Importance of Two‐dimensional Echocardiographic Assessment of Left Ventricular Systolic Function in Patients Presenting to the Emergency Room With Cardiac‐Related Symptoms

BackgroundThis prospective study was designed to test the hypothesis that the assessment of left ventricular systolic function at the time of emergency room (ER) presentation provides valuable diagnostic and prognostic information in patients with cardiac-related symptoms. Methods and ResultsThe study is based on a 2-year follow-up of 171 consecutive patients evaluated in the ER for such symptoms. In the course of follow-up, one third of the patients (55 of 171) suffered a major cardiac event. For those with left ventricular systolic dysfunction (LVSD), the age-adjusted rate of early events (occurring within 48 hours of presentation) was more than eight times higher than for those without LVSD (26.9% versus 3.3%, p < 0.01). For events occurring after 48 hours of ER presentation, LVSD was associated with a nearly fourfold excess of cardiac events (23.9% versus 6.4%, p < 0.01). Other than advanced age, the most important confounder for early events included an abnormal electrocardiogram diagnostic for acute myocardial infarction. Confounders for late events included advanced age and a history of hypertension. LVSD on two-dimensional echocardiography (2DE) was the only finding associated with early and late events after controlling for other risk factors. In addition, the prediction of these events derived from the combination of historical, clinical, electrocardiographic, and 2DE findings was significantly improved when accounting for the presence or absence of LVSD (p < 0.01). ConclusionsWe conclude that the 2DE assessment of left ventricular systolic function provides valuable diagnostic and prognostic information in subjects presenting to the ER with cardiac-related symptoms.

[1]  Gruppo Italiano per lo Studio della Soprawivenza nell'Inf Miocardico. MEDICAL SCIENCE GISSI-2: A factorial randomised trial of alteplase versus streptokinase and heparin versus no heparin among 12 490 patients with acute myocardial infarction , 1990, The Lancet.

[2]  C. Visser,et al.  Usefulness of two-dimensional echocardiography for immediate detection of myocardial ischemia in the emergency room. , 1990, The American journal of cardiology.

[3]  GISSI-2: a factorial randomised trial of alteplase versus streptokinase and heparin versus no heparin among 12,490 patients with acute myocardial infarction. Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico. , 1990, Lancet.

[4]  S. Kaul,et al.  Effects of successful intravenous reperfusion therapy on regional myocardial function and geometry in humans: a tomographic assessment using two-dimensional echocardiography. , 1989, Journal of the American College of Cardiology.

[5]  A. M. Skene,et al.  TRIAL OF TISSUE PLASMINOGEN ACTIVATOR FOR MORTALITY REDUCTION IN ACUTE MYOCARDIAL INFARCTION Anglo-Scandinavian Study of Early Thrombolysis (ASSET) , 1988, The Lancet.

[6]  L. Bolognese,et al.  RANDOMISED TRIAL OF INTRAVENOUS STREPTOKINASE, ORAL ASPIRIN, BOTH, OR NEITHER AMONG 17 187 CASES OF SUSPECTED ACUTE MYOCARDIAL INFARCTION: ISIS-2 , 1988, The Lancet.

[7]  E F Cook,et al.  A computer protocol to predict myocardial infarction in emergency department patients with chest pain. , 1988, The New England journal of medicine.

[8]  Aims Trial Study Group EFFECT OF INTRAVENOUS APSAC ON MORTALITY AFTER ACUTE MYOCARDIAL INFARCTION: PRELIMINARY REPORT OF A PLACEBO-CONTROLLED CLINICAL TRIAL , 1988, The Lancet.

[9]  G W Rouan,et al.  Clinical characteristics and natural history of patients with acute myocardial infarction sent home from the emergency room. , 1987, The American journal of cardiology.

[10]  E F Cook,et al.  Sensitivity of routine clinical criteria for diagnosing myocardial infarction within 24 hours of hospitalization. , 1987, Annals of internal medicine.

