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10.1136/bmjopen-2024-085677
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Original Research
Cardiovascular Medicine
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Regional wall motion abnormalities on focused transthoracic echocardiography in patients presenting with acute chest pain: a predefined post hoc analysis of the prospective single-centre observational EPIC-ACS study
http://orcid.org/0000-0002-3095-9488
Roggel Anja 1anja.roggel@uk-essen.de

Jehn Stefanie 1stefanie.jehn@uk-essen.de

Dykun Iryna 1iryna-dykun@uk-essen.de

Balcer Bastian 1bastian.balcer@uk-essen.de

Al-Rashid Fadi 1Fadi.AlRashid@joho-dortmund.de

Totzeck Matthias 1Matthias.Totzeck@uk-essen.de

Risse Joachim 2Joachim.Risse@uk-essen.de

Kill Clemens 2clemens.kill@uk-essen.de

https://twitter.com/TRassafMD
Rassaf Tienush 1Tienush.Rassaf@uk-essen.de

http://orcid.org/0000-0003-2336-7991
Mahabadi Amir 1Amir-Abbas.Mahabadi@uk-essen.de

1 Department of Cardiology and Vascular Medicine, University Hospital Essen, Essen, Germany
2 Center of Emergency Medicine, University Hospital Essen, Essen, Germany
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

None declared.

Dr; Amir-Abbas.Mahabadi@uk-essen.de
2024
10 9 2024
14 9 e08567726 2 2024
26 7 2024
Copyright © Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
2024
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Abstract

Objectives

We evaluated the ability of the assessment of regional wall motion abnormalities (RWMA) detected via transthoracic echocardiography to predict the presence of obstructive coronary artery disease (CAD) in patients presenting with acute chest pain to the emergency department.

Design

Prospective single-centre observational study.

Setting

Tertiary care university hospital emergency unit.

Participants

Patients presenting to the emergency department with acute chest pain suggestive of obstructive CAD.

Primary outcome measure

The primary endpoint was defined as the presence of obstructive CAD, requiring revascularisation therapy.

Results

Overall, 657 patients (age 58.1±18.0 years, 53% men) were included in our study. RWMA were detected in 76 patients (11.6%). RWMA were significantly more frequent in patients reaching the primary endpoint (26.2% vs 7.6%, p<0.001). In multivariable regression analysis, the presence of RWMA was associated with threefold increased odds of the presence of obstructive CAD (3.41 (95% CI 1.99 to 5.86), p<0.001). Adding RWMA to a multivariable model of the Thrombolysis in Myocardial Infarction (TIMI) risk score, cardiac biomarkers and traditional risk factors significantly improved the area under the curve for prediction of obstructive CAD (95% CI 0.777 to 0.804, p=0.0092).

Conclusion

RWMA strongly and independently predicts the presence of obstructive CAD in patients presenting with acute chest pain to the emergency department.

Trial registration

The study has been registered online (NCT03787797).

Coronary heart disease
Echocardiography
Coronary intervention
http://dx.doi.org/10.13039/501100010068 Medizinische Fakultät, Universität Duisburg-Essen http://dx.doi.org/10.13039/501100001659 Deutsche Forschungsgemeinschaft DY149/2
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pmcStrengths and limitations of this study

This analysis is a predefined post hoc analysis of the prospective observational Epicardial adipose tissue thickness PredIcts obstructive Coronary artery disease in Acute Coronary Syndrome study.

Strength of the study include the prospective design and the blinded echocardiography assessment.

Limitation includes the single-centre study design.

