Two-dimensional strain echocardiography for diagnosing chest pain in the emergency room: a multicentre prospective study by the Israeli echo research group

Abstract

AimsLeft ventricular (LV) two-dimensional longitudinal strain (2DLS) analysis by echocardiography has been suggested as a useful tool for the detection of acute coronary syndromes (ACS). Our aim was to determine whether 2DLS analysis could assist in triage of patients with chest pain (CP) in the emergency department (ED). Methods and resultsWe prospectively enrolled patients presenting to the ED with CP and suspected ACS but without a diagnostic ECG or elevated troponin. An echocardiogram was performed within 24 h of CP. For each patient, a histogram of LV myocardial peak systolic strain (PSS) was generated and the value identifying the 20% worst strain values (PSS20%) was determined. A predefined value of greater than 217% was considered abnormal.2DLS analysis was available for 605 patients (mean age 58 + 9 years, 70% males), of which 74 (12.2%) had ACS. During a 6-month follow-up, MACE occurred in 4 (5.8%) patients with and in 3 (0.6%) without ACS. An abnormal PSS20% was present in 60/74 patients with ACS (sensitivity 81%, negative predictive value 91%), but also in 391/531 patients without ACS (specificity 26%, positive predictive value 13%). Similar results were found for global longitudinal strain (GLS). Receiver-operating characteristic curves showed an area under curve of 0.59 for PSS20% and 0.6 for GLS (P ¼ 0.3). Independent predictors of abnormal 2DLS were male gender, body mass index, heart rate, and mean tissue Doppler e ′ , but not ACS. ConclusionIn this large multicentre prospective study, 2DLS was not a useful tool to rule out ACS in the ED. Clinical trial registration

Global longitudinal strain and long‐term outcome in patients presenting to the emergency department with suspected acute coronary syndrome

“…We have previously reported a significantly higher 6-month MACE in patients with ACS as compared to patients in which ACS was excluded (5.8% vs 0.6%, P = .0002). 15 The fact that 6-month MACE was extremely rare in 2DSPER in patients in whom ACS was excluded, regardless of GLS, suggests that the likelihood of missing significant CAD during the initial admission in these patients was very low, despite the fact that many of the patients did not undergo coronary angiography.…”

“…17 Unfortunately, in the 2DSPER study, PSS20% was not superior to GLS in diagnosing ACS. 15 Similar to most other studies assessing the utility of LV strain in predicting outcome, we used GLS, since GLS is a simple and robust diagnostic tool, readily available in most commercial echo machines.…”

“…The 2DSPER was a prospective multicenter blinded study conducted by the Israeli Echo Research Group. 15 The study was approved by the local institutional review board of each participating center, and all patients signed an informed consent form.…”

“…The 2-Dimensional Strain Echocardiography for Diagnosing Chest Pain in the Emergency Room (2DSPER) study was a multicenter, prospective, blinded study designed to assess the utility of 2DLS in the assessment of low to moderate risk patients presenting to the emergency department (ED) with suspected acute coronary syndrome (ACS). 15 In that study, 2DLS was not found to be a useful tool for ruling out ACS in the ED, despite the fact that several small studies had reported that 2DLS can accurately detect coronary artery disease (CAD)…”

Subclinical left ventricular myocardial dysfunction in non-obstructive coronary artery disease

“…Conversely, Smedsrud and co-authors investigated the predictive value of 2D GLS in detecting significant CAD is only modest in patients with stable chest pain undergoing elective coronary angiography (164). This is further supported by a large prospective multicenter study demonstrating considerable overlap in the distribution of 2D GLS between those with and without acute coronary syndrome (170). A recent metaanalysis revealed similar conclusion (171).…”