Serena Rovida, Jalal El Ali

LEARNING OBJECTIVE

Ultrasound evaluation of chest pain can be easily performed by EPs and can assist in narrowing the differential diagnosis, speed up the decision-making process along with ECG and cardiac markers, and rule-in main cardiac complications in the acute coronary syndrome scenario.

BACKGROUND

The differential diagnosis of patients presenting to the Emergency Department (ED) with chest pain are broad and non-specific (1).

Over the past decades the use of ultrasound has developed into an indispensable first-line test for the cardiac evaluation of symptomatic patients as it helps to expedite the diagnosis at the bedside, to initiate prompt treatment and triage decisions by the Emergency Physician (2, 3).

Whether Point of care ultrasound (POCUS) can help differentiate cardiac from non-cardiac chest pain is still a debated argument in literature as the use of comprehensive echocardiography in patients with chest pain due to suspected acute myocardial ischemia is strongly recommended (3).

Up to date, analysis of left ventricular segmental wall motion is beyond the scope of focused cardiac ultrasonography. Therefore, POCUS should not be used primarily for this purpose, but can contribute to rule-in other main causes of chest pain in the emergency setting (4).

We reported our experience over the period of six months in Emergency Department with three previously healthy middle-aged male patients who presented to Emergency department with sudden onset of chest pain.

This clinical report highlights the contribution of bedside ultrasound in recognizing the presence of further cardiac complications in acute coronary syndrome

CASE REPORT

Three middle-age men (aged 49, 51, 63 years respectively) attended separately our ED with sudden onset of chest pain within the last two hours from presentation.

No dyspnea, palpitations or pain radiation were reported. None of them had significant past medical history or known familiarity for cardiac diseases. Their vital parameters and their physical examinations were overall unremarkable.

While waiting for the ECG to be recorded an Emergency Physician (EP) performed a Cardiac POCUS at the triage. All the examinations revealed a focal regional asynergy of left ventricular wall motion, without signs of pericardial effusion, dilated chambers or widened aorta root.

Two out of three patients had related ECG abnormalities, while the third one had a non-diagnostic normal ECG. No previous ECG to compare with were available. Prior to blood results a cardiologist was consulted and patients were transferred to Cardiac Unit for an acute Percutaneous Coronary Intervention.

The segmental wall motion abnormalities seen by POCUS earlier corresponded closely with coronary artery territories occluded. The Troponin series showed a positive curve afterwards.

DISCUSSION

Chest pain is a common complaint among patients presenting to the ED and bedside ultrasound is the most rapid imaging approach that can shorten the time needed to formulate an accurate and real time diagnosis.

Despite POCUS indication for coronary syndrome is debated, together with ECG changes and clinical history, it could strongly help physician to emphasize this hypothesis in a broad spectrum of diagnosis.

Nonetheless, its real time results at bedside facilitate ruling in other major causes of chest pain in adult patients presenting to ED such as pericardial effusion, tamponade and left ventricular global dysfunction.

CONCLUSION

Ultrasound evaluation of chest pain is a rapid and clinically useful bedside investigation that can be easily performed by EPs and can assist in narrowing the differential diagnosis, speed up the decision-making process along with ECG and cardiac markers and role in main cardiac complications in a specific situation such as acute coronary syndrome when time for an acute intervention really matters given the importance of early reperfusion.

REFERENCES

(1) Zanobetti M, Scorpiniti M, Gigli C, et al. Point-of-care ultrasonography for evaluation of acute dyspnea in the ED. Chest. 2017;151(6):1295- 1301.

(2) Nishigami K. Point-of-care echocardiography for aortic dissection, pulmonary embolism and acute coronary syndrome in patients with killer chest pain: EASY screening focused on the assessment of effusion, aorta, ventricular size and shape and ventricular asynergy. J Echocardiogr. 2015;134(4):141-144.

(3) Labovitz AJ, Noble VE, Bierig M, et al. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr. 2010;23(12): 1225-1230.

(4) Point-of-Care Ultrasonography for Acute Coronary Syndrome Rule This in or Rule Out Others? Li-Ta Keng. Department of Internal Medicine, Nation Taiwan University Hospital Hsinchu Branch, Hsinchu City, Taiwan. Chest. 2017;152(63):688.