Key result
Point-of-care echo findings of RWMA and increased EAT link to significantly higher obstructive CAD rates.
Why the study?
The 2023 ESC guidelines recommend assessing acute chest pain via ECG and serial troponin, leaving it uncertain whether adding initial point-of-care echocardiography improves prediction of obstructive CAD beyond ECG and troponin evaluation alone.
Does initial point-of-care echocardiography improve the prediction of obstructive coronary artery disease over initial ECG and troponin evaluation alone in patients presenting with acute chest pain?
Cohort (n=511)
Single-blind
No
Does initial point-of-care echocardiography improve the prediction of obstructive coronary artery disease over initial ECG and troponin evaluation alone in patients presenting with acute chest pain?
Point-of-care echocardiography assessing regional wall motion abnormalities and epicardial adipose tissue thickness can help re-stratify patients with acute chest pain for obstructive CAD alongside standard ECG and troponin pathways.
RWMA and EAT ≥5.5 mm were associated with obstructive CAD; leaves open whether point-of-care echocardiography improves stratification beyond ECG and troponin.
Background The acute coronary syndrome (ACS) is one of the most common working diagnoses in emergency departments worldwide. The 2023 ESC guidelines for the management of ACS recommend an initial assessment of patients presenting with acute chest pain via electrocardiogram (ECG) and serial troponin assessment, classifying patients into rule-in, rule-out, or observe pathway. Purpose We aimed to evaluate whether an initial point-of-care (POC) echocardiography can improve the prediction of obstructive coronary artery disease (CAD) above initial ECG and troponin evaluation alone. Methods The present analysis is based on the prospective EPIC-ACS study (Epicardial adipose tissue thickness predicts obstructive CAD in ACS patients) of patients presenting with acute chest pain, suggestive of ACS, to the emergency department of our Hospital. Patients with ST-elevation myocardial infarction, haemodynamic instability or known CAD were excluded. A blinded echocardiographer, assessed left ventricular ejection fraction (LVEF, ≥50% or < 50%), regional wall motion abnormalities (yes or no, RWMA), left-atrial diameter in parasternal long axis view, and an epicardial adipose tissue (EAT) thickness of < vs. ≥ 5.5mm. The primary endpoint was defined as the presence of obstructive CAD detected in subsequent invasive coronary angiography. Results Between 2019 and 2020, a total of 511 patients (Age: 57.52 ± 18.1 years; 52% male) were included in this prospective observational cohort study. Among those, 214 were transferred to invasive coronary angiography, of which 97 patients had obstructive CAD requiring revascularization therapy. These patients had RWMA (26.8% vs. 6.1%, p < 0.001) and EAT of ≥ 5.5mm (88.7% vs. 11.3%, p < 0.001) significantly more often. LVEF and left-atrial diameter were not significantly different between patients with vs. without obstructive CAD (LVEF >= 50%: 81.4% vs. 87.7%, p = 0.48, LA-Diameter > 4.5cm: 5.2% vs. 6.3%, p = 0.44). Figure 1 shows the presence of obstructive CAD, stratified by echocardiographic parameters, with normal and abnormal values showing that EAT > 5.5mm was markedly more frequently present in patients with obstructive CAD (p < 0.001, overall). In addition, the presence of RWMA differentiated patients with and without obstructive CAD in the rule-in (76% vs. 40%, p = 0.003) and rule-out (26% vs. 6%, p = 0.028) pathways, while no significant difference was observed in the observe group (p = 0.173). LVEF (rule-in: p = 0.313, observe: p = 0.441, rule-out: p = 0.685) and LA-Diameter (rule-in: p = 0.084, observe: p = 0.832, rule-out: p = 0.531) did not qualify for differentiating. Conclusion POC- echocardiography can help re-stratify patients with acute chest pain in addition to the guideline-recommended rule-in or rule-out pathway. Our results support the frequent use of POC- echocardiography for clinical decision-making in patients presenting with suspected ACS.
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Jurgeleit et al. (2026) conducted a cohort in Acute chest pain suggestive of acute coronary syndrome (ACS) (n=511). Point-of-care (POC) echocardiography (assessing RWMA, EAT thickness ≥5.5mm, LVEF, and LA diameter) vs. Initial ECG and serial troponin evaluation alone / normal echocardiographic parameters was evaluated on Presence of obstructive coronary artery disease (CAD) detected in subsequent invasive coronary angiography (p=<0.001). Point-of-care echocardiography showing RWMA (26.8% vs 6.1%, p<0.001) and EAT ≥5.5mm (88.7% vs 11.3%, p<0.001) identified obstructive CAD significantly more often in acute chest pain patients.
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