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Feasibility and accuracy of speckle tracking echocardiography in emergency department patients

  • Author Footnotes
    1 Present address: Department of Emergency Medicine, Stony Brook University, Stony Brook, New York, United States of America.
    Lindsay Reardon
    Correspondence
    Corresponding author at: Department of Emergency Medicine, HSC L4-080, 8350 SUNY, Stony Brook, NY 11794-8350, United States of America.
    Footnotes
    1 Present address: Department of Emergency Medicine, Stony Brook University, Stony Brook, New York, United States of America.
    Affiliations
    Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States of America
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  • Author Footnotes
    2 Present address: Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America.
    William J. Scheels
    Footnotes
    2 Present address: Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America.
    Affiliations
    Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States of America
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  • Adam J. Singer
    Affiliations
    Department of Emergency Medicine, Stony Brook University, Stony Brook, NY, United States of America
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  • Robert F. Reardon
    Affiliations
    Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States of America
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  • Author Footnotes
    1 Present address: Department of Emergency Medicine, Stony Brook University, Stony Brook, New York, United States of America.
    2 Present address: Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America.
Published:September 04, 2018DOI:https://doi.org/10.1016/j.ajem.2018.08.074

      Abstract

      Background

      Speckle tracking echocardiography (STE) is a novel technology that measures regional wall-motion abnormalities that may speed diagnosis and intervention of acute coronary occlusion in Emergency Department (ED) patients with non-ST elevation ACS (NSTE-ACS). STE provides an objective measurement of myocardial strain that is superior to visual assessment of wall motion when performed as part of a point-of-care (POC) echocardiogram. We determined the feasibility and preliminary accuracy of POC STE operated by emergency providers when compared to comprehensive echocardiography or final diagnosis of ACS.

      Methods

      We retrospectively reviewed 187 emergency provider POC echocardiograms with STE from 7/2014–5/2016 for suspected ACS at a large academic trauma center. Feasibility of POC STE was determined by calculating the percentage of complete exams (adequate apical 4-chamber and parasternal short axis views) out of all STE exams. We then used two different criterion standards for calculating diagnostic accuracy of STE: comprehensive echocardiograms with wall motion abnormalities or formal diagnosis of ACS based on elevated cardiac troponins, unstable angina, percutaneous coronary intervention, or coronary artery stenosis >70% on catheterization.

      Results

      Of 187 STE studies performed, 75 (40%) were considered complete. Ultrasound-experienced providers had higher rates of complete exams (65% vs. 35%, P = 0.01). 16 of 75 exams (21%) were positive for myocardial strain, and of these 16 (100%) were admitted, 12 (75%) had positive troponins, 6 (46%) had positive comprehensive echocardiograms, and 3 (19%) had PCI or >70% stenotic lesion on catheterization. Compared with comprehensive echocardiography, POC STE had 35% sensitivity, 70% specificity, 46% positive predictive value (PPV), and 59% negative predictive value (NPV). Compared with formal diagnosis of ACS, POC STE had 29% sensitivity, 88% specificity, 75% positive predictive value (PPV), and 51% negative predictive value (NPV).

      Conclusion

      STE is a potentially feasible adjunct to standard bedside echocardiography in ED patients with suspected ACS when operated by experienced ultrasound-trained physicians in the ED. This data shows STE performed by emergency providers is not yet sensitive enough alone to diagnose ACS, and has low accuracy when compared to comprehensive echocardiography. However, the PPV and specificity improve when performed by expert ultrasound-trained providers. STE should be considered for inclusion in the Emergency Ultrasound Fellowship curriculum.

