Role of echocardiography in acute myocardial infarction
- Neil J Weissman, MD
Neil J Weissman, MD
- Professor of Medicine
- Georgetown University School of Medicine
- Bryan Ristow, MD, FACC, FASE, FACP
Bryan Ristow, MD, FACC, FASE, FACP
- Associate Clinical Professor of Medicine
- University of California, San Francisco
- Nelson B Schiller, MD
Nelson B Schiller, MD
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Medicine and Anesthesia
- University of California, San Francisco
The echocardiogram is a standard tool in the management of patients with acute myocardial infarction (MI). The role of echocardiography in establishing the diagnosis, location, and extent of MI, in diagnosing mechanical complications of infarction, and in providing prognostic information that is important for risk stratification will be reviewed. The use of transthoracic echocardiography for the evaluation of chest pain in the emergency department is discussed separately. (See "Transthoracic echocardiography for the evaluation of chest pain in the emergency department".)
DIAGNOSIS OF MI
The diagnosis of an acute myocardial infarction (MI) is typically based upon the history, electrocardiogram, and cardiac enzymes, particularly serum troponins and creatine kinase MB fraction (CK-MB). (See "Criteria for the diagnosis of acute myocardial infarction".) Although not routinely performed for diagnosis, echocardiography is an accurate, noninvasive test that is able to detect evidence of myocardial ischemia or necrosis.
A 2003 task force update of the 1997 American College of Cardiology, the American Heart Association, and the American Society of Echocardiography (ACC/AHA/ASE) guidelines for echocardiography recommended the use of echocardiography in the diagnosis of suspected acute ischemia or infarction not evident by standard means, but did not recommend echocardiography when the diagnosis was already apparent . Similarly, the 2011 appropriate use criteria for echocardiography classified use of echocardiography in the diagnosis of suspected MI as appropriate .
Evaluation of wall motion while a patient is experiencing chest pain can be useful when the electrocardiogram is nondiagnostic . Evaluation of wall motion may also be useful if there is electrocardiographic or laboratory evidence of MI even in the absence of chest pain . (See "Noninvasive testing and imaging for diagnosis in patients at low to intermediate risk for acute coronary syndrome", section on 'Rest imaging'.)
Severe ischemia produces regional wall motion abnormalities (RWMAs) that can be visualized echocardiographically within seconds of coronary artery occlusion (12±5 and 19±8 seconds in two series of patients evaluated during transient coronary occlusions induced by angioplasty) [3,4]. These changes occur prior to the onset of electrocardiographic changes or the development of symptoms (figure 1) . The RWMAs reflect a localized decrease in the amplitude and rate of myocardial excursion, as well as a blunted degree of myocardial thickening and local remodeling.
- Cheitlin MD, Armstrong WF, Aurigemma GP, et al. ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography). Circulation 2003; 108:1146.
- American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, et al. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance Endorsed by the American College of Chest Physicians. J Am Coll Cardiol 2011; 57:1126.
- Hauser AM, Gangadharan V, Ramos RG, et al. Sequence of mechanical, electrocardiographic and clinical effects of repeated coronary artery occlusion in human beings: echocardiographic observations during coronary angioplasty. J Am Coll Cardiol 1985; 5:193.
- Wohlgelernter D, Cleman M, Highman HA, et al. Regional myocardial dysfunction during coronary angioplasty: evaluation by two-dimensional echocardiography and 12 lead electrocardiography. J Am Coll Cardiol 1986; 7:1245.
- Beller GA. Myocardial perfusion imaging for detection of silent myocardial ischemia. Am J Cardiol 1988; 61:22F.
- Sabia P, Afrookteh A, Touchstone DA, et al. Value of regional wall motion abnormality in the emergency room diagnosis of acute myocardial infarction. A prospective study using two-dimensional echocardiography. Circulation 1991; 84:I85.
- Lang RM, Bierig M, Devereux RB, et al. 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.
- Jeroudi MO, Cheirif J, Habib G, Bolli R. Prolonged wall motion abnormalities after chest pain at rest in patients with unstable angina: a possible manifestation of myocardial stunning. Am Heart J 1994; 127:1241.
- Gerber BL, Wijns W, Vanoverschelde JL, et al. Myocardial perfusion and oxygen consumption in reperfused noninfarcted dysfunctional myocardium after unstable angina: direct evidence for myocardial stunning in humans. J Am Coll Cardiol 1999; 34:1939.
