J Cardiovasc Ultrasound.  2017 Mar;25(1):20-27. 10.4250/jcu.2017.25.1.20.

Role of Quantitative Wall Motion Analysis in Patients with Acute Chest Pain at Emergency Department

• Kim KH
• Na SH
• Park JS

• KMID: 2375293
• DOI: http://doi.org/10.4250/jcu.2017.25.1.20

Abstract

BACKGROUND
Evaluation of acute chest pain in emergency department (ED), using limited resource and time, is still very difficult despite recent development of many diagnostic tools. In this study, we tried to determine the applicability of new semi-automated cardiac function analysis tool, velocity vector imaging (VVI), in the evaluation of the patients with acute chest pain in ED.
METHODS
We prospectively enrolled 48 patients, who visited ED with acute chest pain, and store images to analyze VVI from July 2005 to July 2007.
RESULTS
In 677 of 768 segments (88%), the analysis by VVI was feasible among 48 patients. Peak systolic radial velocity (V(peak)) and strain significantly decreased according to visual regional wall motion abnormality (V(peak), 3.50 ± 1.34 cm/s for normal vs. 3.46 ± 1.52 cm/s for hypokinesia, 2.51 ± 1.26 for akinesia, p < 0.01; peak systolic radial strain -31.74 ± 9.15% fornormal, -24.33 ± 6.28% for hypokinesia, -20.30 ± 7.78% for akinesia, p < 0.01). However, the velocity vectors at the time of mitral valve opening (MVO) were directed outward in the visually normal myocardium, inward velocity vectors were revealed in the visually akinetic area (V(MVO), -0.85 ± 1.65 cm/s for normal vs. 0.10 ± 1.46 cm/s for akinesia, p < 0.001). At coronary angiography, V(MVO) clearly increased in the ischemic area (V(MVO), -0.88+1.56 cm/s for normal vs. 0.70 + 2.04 cm/s for ischemic area, p < 0.01).
CONCLUSION
Regional wall motion assessment using VVI showed could be used to detect significant ischemia in the patient with acute chest pain at ED.

Keyword

Velocity vector imaging; Emergency department; Chest pain; Wall motion abnormality

MeSH Terms

Chest Pain*
Coronary Angiography
Emergencies*
Emergency Service, Hospital*
Humans
Hypokinesia
Ischemia
Mitral Valve
Myocardium
Prospective Studies
Thorax*

Figure

• 

  Fig. 1 Study flow diagram. Patients meeting the exclusion criteria were countered in the multiple response data. ED: emergency department, ECG: electrocardiogram, CAD: coronary artery disease, STEMI: ST-elevation myocardial infarction, CM: cardiomyopathy, VHD: valvular heart disease, PAH: pulmonary artery hypertension, CAG: coronary angiography.

• 

  Fig. 2 Color M-mode echocardiography map showing velocity (Vel), strain and strain rate (SR) in the short-axis view (left). Time curves of velocity, strain and SR (right). AVC: aortic valve closure, MVO: mitral valve opening.

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  Fig. 3 The receiver operating characteristic curve analysis for detecting ischemia from values in theregional wall motion abnormality. The areas under the curve for Vpeak, peak systolic radial strain, VMVO were 0.791 (p < 0.01, 95% CI 0.690 to 0.830), 0.792 (p < 0.01, 95% CI 0.701 to 0.841), and 0.781 (p < 0.01, 95% CI 0.780 to 0.836), respectively. SR: strain rate, MVO: mitral valve opening, Vel: velocity, AVC: aortic valve closure, PSI: post systolic index, CI: confidence interval.

• 

  Fig. 4 The receiver operating characteristic curve analysis for detecting significant stenosis from values in the visually assessed normal myocardial wall motion. The areas under the curve for Vpeak, peak systolic radial strain, VMVO were 0.661 (p < 0.01, 95% CI 0.591 to 0.720), 0.641 (p < 0.01, 95% CI 0.601 to 0.703), and 0.60 (p < 0.01, 95% CI 0.521 to 0.679), respectively. SR: strain rate, MVO: mitral valve opening, Vel: velocity, AVC: aortic valve closure, PSI: post systolic index, CI: confidence interval.

Reference

1. Selker HP, Beshansky JR, Griffith JL, Aufderheide TP, Ballin DS, Bernard SA, Crespo SG, Feldman JA, Fish SS, Gibler WB, Kiez DA, McNutt RA, Moulton AW, Ornato JP, Podrid PJ, Pope JH, Salem DN, Sayre MR, Woolard RH. Use of the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) to assist with triage of patients with chest pain or other symptoms suggestive of acute cardiac ischemia. A multicenter, controlled clinical trial. Ann Intern Med. 1998; 129:845–855.

