Significance of early two-dimensional echocardiography after acute myocardial infarction

Hiatal hernia mimicking ST elevation myocardial infarction

A 72-year-old man with a history of hypertension, hiatal hernia, prostate cancer and lung cancer was admitted with complaints of abdominal pain, sweating and rigors. An electrocardiogram showed ST elevation in multiple leads. Noninvasive and invasive cardiovascular work-up was performed that was negative for occlusive coronary artery disease. Further studies demonstrated a large hiatal hernia; this was found to be the culprit causing his symptoms. Hiatal hernia is a very rare cause of ST segment elevation and should be considered in the differential diagnosis of disorders that can cause ST elevation.

Impact of valvular regurgitation and ventricular dysfunction on long-term survival in patients with chest pain

Doppler echocardiography is often used in evaluating patients with chest pain, but information on prognostic value of this testing and data to help guide selective use are limited. We prospectively studied 448 patients admitted from the emergency department for acute chest pain to assess the utility of qualitative echocardiographic data in predicting long-term survival and the incremental value of this information over routine clinical and electrocardiographic data. Doppler echocardiograms, recorded an average of 21 hours after presentation, were analyzed independently by 2 echocardiographers for global left and right ventricular function and valvular disease. Regional function was assessed by wall motion index. Data on long-term survival were collected with an average follow-up of 35.0 +/- 12.1 months. In univariate Cox regression analysis, left ventricular function and size, wall motion index, right ventricular function, and aortic, mitral, and tricuspid insufficiency were significant predictors of total and cardiovascular mortality. In multivariate analysis, moderate or severe left ventricular dysfunction (mortality rate ratio 3.2, 95% confidence intervals 1.8 to 5.8] and more than mild valvular regurgitation (mortality rate ratio 2.0, 95% confidence interval 1.1 to 3.6) were independent predictors of mortality in a model adjusted for clinical and electrocardiographic data. These factors were more common in patients aged >60 years, in those with prior acute myocardial infarction or angina, and in those with rales on physical examination. In the absence of these clinical characteristics, only 8 of 124 patients (7%) had moderate or severe left ventricular dysfunction or valvular regurgitation. In patients with moderate or severe regurgitation, a murmur was noted on the admission physical examination in 41 of 69 cases (59%). We conclude that echocardiographic evidence of moderate or severe left ventricular dysfunction or valvular regurgitation identifies a high-risk group for overall and cardiovascular mortality in patients with chest pain, and this evidence may not be detected clinically.

Echocardiographic prediction of complications in patients with chest pain

The optimal role of Doppler echocardiography in the evaluation of patients with acute chest pain syndromes is unclear. We prospectively studied a cohort of 466 patients admitted with acute chest pain syndromes to clarify the relation between echocardiographic data and the risk of serious predischarge complications, and to determine if echocardiographic data can provide incremental prognostic information beyond clinical and electrocardiographic variables. Doppler echocardiograms, performed an average of 21 hours after presentation, were independently analyzed by 2 echocardiographers for information on global left and right ventricular function and valvular disease. Regional function was assessed by a wall motion index (WMI). A composite complications end point was positive if significant recurrent myocardial ischemia, heart failure, or arrhythmia developed after the echocardiogram. In univariate analysis, left (odds ratio [OR] 2.9, 95% confidence interval [CI] 1.6, 5.1) and right (OR 2.7, 95% CI 1.2, 6.2) ventricular function, left ventricular end-diastolic (OR 1.6/cm, 95% CI 1.1, 2.3) and end-systolic (OR 1.4/cm, 95% CI 1.1, 1.9) dimensions, and WMI (OR 3.0, 95% CI 1.8, 4.8) predicted complications that developed after the echocardiogram. In multivariate analysis, WMI remained an incremental predictor of risk with an OR of 2.2/unit (95% CI 1.2, 3.9) scaled from 1 to 4. Even in the subset of 403 patients without acute myocardial infarction, WMI was associated with an OR of 1.9 (95% CI 1.0, 3.7). We conclude that early echocardiography provides incremental prognostic information concerning risk of subsequent complications in patients hospitalized with chest pain.

Echocardiographic correlates of survival in patients with chest pain

OBJECTIVES

This study sought to identify echocardiographic predictors of survival in patients with chest pain and to assess the utility of qualitative echocardiographic data in the prognostic stratification of this cohort.

