CHAPTER 7: Coronary Artery Disease

The “bread and butter” of adult cardiology is coronary artery disease.

INTRODUCTION

“Look locally—interpret globally.”

• Regional left ventricular wall motion analysis is the cornerstone of echocardiographic imaging in coronary artery disease.

• Regional left ventricular wall motion abnormalities are indicators of myocardial ischemia during a stress test.

• Regional left ventricular wall motion abnormalities are present in acute myocardial infarction.

• In addition to localizing myocardial infarction, echocardiography serves to diagnose complications of infarction.

• Anterior myocardial infarction can be complicated by an apical left ventricular aneurysm.

• Inferior myocardial infarction can be complicated by mitral regurgitation.

• Pulmonary edema and a new murmur, in a patient with myocardial infarction, may indicate either papillary muscle rupture or ventricular septal rupture. Echocardiography helps to identify these critical complications.

• Right ventricular infarction is an important complication of inferior myocardial infarction, and echocardiography is used for diagnosis and subsequent management.

• The electrocardiogram is utilized in conjunction with the echocardiogram in all patients with coronary artery disease.

• Basic roles of echocardiography:

  • - Regional left ventricular wall motion analysis.

  • - Stress testing for myocardial ischemia.

  • - Complications of myocardial infarction.

  • - Differential diagnosis of chest pain.

ROLE OF ECHO IN ACUTE MYOCARDIAL INFARCTION

• The decision for initiating treatment in acute ST-elevation myocardial infarction is made quickly and is based on the ECG and cardiac symptoms.

• The echocardiogram serves to help exclude alternative diagnoses for the cause of chest pain, such as aortic dissection or pericarditis.

• The echocardiogram can help diagnose the following complications of myocardial infarction:

  • - Apical left ventricular aneurysm in anterior myocardial infarction.

  • - Apical left ventricular thrombus.

  • - Basal inferior aneurysm.

  • - Mitral regurgitation and/or papillary muscle rupture.

  • - Ventricular septal rupture.

  • - Left ventricular pseudoaneurysm (ventricular rupture into the pericardial space).

  • - Right ventricular infarction.

Source

• Marangelli V, Cacciavillani L, Pontarollo S, et al. Images in cardiovascular medicine. Three-dimensional imaging in rupture of papillary muscle after acute myocardial infarction. Circulation. 2005;111:e385–e387.

LOCALIZED REGIONAL VS DIFFUSE ST-SEGMENT ABNORMALITIES

• The role of echocardiography in coronary artery disease centers on regional wall motion analysis of the left ventricle.

• The ECG of myocardial infarction is complemented by regional left ventricular wall motion on echo to help localize and to define extent of infarction.

• Both the ECG and the echocardiogram serve to localize the affected territory in coronary artery disease.

• In contrast, the ECGs of pericarditis and myocarditis show diffuse ST-segment abnormalities.

• The echocardiogram helps to distinguish between myocarditis and pericarditis.

• There should be diffuse left ventricular motion abnormalities, as well as left ventricular cavity dilatation, on the echocardiogram of patients with myocarditis.

• There should be a pericardial effusion on the echocardiogram of patients with pericarditis.

• Caution: Pericarditis and myocarditis are not always mutually exclusive. Elevated troponins in pericarditis may indicate coexisting myocarditis.

Source

• Wang ...