The Use of Cardiac Imaging in Acute Coronary Syndrome

Clinical presentation of Acute Coronary Syndrome (ACS) varies from the widely known heart attack, unstable electricity to hemodynamically unstable cardiogenic shock due to ischemic or mechanical complications. Patients usually present complaining chest pain, pressure-like pain, or burning sensation but they may also have other symptoms such as dyspnea, epigastric pain, and left arm pain.

Clinical Manifestation Diagnosing ACS can be difficult because it may present with atypical signs and symptoms. Even the most classic presentation of ischemic angina may actually be a pulmonary embolism, aortic dissection, or other life-threatening conditions. Vital signs measurement and initial assessment is the first step approach for these patients. History taking and physical examination should focus on breath and heart sounds, neck vein distention, and peripheral circulation to decide or eliminate timely sensitive diagnoses like tension pneumothorax and pericardial tamponade. The main concern of patients with chest pain is risk stratification. Being able to stratify the risk accurately helps to decide the next step needed to manage the patient appropriately.

Cardiac MR Imaging Magnetic resonance imaging (MRI) evaluation for ACS patients can be undergone to evaluate chest pain prior to reperfusion, early after reperfusion, and late after perfusion. In patients presenting with suggestive symptoms of ACS, negative serum biomarkers, and non-specific changes in EKG, heart imaging can be done in emergency room or after discharge from emergency room. In low-risk factor patients, MRI has the benefit to determine the myocardial function, perfusion, and viability in one session. Imaging also helps to eliminate other causes of acute chest pain, including myocarditis, aortic dissection, aortic stenosis, and cardiomyopathy. In low-risk group, angiography computed tomographic (CT) proved to be a valuable diagnostic tool to evaluate coronary artery integrity and eliminate pulmonary embolism and aorta dissection.

Imaging in the early presentation of STEMI is usually not necessary and can be limited to emergency echocardiography to evaluate myocardial function.

Early after the first reperfusion medication (in the first week), all patients should undergo non-invasive heart imaging (e.g. MRI, nuclear imaging, ECG) to identify the risk of recurrent heart events. In this phase, heart MRI can accurately evaluate many imaging parameters, including regional myocardial dysfunction, infarct distribution, infarct size, myocardium risk (edema), microvascular obstruction (MVO), and intramyocardial bleeding. The accurate evaluation of these parameters will help as additional prognostic value above traditional stratification risk method, including left ventricle ejection fraction with echocardiography, estimated infarct size, and TIMI risk score. Around 4-6 weeks after reperfusion, further imaging evaluation are usually needed for geriatric patients, patients with anterior infarct, previous infarct, vascular diseases, longer ischemic time, or heart failure. MRI end phase is used to evaluate end infarct size, and MRI stress is recommended to determine ischemia. The table below shows cardiac MRI protocol for patients with ACS post-early reperfusion.

  1. Collet, J.P., Thiele, H., Barbato, E, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2020; 42.
  2. Hamilton, B., Kwakyi, E., Kofyan, A, et al. Diagnosis and management of acute coronary syndrome. Afr J Emerg Med. 2013.
  3. Saremi, F. Cardiac MR imaging in acute coronary syndrome: application and image interpretation. 2016.

Written by: I Ketut Suarthaputra Pratama, S.Ked, Azhar Rafiq, S.Ked
The writer is currently on his clerkship as a final year of co-assistant in West Nusa Tenggara Central Hospital, Universitas Mataram, West Nusa Tenggara. He has been actively writing on Medical Subject.

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The Use of Cardiac Imaging in Acute Coronary Syndrome

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