricular ejection fraction

GCS:

Global circumferential strain

GLS:

Global longitudinal strain

GRS:

Global radial strain

LV:

Left ventricle/ventricular

MI:

Myocardial infarction

MRI:

Agnetic resonance imaging

NSTE:

Non-ST-segment elevation

PCI:

Percutaneous coronary intervention

ROC:

Receiver-operating characteristic

SD:

Standard deviations

SPECT:

Single-photon emission computed tomography

WMSI:

Wall motion score index

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Acknowledgments

MB designed the study and managed research process, MB and JS chaired data acquisition and analysis and interpretation of results, MB and SH wrote the report. MB, JS and SH had full access to all of the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis. Data were analyzed by NG, TR, EA and KU. AK contributed to statistical interpretation of results. NM and EA contributed to data analysis and interpretation and reviewed the report. NM, JS and KU contributed to the writing of the report.

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    Authors and Affiliations

    1. Department of Cardiology, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany

      Joerg Schroeder, Sandra Hamada, Tanja Rubeau, Ertunc Altiok, Katrin Ulbrich, Nikolaus Marx & Michael Becker

    2. Department of Internal Medicine, Hospital St. Brigida, Simmerath, Germany

      Nina Gründlinger

    3. Department of Medical Statistics, RWTH Aachen University, Aachen, Germany

      Andras Keszei

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    1. Joerg Schroeder
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    Correspondence to Michael Becker.

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    J. Schroeder and S. Hamada distributed equally.

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    Schroeder, J., Hamada, S., Gründlinger, N. et al. Myocardial deformation by strain echocardiography identifies patients with acute coronary syndrome and non-diagnostic ECG presenting in a chest pain unit: a prospective study of diagnostic accuracy. Clin Res Cardiol 105, 248–256 (2016). https://doi.org/10.1007/s00392-015-0916-2

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    • DOI: https://doi.org/10.1007/s00392-015-0916-2

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