EXPEDITED REVIEW
Myocardial Contrast Echocardiography Versus Thrombolysis in Myocardial Infarction Score in Patients Presenting to the Emergency Department With Chest Pain and a Nondiagnostic Electrocardiogram
Khim Leng Tong, MD*,
Sanjiv Kaul, MD, FACC*,
Xin-Qun Wang, MS ,
Diana Rinkevich, MD, FACC*,
Saul Kalvaitis, MD*,
Todd Belcik, RDCS*,
Wolfgang Lepper, MD*,
William A. Foster, MD* and
Kevin Wei, MD, FACC*,*
* Cardiovascular Imaging Center, Cardiovascular Division
Division of Biostatistics and Epidemiology, Department of Health Evaluation Sciences, University of Virginia School of Medicine, Charlottesville, Virginia
Manuscript received May 6, 2004;
revised manuscript received March 27, 2005,
accepted March 29, 2005.
* Reprint requests and correspondence: Dr. Kevin Wei, Cardiovascular Division, OHSU, UHN62, SW Sam Jackson Park Road, Portland, Oregon 97239 (Email: weik{at}OHSU.edu).
Presented in part at the Samuel Levine Young Investigator Award Competition at the 77th Annual Scientific Session of the American Heart Association, New Orleans, Louisiana. Drs. Kaul and Wei are currently located at the Cardiovascular Division, OHSU, Portland, Oregon.
OBJECTIVES: We hypothesized that regional function (RF) and myocardial perfusion (MP) are superior to the Thrombolysis In Myocardial Infarction (TIMI) score for diagnosis and prognostication in patients presenting to the emergency department (ED) with chest pain (CP) and a nondiagnostic electrocardiogram.
BACKGROUND: Rapid diagnosis and prognostication is difficult in patients presenting to the ED with suspected cardiac CP.
METHODS: Contrast echocardiography was performed to assess RF and MP on 957 patients presenting to the ED with suspected cardiac CP and a nondiagnostic electrocardiogram. A modified TIMI (mTIMI) score was calculated from six immediately available variables. A full TIMI score also was derived after troponin levels were able to be accessed adequately. Follow-up was performed for early (within 24 h), intermediate (30 day), and late primary (death and myocardial infarction) or secondary (unstable angina and revascularization) events.
RESULTS: The mTIMI score was unable to discriminate between intermediate- compared to high-risk patients at any follow-up time point, whereas only 2 of 523 patients with normal RF had an early primary event. Regional function provided incremental prognostic value over mTIMI scores for predicting intermediate and late events. In patients with abnormal RF, MP further classified patients into intermediate- and high-risk groups. The full TIMI score could not improve upon these results at any follow-up time point.
CONCLUSIONS: Contrast echocardiography can rapidly and accurately provide short-, intermediate-, and long-term prognostic information in patients presenting to the ED with suspected cardiac CP even before serum cardiac markers are known. Integrating contrast echocardiography into the ED evaluation of CP may improve the risk stratification of such patients.
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Abbreviations and Acronyms
| | AMI = acute myocardial infarction | | CE = contrast echocardiography | | CP = chest pain | | ECG = electrocardiogram | | ED = emergency department | | LV = left ventricular | | MP = myocardial perfusion | | mTIMI = modified Thrombolysis In Myocardial Infarction | | RF = regional function | | TIMI = Thrombolysis In Myocardial Infarction |
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