BACKGROUND

The potential usefulness of echocardiographic data in prognostic stratification of patients with acute chest pain is unclear, in part because of the qualitative nature of routinely available echocardiographic readings.

METHODS

The study group comprised 513 patients who underwent transthoracic two-dimensional and Doppler echocardiography within 1 month of emergency department visits for acute chest pain. Clinical and electrocardiographic (ECG) data were recorded for these patients at the time of their initial evaluations, and echocardiographic data were subsequently obtained from the official hospital reports. Follow-up survival rate data were obtained from medical records or the Massachusetts Bureau of Vital Statistics.

RESULTS

A mean of 28.5 months after the index visit, 102 patients (20%) had died, including 58 (57%) for whom the primary cause of death was cardiovascular. In analysis of routinely available qualitative echocardiographic data, left ventricular size and function, the presence of regional wall motion abnormalities, mitral regurgitation and structural abnormalities of the mitral valve were significant univariate correlates of both overall mortality and death from cardiovascular causes. Severe left ventricular dysfunction (adjusted rate ratio 3.8, 95% confidence interval [CI] 1.9-7.5) and moderate or severe mitral regurgitation (adjusted rate ratio 2.4, 95% CI 1.5-3.7) were independent predictors of mortality in a multivariate Cox regression analysis that adjusted for clinical and ECG variables. Moderate or severe left ventricular dysfunction and mitral regurgitation were predictors of mortality in the subset of patients without acute myocardial infarction.

CONCLUSIONS

Qualitative echocardiographic reports of left ventricular dysfunction and mitral regurgitation were independent correlates of prognosis in patients with acute chest pain, including patients without acute myocardial infarction. Further data are needed to assess the generalizability of these findings and the implications for use of this diagnostic technology.

Left ventricular blood flow analysis in patients with and without a thrombus after first Q wave acute anterior myocardial infarction: two-dimensional Doppler echocardiographic study

The authors studied 80 consecutive patients with a first Q wave anterior myocardial infarction (MI) by 2-dimensional and color Doppler echocardiography (echo), on day 3 and day 10 after admission, to determine whether left ventricular (LV) blood flow dynamics differ between those who develop LV thrombus and those who do not. With pulsed Doppler echo, peak flow velocities were measured in diastole at the inflow tract, at the apex in diastole and systole, and at the outflow tract in systole. There were 11 patients (14%) who had LV thrombosis on day 3. On day 10, no other patient developed a thrombus. There was no difference in the Doppler flow velocities, except for lower apical diastolic velocities (0.23 +/- 0.04 m/s) (+/- SEM) in patients with thrombus as compared with those without it (0.33 +/- 0.01 m/s) (p less than 0.05). All patients with thrombus had apical dyskinesis and 8 (73%) had an anteroapical aneurysm, while 40 (58%) patients without thrombosis had dyskinesis and 11 (16%) had an aneurysm (p less than 0.01). The ejection fraction was lower (25.4 +/- 3.2%), the wall motion score was higher (10.6 +/- 0.7), and mitral regurgitation was seen more frequently (45%) in those with LV thrombus (respective values in no thrombus group patients: 32.9 +/- 1.4%, 7.6 +/- 0.3, 7%). The authors conclude that LV thrombus prediction is difficult by Doppler flow velocity study, whereas dyskinesis and aneurysmal dilatation of the LV apex is significantly associated with thrombus.

Early estimation of risk by echocardiographic determination of wall motion index in an unselected population with acute myocardial infarction

In a prospective series of 201 consecutive patients with creatine kinase-MB--documented acute myocardial infarction (AMI), postadmittance and predischarge echocardiographic wall motion indexes (WMI) were determined (median 45 hours vs 14 days after AMI). No significant change of left ventricular systolic performance was found between postadmittance and predischarge examinations in 179 survivors (WMI 1.3 +/- 0.4 vs 1.4 +/- 0.4, p greater than 0.05). Hospital mortality was 11% (22 of 201), cumulated 2-month mortality 15% (31 of 201) and cumulated 1-year mortality 26% (52 of 201). Mortality increased rapidly with decreasing left ventricular function as determined by WMI. When early WMI was less than 1.0, 1-year mortality was 51% (28 of 55) versus 8% (7 of 83) when WMI was greater than 1.3 (p less than 0.0001). Ventricular fibrillation (n = 24) and cardiogenic shock (n = 27) carried a much better prognosis when WMI showed good left ventricular function. When WMI was less than 1.0, 1-year mortality was 83% (10 of 12) versus 93% (13 of 14) in ventricular fibrillation and cardiogenic shock, respectively, whereas it was 0% (0 of 4) versus 33% (2 of 6) when WMI was greater than 1.3. In 15% of patients major discrepancies between early Killip class and WMI were noted. WMI showed much smaller fluctuations during the hospital course of AMI than did Killip class and appeared to be a more stable prognostic marker. Large-scale, early risk stratification by echocardiography has now become available and appears to facilitate a rational, individualized discharge policy in the coronary care unit and to provide an improved basis for randomization of patients in controlled studies aimed at tailoring new treatment in AMI.