- Weiss JL, Bulkley BH, Hutchins GM, Mason SJ. Two-dimensional echocardiographic recognition of myocardial injury in man: comparison with postmortem studies. Circulation 1981; 63:401.
- Schiller NB, Shah PM, Crawford M, et al. Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of Two-Dimensional Echocardiograms. J Am Soc Echocardiogr 1989; 2:358.
- Cerqueira MD, Weissman NJ, Dilsizian V, et al. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Circulation 2002; 105:539.
- D'Arcy B, Nanda NC. Two-dimensional echocardiographic features of right ventricular infarction. Circulation 1982; 65:167.
- Goldberger JJ, Himelman RB, Wolfe CL, Schiller NB. Right ventricular infarction: recognition and assessment of its hemodynamic significance by two-dimensional echocardiography. J Am Soc Echocardiogr 1991; 4:140.
- Bowles CR, Daves ML. Ramus limbi dextri: demonstration by coronary angiography. Radiology 1985; 155:574.
- Tsuchihashi K, Ueshima K, Uchida T, et al. Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. Angina Pectoris-Myocardial Infarction Investigations in Japan. J Am Coll Cardiol 2001; 38:11.
- Stamm RB, Gibson RS, Bishop HL, et al. Echocardiographic detection of infarct-localized asynergy and remote asynergy during acute myocardial infarction: correlation with the extent of angiographic coronary disease. Circulation 1983; 67:233.
- Heger JJ, Weyman AE, Wann LS, et al. Cross-sectional echocardiography in acute myocardial infarction: detection and localization of regional left ventricular asynergy. Circulation 1979; 60:531.
- Andersen HR, Falk E, Nielsen D. Right ventricular infarction: frequency, size and topography in coronary heart disease: a prospective study comprising 107 consecutive autopsies from a coronary care unit. J Am Coll Cardiol 1987; 10:1223.
- Lorell B, Leinbach RC, Pohost GM, et al. Right ventricular infarction. Clinical diagnosis and differentiation from cardiac tamponade and pericardial constriction. Am J Cardiol 1979; 43:465.
- Arditti A, Lewin RF, Hellman C, et al. Right ventricular dysfunction in acute inferoposterior myocardial infarction. An echocardiographic and isotopic study. Chest 1985; 87:307.
- Young E, Cohn PF, Gorlin R, et al. Vectorcardiographic diagnosis and electrocardiographic correlation in left ventricular asynergy due to coronary artery disease. I. Severe asynergy of the anterior and apical segments. Circulation 1975; 51:467.
- Bogaty P, Boyer L, Rousseau L, Arsenault M. Is anteroseptal myocardial infarction an appropriate term? Am J Med 2002; 113:37.
- Nishimura RA, Reeder GS, Miller FA Jr, et al. Prognostic value of predischarge 2-dimensional echocardiogram after acute myocardial infarction. Am J Cardiol 1984; 53:429.
- Kutty RS, Jones N, Moorjani N. Mechanical complications of acute myocardial infarction. Cardiol Clin 2013; 31:519.
- Smyllie JH, Sutherland GR, Geuskens R, et al. Doppler color flow mapping in the diagnosis of ventricular septal rupture and acute mitral regurgitation after myocardial infarction. J Am Coll Cardiol 1990; 15:1449.
- Recusani F, Raisaro A, Sgalambro A, et al. Ventricular septal rupture after myocardial infarction: diagnosis by two-dimensional and pulsed Doppler echocardiography. Am J Cardiol 1984; 54:277.
- Harpaz D, Shah P, Bezante GP, Meltzer RS. Ventricular septal rupture after myocardial infarction. Detection by transesophageal echocardiography. Chest 1993; 103:1884.
- Lim YJ, Masuyama T, Nanto S, et al. Left ventricular papillary muscle perfusion assessed with myocardial contrast echocardiography. Am J Cardiol 1996; 78:955.
- Nishimura RA, Shub C, Tajik AJ. Two dimensional echocardiographic diagnosis of partial papillary muscle rupture. Br Heart J 1982; 48:598.
- Moursi MH, Bhatnagar SK, Vilacosta I, et al. Transesophageal echocardiographic assessment of papillary muscle rupture. Circulation 1996; 94:1003.
