Predictive value of noninvasive myocardial work indices in guiding revascularization of associated intermediate non culprit coronary lesions in acute coronary syndromes patients

Background A significant proportion of patients with acute coronary syndromes (ACS) present with multivessel disease. In such cases, staged revascularization of both culprit and non-culprit lesions reduces adverse events. Intermediate coronary lesions (40–70% diameter stenosis) are particularly challenging to assess. While fractional flow reserve (FFR) is a validated standard for determining lesion significance, its widespread use is hindered by cost and invasiveness. Recently, noninvasive myocardial work (MW) indices derived from speckle tracking echocardiography (STE) and blood pressure measurements have emerged as promising tools for evaluating myocardial efficiency and ischemia. Aim To evaluate the predictive accuracy of regional MW indices—namely regional work index (RWI) and regional work efficiency (RWE)—in identifying functionally significant intermediate coronary lesions compared to FFR (reference standard) and optical coherence tomography (OCT) findings. Methods We prospectively studied 123 patients with a first ACS, admitted within 7 days, with at least one non-culprit lesion (40–70% stenosis) and no wall motion abnormalities outside the culprit territory. Patients underwent FFR, OCT, and PCI (if indicated) for non-culprit lesions. Echocardiographic assessment with 2D STE was performed 2–7 days post-ACS, calculating regional MW indices based on the 17-segment AHA model. Revascularization decisions guided by FFR <0.80 and OCT served as reference standards. ROC curve analysis was performed using SPSS v26. Results After excluding patients with left main disease or complex multilevel stenoses, 93 patients with 129 intermediate lesions were included (LAD: 76; LCX: 28; RCA: 25). A total of 89 lesions (69%) were revascularized. In the LAD territory, RWI showed a good predictive value for revascularization at a cutoff of 1180 mmHg% (sensitivity: 88%, specificity: 85%; AUC = 0.67, p = 0.05). RWE <90% in LAD had similar performance (Sn: 87%, Sp: 94%; AUC = 0.66, p = 0.022). In the RCA territory, RWI <1163 mmHg% predicted revascularization with 80% sensitivity but lower specificity (53%; AUC = 0.66, p = 0.05). RWE <88% also had borderline significance (AUC = 0.58, p = 0.05). MW indices in the LCX territory did not reach statistical significance. Overall, LAD-specific MW indices outperformed those for RCA and LCX in predicting the need for revascularization. Conclusions In ACS patients, noninvasive regional MW indices obtained via STE show predictive value for identifying functionally significant intermediate coronary lesions, particularly in the LAD territory, guiding the decision for revascularisation . If validated, these findings may support the use of MW parameters as a feasible noninvasive alternative aiding in personalised revascularisation strategies. to invasive FFR, aiding in tailored revascularization strategies.