Emergency Physician-performed Echocardiogram in Non-ST Elevation Acute Coronary Syndrome Patients Requiring Coronary
Ting Xu Tan1,2, Donald Wright1, Cristiana Baloescu1
1Yale University School of Medicine, Department of Emergency Medicine, New Haven, Connecticut.
Insights
Emergency physician-performed point-of-care transthoracic echocardiography (POC TTE) showed limited accuracy in identifying patients needing coronary intervention. However, "new" regional wall motion abnormalities on POC TTE demonstrated high specificity for guiding intervention decisions.
Area of Science:
- Cardiology
- Emergency Medicine
- Diagnostic Imaging
Background:
- Identifying patients in the emergency department (ED) who need early coronary intervention but do not meet standard electrocardiogram (ECG) criteria is challenging.
- Point-of-care transthoracic echocardiography (POC TTE) performed by emergency physicians (EPs) is a potential tool to aid in this identification process.
Purpose of the Study:
- To evaluate the effectiveness of EP-performed POC TTE in identifying patients requiring coronary intervention who initially did not meet ECG activation criteria.
- To assess the diagnostic performance of POC TTE in detecting regional wall motion abnormalities (RWMA) for guiding coronary intervention decisions.
Main Methods:
- A retrospective observational cohort study included adult patients presenting to two EDs from 2018-2020 who received POC TTE and coronary angiography within 72 hours.
- Patients meeting catheterization laboratory activation criteria on initial ED ECG were excluded.
- Two blinded, fellowship-trained EPs independently reviewed POC TTE studies for RWMA, and test characteristics for coronary intervention were calculated.
Main Results:
- Of 221 eligible patients, 47% received coronary intervention or coronary artery bypass grafting (CABG) referral.
- The overall prevalence of RWMA on POC TTE was 35%.
- Presence of RWMA had 38% sensitivity and 68% specificity for intervention/CABG referral. "New" RWMA showed 43% sensitivity and 93% specificity. EP-performed POC TTE interpretation of RWMA had 57% sensitivity and 96% specificity compared to cardiology echocardiograms.
Conclusions:
- EP-performed POC TTE demonstrated limited sensitivity and specificity for identifying patients needing coronary intervention or CABG referral.
- The specificity for detecting RWMA trended higher in patients with prior normal echocardiograms, suggesting potential utility with further study.
- EP-performed POC TTE showed high specificity for detecting RWMA compared to subsequent cardiology echocardiograms, warranting further investigation in a dedicated cohort.
Introduction:
Identification of patients not meeting catheterization laboratory activation criteria by electrocardiogram (ECG) but who would benefit from early coronary intervention remains challenging in the emergency department (ED). The purpose of this study was to evaluate whether emergency physician (EP)-performed point-of-care transthoracic echocardiography (POC TTE) could help identify patients who required coronary intervention within this population.
Methods:
This was a retrospective observational cohort study of adult patients who presented to two EDs between 2018-2020. Patients were included if they received a POC TTE and underwent diagnostic coronary angiography within 72 hours of ED presentation. We excluded patients meeting catheterization laboratory activation criteria on initial ED ECG. Ultrasound studies were independently reviewed for presence of regional wall motion abnormalities (RWMA) by two blinded ultrasound fellowship-trained EPs. We then calculated test characteristics for coronary intervention.
Results:
Of the 221 patient encounters meeting inclusion criteria, 104 (47%) received coronary intervention or coronary artery bypass grafting (CABG) referral. Overall prevalence of RWMA on POC TTE was 35% (95% confidence interval [CI] 29-42%). Presence of RWMA had 38% (95% CI 29-49%) sensitivity and 68% (95% CI 58-76%) specificity for coronary intervention/CABG referral. Presence of "new" RWMA (presence on EP-performed POC TTE and prior normal echocardiogram) had 43% (95% CI 10-82%) sensitivity and 93% (95% CI 66-100%) specificity for coronary intervention/CABG referral. The EP-performed POC TTE interpretation of RWMA had 57% (95% CI 47-67%) sensitivity and 96% (95% CI 87-100%) specificity for presence of RWMA on subsequent cardiology echocardiogram during the same admission.
Conclusion:
Presence of RWMA on EP-performed POC TTE had limited sensitivity or specificity for coronary intervention or referral to CABG. The observed specificity appeared to trend higher in subjects with a prior echocardiogram demonstrating absence of RWMA, although a larger sample size will be required to confirm this finding. The EP-performed POC TTE RWMA had high specificity for presence of RWMA on subsequent cardiology echocardiogram. Further evaluation of the diagnostic performance of new RWMA on EP-performed POC TTE with a dedicated cohort is warranted.
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