Introduction

Current guidelines for acute coronary syndromes suggest initial risk stratification of patients presenting with acute chest pain to the emergency department for rule-in and rule-out of acute myocardial infarction based on clinical symptoms, ECG and cardiac biomarkers.13 In addition to those routinely assessed characteristics, cardiac imaging offers incremental value to confirm or refuse the diagnosis of coronary artery disease (CAD).4 5 In particular, transthoracic echocardiography is a routinely available non-invasive diagnostic imaging modality in the emergency department.6 Besides the detection of alternative pathologies associated with chest pain, echocardiography can screen for regional wall motion abnormalities (RWMA) as a sign of myocardial ischaemia or necrosis.7 8 RWMA are often the first clinically evident sign of acute cardiac ischaemia, even before chest pain or ECG changes occur.9 Regardless, echocardiography is only performed in 25% of patients in the emergency department with issues suggestive of acute coronary syndrome.10 Current European Society of Cardiology (ESC) guidelines for acute coronary syndromes suggest performing a transthoracic echocardiography in patients with inconclusive initial electrocardiography and cardiac enzymes with a level C recommendation.1 11 This underlines the need for studies, evaluating the value of focused echocardiography-derived assessment of RWMA to predict the presence of obstructive CAD in the workup of patients with acute chest pain.

The present predefined post hoc analysis of the prospective observational Epicardial adipose tissue thickness PredIcts obstructive Coronary artery disease in Acute Coronary Syndrome patients (EPIC-ACS) study aims to evaluate the ability of RWMA as assessed via bedside transthoracic echocardiography to predict the presence of obstructive CAD in patients presenting with acute chest pain to the emergency department and to improve diagnostic algorithms of patients with suspected acute coronary syndrome.

Patients and methods

Study sample

The present analysis represents a predefined post hoc analysis of the EPIC-ACS study (Epicardial adipose tissue thickness PredIcts obstructive Coronary artery disease in Acute Coronary Syndrome patients) of consecutive patients presenting with acute chest pain suggestive of acute coronary syndrome (ACS) to the emergency department of the University Hospital Essen. Details on the study have been described previously.12 13 In brief, patients were enrolled between December 2018 and August 2020. Patients with a history of established CAD and prior revascularisation therapy were excluded from this analysis. Further exclusion criteria were ST-segment elevation, myocardial infarction, haemodynamic instability, age <18 years, pregnancy and unwillingness or inability to provide informed consent. All participants gave written informed consent.

Assessment of regional wall motion abnormalities

As part of the study protocol, all patients underwent focused bedside echocardiography evaluation by dedicated study physicians, blinded to the patient’s anamnesis, clinical presentation, ECG and laboratory results. Two-dimensional transthoracic echocardiography was performed using standard echocardiography systems without the use of specific applications (Philips CX50 or Philips Sparq system, Philips Healthcare, Best, the Netherlands). Echocardiographic examination was performed in parasternal short-axis and long-axis as well as in apical four-chamber, two-chamber and three-chamber view. An RWMA was defined by decreased contraction of a region of the myocardium in comparison to the rest of the myocardium.14 In addition, left ventricular ejection fraction (LVEF) was determined by visual interpretation and was categorised in LVEF ≥50%, 41–49% and ≤40%.

Endpoint definition

The primary endpoint was specified as the presence of obstructive CAD, defined as the detection of obstructive CAD with the need for revascularisation therapy (percutaneous coronary intervention/stent or coronary bypass operation) by conventional coronary angiography. All coronary angiography examinations within 90 days after the initial presentation to the emergency room were evaluated. The indication for coronary angiography and revascularisation therapy was as per discretion of the treating physicians or interventional cardiologists. Decisions were based on angiographic findings, intravascular ultrasound (Philips IntraSight, Best, the Netherlands), optical coherence tomography (Infinity OCT system, Medtronic, Dublin, Ireland) and/or functional measurements (instantaneous wave-free ratio, fractional flow reserve, Philips IntraSight, Best, the Netherlands).

