J Cardiovasc Ultrasound.  2009 Jun;17(2):40-53. 10.4250/jcu.2009.17.2.40.

Role of Echocardiography in the Emergency Department

• Kim TS
• Youn HJ

• KMID: 2135444
• DOI: http://doi.org/10.4250/jcu.2009.17.2.40

Abstract

Echocardiography can play a key role in the diagnosis, evaluation and triage of patients presenting with acute chest pain in the emergency department, because of its rapid, accurate and repetitive image acquisition. Echocardiography can detect coronary artery disease, complications of acute myocardial infarction, pericardial emergency, acute aortic diseases, and pulmonary embolic events, all of which may cause acute chest pain. Depending on the clinical situation, stress echocardiography or contrast echocardiography may provide additional information. Ongoing technical development of imaging acquisition and analysis in echocardiography will increase its use in the differential diagnosis of acute chest pain.

Keyword

Echocardiography; Emergencies; Chest pain

MeSH Terms

Aortic Diseases
Chest Pain
Coronary Artery Disease
Diagnosis, Differential
Echocardiography
Echocardiography, Stress
Emergencies
Humans
Myocardial Infarction
Triage

Figure

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  Fig. 1 Ischemic cascade: In experimental models, left ventricular regional wall motion abnormalities are detected after the onset of ischemic stress, but before the appearance of ECG changes and subjective symptoms.

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  Fig. 2 17-Segmental analysis of LV walls. 1: basal anterior, 2: basal anteroseptal, 3: basal inferoseptal, 4: basal inferior, 5: basal inferolateral, 6: basal anterolateral, 7: mid anterior, 8: mid anteroseptal, 9: mid inferoseptal, 10: mid inferior, 11: mid inferolateral, 12: mid anterolateral, 13: apical anterior, 14: apical septal, 15: apical inferior, 16: apical lateral, 17: apex.

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  Fig. 3 Typical distributions of the coronary arteries. Some segments are supplied by variable coronary arteries. RCA: right coronary artery, LAD: left coronary artery, LCX: left circumflex artery.

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  Fig. 4 This figure illustrates the myocardial responses to a low dose and a peak dose of dobutamine. As the dobutamine dose is increased, coronary blood flow and contractility of the myocardium increase, and these improve the wall motion of myocardium. In ischemia, coronary artery stenosis prevents sufficient coronary blood flow, resulting in worsening of wall motion at a peak dose of dobutamine. If the myocardium that is akinetic at rest, is viable, myocardial contractility increases continuously with a low dose and a peak dose of dobutamine, indicating no further coronary stenosis after acute coronary artery disease. If the myocardium is viable but the coronary artery is still stenotic after acute coronary artery disease, myocardial wall motion improves initially at a low dose of dobutamine, but worsens with a peak dose. This phenomenon is called a biphasic response. When the myocardium is scarred, no improvement of myocardial wall motion occurs with an escalating dose of dobutamine.

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  Fig. 5 Contrast harmonic imaging from the apical four-chamber view with intravenous microbubbles as the echocardiographic contrast agent. The definition of the left ventricular (LV) endocardial border (dotted line) is more distinguishable by injection of an echocardiographic contrast agent.

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  Fig. 6 Imaging of ventricular septal rupture after myocardial infarction: A transthoracic apical four-chamber view with color Doppler image demonstrates a shunt from the left ventricle (*) to the right ventricle (RV) in a patient with anterior wall myocardial infarction (arrow).

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  Fig. 7 Transesophageal echocardiographic images show the rupture of a papillary muscle and mitral regurgitation (MR) in a patient with acute myocardial infarction. A: In a multiplane four-chamber view (0 degrees with retroflexion of the transducer tip), a ruptured posteromedial papillary muscle (arrow), which is attached to the posterior mitral leaflet prolapses into the left atrium (LA). B: Color Doppler image demonstrates severe mitral regurgitation caused by a rupture of a papillary muscle. LV: left ventricle.

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  Fig. 8 Transthoracic echocardiography examination of a 72-year-old man who had an acute chest pain appeared about 24 hours ago. Initial images {A: parasternal long axis view (left). B: apical four-chamber view (left)} showed an akinesis of LV anterior wall and apex, indicating an acute anterior wall myocardial infarction. After 3 minutes, the echo-free space appeared suddenly, which represented a hemorrhagic pericardial effusion, caused by a rupture of the ventricular free wall {A: parasternal long axis view (right). B: apical four-chamber view (right)}. Arrowheads indicate the possible site of rupture. LV: left ventricle.

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  Fig. 9 A: The wall of the true aneurysm is composed of fibrous tissue and contains elements of the cardiac wall. The true aneurysm represents a wide mouth resulting from a gradual bulge of the involved portion of the wall. B: The pseudoaneurysm occurs when a rupture of the ventricular free wall is contained by overlying, adherent pericardium. Abrupt loss of muscular continuity exists at the ostium of the pseudo-aneurysm. Characteristically, the mouth of a false aneurysm is narrow compared with the width of the fundus.

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  Fig. 10 Transthoracic echocardiographic images show an example of right ventricular (RV) infarction. A: Parasternal views (right: short axis, left: long axis) demonstrates a RV dilatation and RV free wall akinesis. B: Apical four-chamber view shows inferior septal akinesis and right atrial (RA) and RV dilatation. C: The inferior vena cava (IVC) is dilated because of venous congestion.

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  Fig. 11 Two-dimensional echocardiography in an apical four-chamber view shows a mass distinct from the endocardial border and protruding into the left ventricular (LV) cavity (*) in a patient with acute anteroapical wall myocardial infarction.

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  Fig. 12 Transthoracic parasternal long-axis view demonstrates an acute aortic dissection involving the proximal ascending aorta. The image shows intimal flaps (arrow) in the dilated ascending aorta, and not dilated, unaffected descending aorta (*). LV: left ventricle, LA: left atrium.

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  Fig. 13 Transverse transesophageal echocardiographic imaging of descending aorta shows a intimal flap (arrowhead), associated with an acute aortic dissection. An echogenic material, presumed to be a thrombus, is in the false lumen (arrows).

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  Fig. 14 Transthoracic parasternal short axis view at the base of the heart, obtained by tilting the transducer further superiorly. At this level, the great arteries are sectioned transversely. This picture shows a dilated main pulmonary artery (MPA) and a thrombus (arrow) in the bifurcation of the MPA, which extends into the right main branch. Ao: aorta, LPA: left pulmonary artery.

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