The Diagnostic Value of Echocardiography Performed by an Emergency Medicine Physician in the Diagnosis of Acute Coronary Syndrome: A Comparative Study With Cardiologist

Abstract

Objective: Early recognition of acute coronary syndromes (ACSs) is crucial in the emergency department. This study was designed to determine the diagnostic value of echocardiography, which was performed by an emergency medicine (EM) physician, to diagnosis ACS. Materials and Methods: This prospective and cross-sectional study was conducted between June 2011 and December 2011. All patients who were admitted with chest pain, to the EM department, and fulfilled the inclusion criteria were enrolled in this study. The focused echocardiography was performed by the EM physician. All echocardiography videos recorded were shown to the cardiologist. The final comments were compared with EM physician’s early findings. Results: Out of 48 patients, four were diagnosed with ACS. Three out of four patients diagnosed with ACS were detected by the EM physician with echocardiography. The EM physician’s prediction value with echocardiography in ACS diagnosis was 75% (95% confidence interval [CI] range 59%–100%), and the negative predictive value was 97% (95% CI range 77,9%-100%). There was no major cardiac event in the patient in whom the EM physician failed to detect a wall motion defect. Conclusion: Echocardiography is a bedside, noninvasive test for diagnosis of ACS. The EM physician who participated in this study was able to recognize ACS with the absence of a segmental wall motion defect, as well as the cardiologist providing the final report.

The diagnostic accuracy of cardiac ultrasound for acute myocardial ischemia in the emergency department: a systematic review and meta-analysis

“…Mean age of the population across studies ranged from 49 to 68 years (average: 59 years [SD 5.2]) and the proportion of male patients ranged from 42.3 to 84.5% (mean 62.6% [SD 11.9]). Patient spectrum varied across the studies, mainly in the inclusion (13 studies) [ 24 , 29 , 30 , 56 , 61 , 63 , 65 , 70 , 72 – 74 , 76 , 77 ] or exclusion (13 studies) [ 25 , 27 , 57 – 60 , 62 , 64 , 66 , 67 , 69 , 71 , 75 ] of patients with previous heart disease. See e-Table 1 (Additional File 1 : e-Appendix 4) for additional information.…”

“…Cardiac ultrasound was conducted as POCUS in 5 studies [ 28 , 30 , 59 , 72 , 74 ] and as a TTE in 20 studies (either standard [ 24 , 26 , 29 , 60 – 62 , 66 , 67 , 70 , 71 , 73 , 75 , 76 ] or limited-TTE). [ 25 , 27 , 57 , 58 , 63 , 64 , 69 ] Cardiac ultrasound operators were from the cardiology department in 6 studies (cardiologists, cardiology fellows or sonographers),[ 27 , 60 , 63 , 66 , 67 , 76 ] emergency department in 6 studies (emergency physicians or residents),[ 28 , 30 , 57 , 59 , 72 , 77 ] sonographers without a description of department or training backgrounds in 3 studies[ 24 , 29 , 75 ], and not reported in 11 studies. [ 25 , 26 , 56 , 58 , 62 , 64 , 65 , 68 – 71 ] In two studies, the person performing the ultrasound was described as “an experienced operator” [ 61 , 73 ] and in one study was performed by 3rd year medical students [ 74 ].…”

“…Of note, nine studies reported ultrasound was conducted at arrival to the ED or immediately after arrival [ 24 , 29 , 60 , 69 , 70 , 72 , 73 , 75 , 76 ], during the first 4 h[ 63 ], 8 h [ 25 ], 12 h [ 62 ],or 24 h [ 71 ], and in most studies [ 16 ] the timing of ultrasound was not reported [ 27 , 28 , 30 , 56 – 59 , 61 , 64 – 68 , 74 , 77 ]. Full echocardiography devices were used in 69% of studies [ 20 ], hand-held or cart/tray based devices in four studies [ 28 , 57 , 74 , 76 ] and not reported in five studies [ 26 , 56 , 59 , 65 , 77 ]. The characteristics of the index test for the included studies are summarized in Table 2 .…”

“…The reference standard varied widely across studies, using final diagnosis or chart review [ 26 , 29 , 30 , 57 , 59 , 64 , 71 , 72 , 76 , 77 ], cardiac enzymes results [ 61 , 70 , 73 ], a combination of tests (between ECG, cardiac enzymes, non-invasive testing, and coronary angiography) [ 24 , 25 , 27 , 62 , 63 , 65 – 67 , 74 ] or significant coronary artery stenosis [ 28 , 58 , 60 , 68 , 69 , 75 ]. The definition of significant coronary stenosis varied between ≥ 50% [ 58 , 69 ] to ≥ 70% narrowing in epicardial coronary arteries [ 23 , 66 ].…”

“…Overall, most studies were at high risk of bias due to patient selection and reference standard factors. High risk of bias was found in the patient selection domain (22 studies, 76%) [ 24 – 29 , 56 – 60 , 62 – 67 , 69 – 72 , 74 , 75 ] due to convenience sampling or inappropriate exclusions (patients with previous heart disease, low or high risk of ACS and/or inadequate ultrasound windows); in the reference standard domain (15 studies, 52%) [ 24 , 26 , 27 , 29 , 57 , 61 , 63 , 66 – 68 , 70 – 74 ] due to lack of blinding or because it was not likely to correctly classify myocardial ischemia [ 24 , 26 , 27 , 29 , 57 , 61 , 63 , 66 – 68 , 70 – 74 ]; and in the flow and timing (13 studies, 45%) [ 24 – 26 , 28 , 29 , 57 , 66 , 68 – 72 , 74 ] due to partial or differential verification or the exclusion of patients from the analysis (i.e., patients with inadequate echocardiographic windows) [ 24 – 26 , 28 , 29 , 57 , 66 , 68 , 70 , 71 , 74 ]. The index test domain was judged to be at low risk of bias in most studies (28 studies, 97%).…”