Left ventricular function of survivors of a first complicated acute myocardial infarction. A prehospital discharge cross-sectional echocardiographic study

To assess the left ventricular function of patients who suffer from post-infarction angina and left ventricular failure in the coronary care unit, 79 consecutive survivors (mean age 48 years) of a first acute myocardial infarction were prospectively studied and followed-up for a mean 18- (10-34) month period. Forty-seven had an uncomplicated infarction, 17 suffered from post-infarction angina and 15 had left ventricular failure. The left ventricular function of these patients prior to discharge from hospital was assessed by cross-sectional echocardiography and radionuclide angiography. Analysis of left ventricular wall motion was performed in all patients using a 11-segment model of the left ventricular. The ejection fraction was determined by echocardiography in 47 patients and by radionuclide angiography in 50. The mean echocardiographic wall motion score of post-infarction angina patients (4.8 +/- 0.8) (+/- SEM) was lower than that of patients with left ventricular failure (9.5 +/- 0.5) (P less than 0.001), but was not different from patients suffering uncomplicated infarctions (4.6 +/- 0.3). The mean echocardiographic ejection fraction was also similar in post-infarction angina (45.3 +/- 4.0; n = 16) and patients with uncomplicated infarction (51.9 +/- 2.7; n = 17), but was lowest in the group of patients with left ventricular failure (35.1 +/- 3.3; n = 14). Similarly, the radionuclide ejection fraction of patients with post-infarction angina (41.4 +/- 3.4; n = 17) and patients with uncomplicated infarction (45.6 +/- 2.7; n = 19) did not differ, but was lower in patients with left ventricular failure (25.9 +/- 2.8; n = 14). The echocardiographic ejection fraction correlated with that obtained by radionuclide angiography in all 46 patients (r = 0.71, P less than 0.001). The wall motion score correlated with the radionuclide ejection fraction in all 50 patients (r = -0.73, P less than 0.001) and with the echocardiographic ejection fraction in 47 patients (r = -0.55, P less than 0.001). During follow-up, 3 (18%) patients suffering post-infarction angina and 2 (13%) with left ventricular failure died. New infarction was seen in 2 (12%) and 1 (7%) patients in these groups, respectively. We conclude that the left ventricular function of patients who suffer from post-infarction angina in the coronary care unit is good, but is impaired in those with even transient left ventricular failure. Echocardiographic assessment of cardiac function prior to hospital discharge was highly successful and may be performed in all such patients.

The role of prehospital discharge two-dimensional echocardiography in determining the prognosis of survivors of first myocardial infarction

Two-dimensional echocardiography (2DE) was performed in 47 consecutive survivors (mean age 47 years) of a first myocardial infarction (MI), to assess its value in predicting major cardiac complications (MCC) during the posthospital phase. 2DE was undertaken 1 day before hospital discharge (mean 15 days). A wall motion score was derived by analyzing endocardial motion in 11 left ventricular segments. During a mean 17-month follow-up, 17 patients had MCC: eight (47%) had significant angina; two (12%) reinfarcted, and seven (41%) died. Wall motion scores of patients with MCC (9.2 +/- 0.9) (+/- SEM) were significantly higher compared to those without MCC (3.7 +/- 0.4 (p less than 0.005). A wall motion score greater than or equal to 8 was present in 82% (14 of 17) of patients with MCC compared to 7% (2 of 30) who remained asymptomatic. Patients who died had significantly higher wall motion scores compared to those who survived (11.3 +/- 0.9 vs 4.7 +/- 0.5) (p less than 0.005). Stepwise logistic regression and discriminant analysis, by means of age, infarct site, maximal Killip class, cardiac enzymes, and wall motion score, identified wall motion score and Killip class as the most significant predictors of MCC. Thus predischarge 2DE is capable of identifying high-risk patients prone to developing MCC after a first MI.