2. Pope JH, Aufderheide TP, Ruthazer R, Woolard RH, Feldman JA, Beshansky JR, Griffith JL, Selker HP. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000; 342:1163–1170.

3. Than M, Cullen L, Reid CM, Lim SH, Aldous S, Ardagh MW, Peacock WF, Parsonage WA, Ho HF, Ko HF, Kasliwal RR, Bansal M, Soerianata S, Hu D, Ding R, Hua Q, Seok-Min K, Sritara P, Sae-Lee R, Chiu TF, Tsai KC, Chu FY, Chen WK, Chang WH, Flaws DF, George PM, Richards AM. A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): a prospective observational validation study. Lancet. 2011; 377:1077–1084.

4. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, Picard MH, Roman MJ, Seward J, Shanewise JS, Solomon SD, Spencer KT, Sutton MS, Stewart WJ. Chamber Quantification Writing Group. American Society of Echocardiography's Guidelines and Standards Committee. European Association of Echocardiography. Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr. 2005; 18:1440–1463.

5. Voigt JU, Exner B, Schmiedehausen K, Huchzermeyer C, Reulbach U, Nixdorff U, Platsch G, Kuwert T, Daniel WG, Flachskampf FA. Strain-rate imaging during dobutamine stress echocardiography provides objective evidence of inducible ischemia. Circulation. 2003; 107:2120–2126.

6. Langeland S, D'hooge J, Wouters PF, Leather HA, Claus P, Bijnens B, Sutherland GR. Experimental validation of a new ultrasound method for the simultaneous assessment of radial and longitudinal myocardial deformation independent of insonation angle. Circulation. 2005; 112:2157–2162.

7. Cannesson M, Tanabe M, Suffoletto MS, Schwartzman D, Gorcsan J 3rd. Velocity vector imaging to quantify ventricular dyssynchrony and predict response to cardiac resynchronization therapy. Am J Cardiol. 2006; 98:949–953.

8. Kim DH, Kim HK, Kim MK, Chang SA, Kim YJ, Kim MA, Sohn DW, Oh BH, Park YB. Velocity vector imaging in the measurement of left ventricular twist mechanics: head-to-head one way comparison between speckle tracking echocardiography and velocity vector imaging. J Am Soc Echocardiogr. 2009; 22:1344–1352.

9. Nesto RW, Kowalchuk GJ. The ischemic cascade: temporal sequence of hemodynamic, electrocardiographic and symptomatic expressions of ischemia. Am J Cardiol. 1987; 59:23C–30C.

10. Sasaki H, Charuzi Y, Beeder C, Sugiki Y, Lew AS. Utility of echocardiography for the early assessment of patients with nondiagnostic chest pain. Am Heart J. 1986; 112:494–497.

11. Grenne B, Eek C, Sjøli B, Dahlslett T, Uchto M, Hol PK, Skulstad H, Smiseth OA, Edvardsen T, Brunvand H. Acute coronary occlusion in non-ST-elevation acute coronary syndrome: outcome and early identification by strain echocardiography. Heart. 2010; 96:1550–1556.

12. Kukulski T, Jamal F, Herbots L, D'hooge J, Bijnens B, Hatle L, De Scheerder I, Sutherland GR. Identification of acutely ischemic myocardium using ultrasonic strain measurements. A clinical study in patients undergoing coronary angioplasty. J Am Coll Cardiol. 2003; 41:810–819.

13. Edvardsen T, Gerber BL, Garot J, Bluemke DA, Lima JA, Smiseth OA. Quantitative assessment of intrinsic regional myocardial deformation by Doppler strain rate echocardiography in humans: validation against three-dimensional tagged magnetic resonance imaging. Circulation. 2002; 106:50–56.

14. Urheim S, Edvardsen T, Torp H, Angelsen B, Smiseth OA. Myocardial strain by Doppler echocardiography. Validation of a new method to quantify regional myocardial function. Circulation. 2000; 102:1158–1164.

15. Asanuma T, Masuda K, Taniguchi A, Uranishi A, Ishikura F, Beppu S. Spatial extent of postsystolic thickening during myocardial ischemia: evaluation by velocity vector imaging. J Echocardiogr. 2006; 4:84–85.

16. Claus P, Weidemann F, Dommke C, Bito V, Heinzel FR, D'hooge J, Sipido KR, Sutherland GR, Bijnens B. Mechanisms of postsystolic thickening in ischemic myocardium: mathematical modelling and comparison with experimental ischemic substrates. Ultrasound Med Biol. 2007; 33:1963–1970.

17. Masuda K, Asanuma T, Taniguchi A, Uranishi A, Ishikura F, Beppu S. Assessment of dyssynchronous wall motion during acute myocardial ischemia using velocity vector imaging. JACC Cardiovasc Imaging. 2008; 1:210–220.