Coronary artery disease
Prognostic Value of Myocardial Contrast Echocardiography in Patients Presenting to Hospital With Acute Chest Pain and Negative Troponin

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We hypothesized that myocardial contrast echocardiography (MCE) could be used to stratify risk in patients with suspected acute coronary syndrome but a nondiagnostic electrocardiogram and negative troponin. Pretest Thrombolysis In Myocardial Infarction (TIMI) scores were determined. Exercise electrocardiographic data in those patients undergoing treadmill stress echocardiography as part of risk evaluation were analyzed independently of echocardiographic data. On a separate day, low-power MCE at rest and during vasodilator stress was performed. All patients were followed for cardiac events (cardiac death, myocardial infarction, and revascularization). Of 148 patients, 27 demonstrated abnormal myocardial contrast echocardiographic results and had higher cardiac event rates compared with those with normal myocardial contrast echocardiographic findings (59% vs 7%, p <0.0001) at follow-up (8 ± 5 months). Hard cardiac event rates (death and nonfatal myocardial infarction) were low (3%) in patients with normal myocardial contrast echocardiographic findings. Cardiac events in patients with abnormal myocardial contrast echocardiographic findings (59%) were significantly higher than those predicted by a high-risk TIMI score (33%, p = 0.0023) and compared with those predicted by high-risk exercise electrocardiography (80% vs 57%, p = 0.0003). In conclusion, stress MCE was superior to TIMI risk score and exercise electrocardiography in the assessment of risk in patients with suspected acute coronary syndrome, nondiagnostic electrocardiogram, and negative troponin.

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Patient selection

Patients were selected from a population who had enrolled in a prospective study investigating risk stratification of patients presenting to the hospital with suspected acute coronary syndrome but with nondiagnostic electrocardiogram and negative troponin. Written informed consent was obtained from all patients, and the study was approved by the local ethics committee.

Study design

The study design is shown in Figure 1. A pretest probability of risk was determined on the basis of individual Thrombolysis In

Results

In total, 148 patients underwent MCE. All patients previously underwent risk stratification with SE. Baseline characteristics are listed in Table 1. Median time to testing from SE was 7 days (96% CI 6 to 8). Patients were assigned a pretest risk on the basis of their individual TIMI scores. Proportions of patients classified as low, intermediate, and high risk were 19%, 75%, and 6%, respectively. Most patients (83%) underwent MCE at rest followed by vasodilator stress with dipyridamole. Of the

Discussion

The present study first confirms the findings of other studies that patients presenting with cardiac risk factors with suspected acute coronary syndrome are still at risk of events despite negative troponin.13, 14, 15 The cardiac event rate over 8 ± 5 months in our study was 17%, and thus further risk stratification is mandatory in this group of patients. TIMI risk score and ExECG are widely used to achieve this and, in particular, to facilitate rapid discharge of patients from the hospital.

References (17)

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The study was supported by a grant from Cardiac Research Fund, Northwick Park Hospital, Harrow, United Kingdom.

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