- Burgess J, Clark R, Kamigaki M, Cohn K. Echocardiographic findings in different types of mitral regurgitation. Circulation 1973; 48:97.
- Godley RW, Wann LS, Rogers EW, et al. Incomplete mitral leaflet closure in patients with papillary muscle dysfunction. Circulation 1981; 63:565.
- López-Sendón J, González A, López de Sá E, et al. Diagnosis of subacute ventricular wall rupture after acute myocardial infarction: sensitivity and specificity of clinical, hemodynamic and echocardiographic criteria. J Am Coll Cardiol 1992; 19:1145.
- Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction. www.acc.org/qualityandscience/clinical/statements.htm (Accessed on August 24, 2006).
- Nijland F, Kamp O, Karreman AJ, et al. Prognostic implications of restrictive left ventricular filling in acute myocardial infarction: a serial Doppler echocardiographic study. J Am Coll Cardiol 1997; 30:1618.
- Møller JE, Søndergaard E, Poulsen SH, Egstrup K. Pseudonormal and restrictive filling patterns predict left ventricular dilation and cardiac death after a first myocardial infarction: a serial color M-mode Doppler echocardiographic study. J Am Coll Cardiol 2000; 36:1841.
- Zornoff LA, Skali H, Pfeffer MA, et al. Right ventricular dysfunction and risk of heart failure and mortality after myocardial infarction. J Am Coll Cardiol 2002; 39:1450.
- Moller JE, Hillis GS, Oh JK, et al. Left atrial volume: a powerful predictor of survival after acute myocardial infarction. Circulation 2003; 107:2207.
- Grigioni F, Enriquez-Sarano M, Zehr KJ, et al. Ischemic mitral regurgitation: long-term outcome and prognostic implications with quantitative Doppler assessment. Circulation 2001; 103:1759.
- Møller JE, Hillis GS, Oh JK, et al. Wall motion score index and ejection fraction for risk stratification after acute myocardial infarction. Am Heart J 2006; 151:419.
- Sheehan FH, Doerr R, Schmidt WG, et al. Early recovery of left ventricular function after thrombolytic therapy for acute myocardial infarction: an important determinant of survival. J Am Coll Cardiol 1988; 12:289.
- Solomon SD, Glynn RJ, Greaves S, et al. Recovery of ventricular function after myocardial infarction in the reperfusion era: the healing and early afterload reducing therapy study. Ann Intern Med 2001; 134:451.
- McManus DD, Shah SJ, Fabi MR, et al. Prognostic value of left ventricular end-systolic volume index as a predictor of heart failure hospitalization in stable coronary artery disease: data from the Heart and Soul Study. J Am Soc Echocardiogr 2009; 22:190.
- Haugaa KH, Grenne BL, Eek CH, et al. Strain echocardiography improves risk prediction of ventricular arrhythmias after myocardial infarction. JACC Cardiovasc Imaging 2013; 6:841.
- Meta-Analysis Research Group in Echocardiography (MeRGE) AMI Collaborators, Møller JE, Whalley GA, et al. Independent prognostic importance of a restrictive left ventricular filling pattern after myocardial infarction: an individual patient meta-analysis: Meta-Analysis Research Group in Echocardiography acute myocardial infarction. Circulation 2008; 117:2591.
- Hillis GS, Ujino K, Mulvagh SL, et al. Echocardiographic indices of increased left ventricular filling pressure and dilation after acute myocardial infarction. J Am Soc Echocardiogr 2006; 19:450.
- Perez de Isla L, Zamorano J, Quezada M, et al. Prognostic significance of functional mitral regurgitation after a first non-ST-segment elevation acute coronary syndrome. Eur Heart J 2006; 27:2655.
- DIAGNOSIS OF MI
- LOCATION AND EXTENT OF MI
- - Anteroapical
- - Inferobasal
- - Lateral or free wall
- - Right ventricle
- - Multiple segment
- - Apical ballooning syndrome (takotsubo cardiomyopathy)
- Extent of infarct
- DETECTING COMPLICATIONS AFTER MI
- Mechanical complications
- - VSD
- - Papillary muscle rupture
- - Papillary muscle displacement
- Free wall rupture
- Tricuspid regurgitation
- LV thrombus
- Silent complications
- USE FOR PROGNOSIS
- Left ventricular systolic function
- Left ventricular diastolic function
- Mitral regurgitation
- Residual ischemia
- Other factors