School of Medicine and Health Sciences Poster Presentations

Title

Risk Stratification of Chest Pain Patients in the Emergency Department by Assessing Diastolic Function Using Tissue Doppler Imaging of Left Ventricular Wall Segments

Poster Number

141

Document Type

Poster

Status

Medical Student

Abstract Category

Cardiology/Cardiovascular Research

Keywords

Cardiology, Emergency Medicine, Echocardiography, Tissue Doppler Imaging

Publication Date

Spring 2018

Abstract

BACKGROUND

Chest pain is one of the most common chief complaints seen within emergency departments (ED). Diagnostic tests are therefore key to parsing out high risk and low risk chest pain patients. Tissue Doppler Imaging (TDI) is a means of assessing myocardial tissue motion in order to assess the function of the myocardium. Specifically, TDI can detect impaired relaxation of the heart during early diastole, which precedes ischemic changes on electrocardiogram (EKG) and ischemic systolic wall dysfunction on echocardiography. In this proof-of-concept study, we propose that the use of TDI in the ED can function as an objective tool allowing emergency providers to more accurately stratify chest pain patients into high-risk and low-risk groups.

METHODS

Early diastolic left ventricular wall movement (E’) was measured in a total of 60 patients using the TDI method at the medial, lateral, anterior, and posterior/inferior mitral annulus. Normal tissue velocity was defined as >9 cm/s for the lateral, anterior, and posterior/inferior walls, and a septal wall speed of >7 cm/s. Studies were performed by two independent operators. Patients with one or more abnormal TDI value by either echocardiographer were considered positive for an abnormal study. The results of the study were compared to a diagnosis of ischemic chest pain determined by the gold standard cardiac workup including EKG findings, HEART score for major cardiac events, troponin levels, stress test, and any further intervention.

RESULTS

The specificity of TDI for detecting ischemic causes was 72.55% (95% CI of 58.02-83.67) with a sensitivity of 100% (95% CI of 39.60-100.00). In addition, the test demonstrated a positive predictive value (PPV) of 22.22% (95% CI of 7.37-48.10) and a negative predictive value (NPV) of 1 (95% CI of 88.29-100.00). Likelihood ratios were calculated as a positive likelihood ratio of 3.64 (95% CI of 2.33-5.70) and a negative likelihood ratio of 0.

CONCLUSION

This proof-of-concept study demonstrated a high specificity and sensitivity for detecting ischemic causes of chest pain and can serve as an adjunct to the current standard chest pain workup and aid in decision making. The study does not imply that TDI can replace other modalities of current chest pain workup. Further studies are needed to investigate the limitations of TDI as well as its indications in the management of patients presenting to the ED with chest pain.

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Risk Stratification of Chest Pain Patients in the Emergency Department by Assessing Diastolic Function Using Tissue Doppler Imaging of Left Ventricular Wall Segments

BACKGROUND

Chest pain is one of the most common chief complaints seen within emergency departments (ED). Diagnostic tests are therefore key to parsing out high risk and low risk chest pain patients. Tissue Doppler Imaging (TDI) is a means of assessing myocardial tissue motion in order to assess the function of the myocardium. Specifically, TDI can detect impaired relaxation of the heart during early diastole, which precedes ischemic changes on electrocardiogram (EKG) and ischemic systolic wall dysfunction on echocardiography. In this proof-of-concept study, we propose that the use of TDI in the ED can function as an objective tool allowing emergency providers to more accurately stratify chest pain patients into high-risk and low-risk groups.

METHODS

Early diastolic left ventricular wall movement (E’) was measured in a total of 60 patients using the TDI method at the medial, lateral, anterior, and posterior/inferior mitral annulus. Normal tissue velocity was defined as >9 cm/s for the lateral, anterior, and posterior/inferior walls, and a septal wall speed of >7 cm/s. Studies were performed by two independent operators. Patients with one or more abnormal TDI value by either echocardiographer were considered positive for an abnormal study. The results of the study were compared to a diagnosis of ischemic chest pain determined by the gold standard cardiac workup including EKG findings, HEART score for major cardiac events, troponin levels, stress test, and any further intervention.

RESULTS

The specificity of TDI for detecting ischemic causes was 72.55% (95% CI of 58.02-83.67) with a sensitivity of 100% (95% CI of 39.60-100.00). In addition, the test demonstrated a positive predictive value (PPV) of 22.22% (95% CI of 7.37-48.10) and a negative predictive value (NPV) of 1 (95% CI of 88.29-100.00). Likelihood ratios were calculated as a positive likelihood ratio of 3.64 (95% CI of 2.33-5.70) and a negative likelihood ratio of 0.

CONCLUSION

This proof-of-concept study demonstrated a high specificity and sensitivity for detecting ischemic causes of chest pain and can serve as an adjunct to the current standard chest pain workup and aid in decision making. The study does not imply that TDI can replace other modalities of current chest pain workup. Further studies are needed to investigate the limitations of TDI as well as its indications in the management of patients presenting to the ED with chest pain.