[11]  J. Oh,et al.  Evaluation of acute chest pain syndromes by two-dimensional echocardiography: its potential application in the selection of patients for acute reperfusion therapy. , 1987, Mayo Clinic proceedings.

[12]  A. Buda,et al.  Comparison of two-dimensional echocardiographic wall motion and wall thickening abnormalities in relation to the myocardium at risk. , 1986, American heart journal.

[13]  J B Newell,et al.  Contrast echocardiography in acute myocardial ischemia. III. An in vivo comparison of the extent of abnormal wall motion with the area at risk for necrosis. , 1986, Journal of the American College of Cardiology.

[14]  J. Salerno Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico (GISSI). , 1986, Lancet.

[15]  F. Wackers,et al.  Use of the initial electrocardiogram to predict in-hospital complications of acute myocardial infarction. , 1986, The New England journal of medicine.

[16]  G. Timmis,et al.  Sequence of mechanical, electrocardiographic and clinical effects of repeated coronary artery occlusion in human beings: echocardiographic observations during coronary angioplasty. , 1985, Journal of the American College of Cardiology.

[17]  E F Cook,et al.  Acute chest pain in the emergency room. Identification and examination of low-risk patients. , 1985, Archives of internal medicine.

[18]  R B D'Agostino,et al.  A predictive instrument to improve coronary-care-unit admission practices in acute ischemic heart disease. A prospective multicenter clinical trial. , 1984, The New England journal of medicine.

[19]  C. Link,et al.  Confidence intervals for the survival function using Cox's proportional-hazard model with covariates. , 1984, Biometrics.

[20]  F. V. Van Capelle,et al.  Infarct size estimation from serial CK MB determinations: peak activity and predictability. , 1983, British heart journal.

[21]  I. Loh,et al.  Early diagnosis of nontransmural myocardial infarction by two-dimensional echocardiography. , 1982, American heart journal.

[22]  Jeffrey A. Stem,et al.  A computer-derived protocol to aid in the diagnosis of emergency room patients with acute chest pain. , 1982, The New England journal of medicine.

[23]  P. W. Lane,et al.  Analysis of covariance and standardization as instances of prediction. , 1982, Biometrics.

[24]  N. Weidner Laboratory diagnosis of acute myocardial infarct: usefulness of determination of lactate dehydrogenase (LDH)-1 level and of ratio of LDH-1 to total LDH. , 1982, Archives of pathology & laboratory medicine.

[25]  A. Weyman Cross-sectional echocardiography , 1982 .

[26]  B. Modan,et al.  Evaluation of electrocardiogram in emergency room as a decision-making tool. , 1977, Chest.

[27]  T. Waterston FLUIDS FOR DIARRHŒA IN YOUNG CHILDREN , 1977, The Lancet.

[28]  D. Harrison,et al.  Patients admitted to the coronary care unit for chest pain: high risk subgroup for subsequent cardiovascular death. , 1977, The American journal of cardiology.

[29]  Beyer,et al.  First electrocardiogram in recent myocardial infarction. , 1976, British medical journal.

[30]  E. Veys,et al.  HL-A AND INFECTIVE SACROILEITIS , 1974 .

[31]  M. Scheinman,et al.  Nondiagnostic electrocardiogram in patients with acute myocardial infarction. Clinical and anatomic correlations. , 1973, The American journal of medicine.

[32]  J. Willis Hurst,et al.  Introduction to electrocardiography , 1973 .

[33]  David R. Cox,et al.  Regression models and life tables (with discussion , 1972 .

[34]  D. Short The earliest electrocardiographic evidence of myocardial infarction. , 1970, British heart journal.

[35]  Strother H. Walker,et al.  Estimation of the probability of an event as a function of several independent variables. , 1967, Biometrika.

[36]  E. Kaplan,et al.  Nonparametric Estimation from Incomplete Observations , 1958 .

[37]  C. Wiggers,et al.  THE EFFECT OF CORONARY OCCLUSION ON MYOCARDIAL CONTRACTION , 1935 .

[38]  J. Wolfowitz,et al.  An Introduction to the Theory of Statistics , 1951, Nature.