      Keywords

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      References

        • National Center for Health Statistics
        National Hospital Ambulatory Medical Care Survey: 2014 Emergency Department Summary Tables.
        2017: 1-35
        • Eek C.
        • Grenne B.
        • Brunvand H.
        • Aakhus S.
        • Endresen K.
        • Smiseth O.A.
        • et al.
        Strain echocardiography predicts acute coronary occlusion in patients with non-ST-segment elevation acute coronary syndrome.
        Eur J Echocardiogr. 2010; 11: 501-508https://doi.org/10.1093/ejechocard/jeq008
        • Rowland-Fisher A.
        • Smith S.
        • Laudenbach A.
        • Reardon R.
        Diagnosis of acute coronary occlusion in patients with non-ST-elevation myocardial infarction by point-of-care echocardiography with speckle tracking: a case report.
        Am J Emerg Med. 2016; : 1-4https://doi.org/10.1016/j.ajem.2016.02.017
        • Favot M.
        • Courage C.
        • Ehrman R.
        • Khait L.
        • Levy P.
        Strain echocardiography in acute cardiovascular diseases.
        West J Emerg Med. 2016; 17: 54-60https://doi.org/10.5811/westjem.2015.12.28521
        • Sjøli B.
        • Ørn S.
        • Grenne B.
        • Ihlen H.
        • Edvardsen T.
        • Brunvand H.
        Diagnostic capability and reproducibility of strain by Doppler and by speckle tracking in patients with acute myocardial infarction.
        JCMG. 2009; 2: 24-33https://doi.org/10.1016/j.jcmg.2008.10.007
        • Caspar T.
        • Samet H.
        • Ohana M.
        • Germain P.
        • El Ghannudi S.
        • Talha S.
        • et al.
        Longitudinal 2D strain can help diagnose coronary artery disease in patients with suspected non-ST-elevation acute coronary syndrome but apparent normal global and segmental systolic function.
        Int J Cardiol. 2017; 236: 91-94https://doi.org/10.1016/j.ijcard.2017.02.068
        • Dahlslett T.
        • Karlsen S.
        • Grenne B.
        • Eek C.
        • Sjøli B.
        • Skulstad H.
        • et al.
        Early assessment of strain echocardiography can accurately exclude significant coronary artery stenosis in suspected non-ST-segment elevation acute coronary syndrome.
        J Am Soc Echocardiogr. 2014; 27: 512-519https://doi.org/10.1016/j.echo.2014.01.019
        • Grenne B.
        • Eek C.
        • Sjøli B.
        • Dahlslett T.
        • Uchto M.
        • Hol P.K.
        • et al.
        Acute coronary occlusion in non-ST-elevation acute coronary syndrome: outcome and early identification by strain echocardiography.
        Heart. 2010; 96: 1550-1556https://doi.org/10.1136/hrt.2009.188391
        • Ammar K.A.
        • Paterick T.E.
        • Khandheria B.K.
        • Jan M.F.
        • Kramer C.
        • Umland M.M.
        • et al.
        Myocardial mechanics: understanding and applying three-dimensional speckle tracking echocardiography in clinical practice.
        Echocardiography. 2012; 29: 861-872https://doi.org/10.1111/j.1540-8175.2012.01712.x
        • Bansal M.
        • Kasliwal R.R.
        How do I do it? Speckle-tracking echocardiography.
        Indian Heart J. 2013; 65: 117-123https://doi.org/10.1016/j.ihj.2012.12.004
        • Mor-Avi V.
        • Lang R.M.
        • Badano L.P.
        • et al.
        Current and evolving echocardiographic techniques for the quantitative evaluation of cardiac mechanics: ASE/EAE consensus statement on methodology and indications endorsed by the Japanese Society of Echocardiography.
        J Am Soc Echocardiogr. 2011; 24: 277-313
        • Chan J.
        • Shiino K.
        • Obonyo N.G.
        • Hanna J.
        • Chamberlain R.
        • Small A.
        • et al.
        Left ventricular global strain analysis by two-dimensional speckle-tracking echocardiography: the learning curve.
        J Am Soc Echocardiogr. 2017; 30: 1081-1090https://doi.org/10.1016/j.echo.2017.06.010