Point-of-care echocardiography for decision making in patients with acute chest pain – the EPIC-ACS-Study

Background

The acute coronary syndrome (ACS) is one of the most common working diagnoses in emergency departments worldwide. The 2023 ESC guidelines for the management of ACS recommend an initial assessment of patients presenting with acute chest pain via electrocardiogram (ECG) and serial troponin assessment, classifying patients into rule-in, rule-out, or observe pathway.

Purpose

We aimed to evaluate whether an initial point-of-care (POC) echocardiography can improve the prediction of obstructive coronary artery disease (CAD) above initial ECG and troponin evaluation alone.

Methods

The present analysis is based on the prospective EPIC-ACS study (Epicardial adipose tissue thickness predicts obstructive CAD in ACS patients) of patients presenting with acute chest pain, suggestive of ACS, to the emergency department of our Hospital. Patients with ST-elevation myocardial infarction, haemodynamic instability or known CAD were excluded. A blinded echocardiographer, assessed left ventricular ejection fraction (LVEF, ≥50% or < 50%), regional wall motion abnormalities (yes or no, RWMA), left-atrial diameter in parasternal long axis view, and an epicardial adipose tissue (EAT) thickness of < vs. ≥ 5.5mm. The primary endpoint was defined as the presence of obstructive CAD detected in subsequent invasive coronary angiography.

Results

Between 2019 and 2020, a total of 511 patients (Age: 57.52 ± 18.1 years; 52% male) were included in this prospective observational cohort study. Among those, 214 were transferred to invasive coronary angiography, of which 97 patients had obstructive CAD requiring revascularization therapy. These patients had RWMA (26.8% vs. 6.1%, p < 0.001) and EAT of ≥ 5.5mm (88.7% vs. 11.3%, p < 0.001) significantly more often. LVEF and left-atrial diameter were not significantly different between patients with vs. without obstructive CAD (LVEF >= 50%: 81.4% vs. 87.7%, p = 0.48, LA-Diameter > 4.5cm: 5.2% vs. 6.3%, p = 0.44).

Figure 1 shows the presence of obstructive CAD, stratified by echocardiographic parameters, with normal and abnormal values showing that EAT > 5.5mm was markedly more frequently present in patients with obstructive CAD (p < 0.001, overall). In addition, the presence of RWMA differentiated patients with and without obstructive CAD in the rule-in (76% vs. 40%, p = 0.003) and rule-out (26% vs. 6%, p = 0.028) pathways, while no significant difference was observed in the observe group (p = 0.173). LVEF (rule-in: p = 0.313, observe: p = 0.441, rule-out: p = 0.685) and LA-Diameter (rule-in: p = 0.084, observe: p = 0.832, rule-out: p = 0.531) did not qualify for differentiating.

Conclusion

POC- echocardiography can help re-stratify patients with acute chest pain in addition to the guideline-recommended rule-in or rule-out pathway. Our results support the frequent use of POC- echocardiography for clinical decision-making in patients presenting with suspected ACS.