Covariate assessment

Covariates and risk factors were assessed at the time of the patient’s enrolment. The patient’s age, sex, as well as the duration of chest discomfort and Killip-class were recorded. Height and weight were assessed. Based on height and weight, the body mass index (BMI) was calculated as weight, divided by the square of height. Heart rate, systolic and diastolic blood pressure were measured at time point of inclusion. Traditional cardiovascular risk factors including known diabetes mellitus, hypertension, hyperlipidaemia, smoking status and family history of premature CAD were assessed by standardised questioners. Additionally, prior medication of aspirin, adenosine diphosphate-glucose receptor-antagonists (P2Y12-antagonists), antihypertensive, lipid-lowering and anti-diabetic therapy was recorded. The initial ECG was analysed for the presence of ST-segment elevation/depression (≥0.5 mm) and left bundle branch block (LBBB). Laboratory evaluation included assessment of cardiac markers including troponin, creatine kinase (CK), myoglobin and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) as well as total-cholesterol, low-density lipoprotein-cholesterol, high-density lipoprotein-cholesterol, triglycerides, creatinine and haemoglobin. After the inclusion of the first 147 patients a new high-sensitive Troponin I (Siemens Atellica, Erlangen, Germany) was introduced at our site in addition to a contemporary high-sensitive Troponin I (Siemens Advia Centaur, Erlangen, Germany). Non-ST-elevation myocardial infarction (NSTEMI) was defined in accordance to current guidelines based on symptoms and increase or fall in cardiac troponin level with at least on value over the 99th percentile of healthy individuals.1 Established risk scores like the Global Registry of Acute Coronary Events (GRACE) and the Thrombolysis in Myocardial Infarction (TIMI) risk scores were calculated.15 16

Statistical analysis

Continuous variables are presented as mean±SD or median and IQR, categorical variables as n (%). Baseline characteristics for patients with versus without detectable RWMA were compared using two-sided t-test or Man-Whitney U test for continuous variables and χ2-test for discrete variables. Univariate and multivariable linear regression analysis were performed for the association of RWMA with the presence of obstructive CAD. The following adjustment sets were used: model (1) unadjusted; model (2) adjusted for traditional cardiovascular risk factors (age, gender, BMI, family history of CAD, smoking status, hypercholesterolaemia, diabetes, systolic blood pressure); model (3) GRACE risk score; (4) GRACE risk score plus BMI, hypercholesterolaemia, family history of CAD, diabetes, smoking; and model (5) model 4 plus CK and myoglobin. Sensitivity analyses were performed using TIMI risk score instead of GRACE risk score and using subgroups of patients with available hs-troponin as well as patients receiving coronary angiography. Subgroup analysis was performed stratifying by patients with rule-in/out or observe of acute myocardial infarction. According to the current ESC guidelines for ACSs rule-in included patients with a high baseline value or patients with a 1-hour increase/decrease of high-sensitive cardiac troponin. Patients with a low baseline hs-troponin and without a relevant increase within 1 hour were considered as ruled out of acute myocardial infarction, while patients qualifying for neither the rule in nor the rule out the group were categorised into the observe group.1 The association of traditional cardiovascular risk factors and the presence of RWMA was assessed using logistic regression analysis. Effect sizes were depicted per each SD. The predictive accuracy of RWMA in addition to a multivariable model containing risk scores, cardiac biomarkers and traditional risk factors were evaluated using receiver operating characteristic analysis and quantified by the area under the curve (AUC). Subgroup analyses were assessed stratifying by age groups (<60, ≥60 years), sex, BMI groups (<25, 25–30, ≥30 kg/m²) and presence/absence of traditional cardiovascular risk factors including hypertension, hypercholesterolaemia, diabetes, smoking and family history of premature CAD, for the association of RWMA with the presence of obstructive CAD. All analyses were performed using SAS software (V.9.4, SAS Institute). A p value of <0.05 was considered as statistically significant.

We used the Standards for Reporting Diagnostic Accuracy (STARD) checklist when writing our report.17

Participant involvement

Patients or the public were not involved in the design, conduct, reporting or dissemination plans of our research.

Results

A total of 657 patients (mean age 58.1±18.0 years, 53.0% men) were included in our analysis. RWMA were detected in 76 patients (11.6%) by transthoracic echocardiography. Patients with RWMA were older, had higher blood pressure, higher levels of cardiac biomarkers, NT-proBNP, creatinine and were more frequently diagnosed with NSTEMI. In addition, LBBB was more frequently present in patients with RWMA. Detailed baseline and clinical data for the overall cohort as well as for patients with and without RWMA are presented in table 1.

Table 1 Baseline characteristics

	Overall cohort (n=657)	No RWMA (n=581)	RWMA (n=76)	P value	
Demographics	
 Age (years)	58.1±18.0	56.9±18.2	66.9±13.9	<0.001	
 Male	349 (53.0)	304 (52.3)	45 (59.2)	0.27	
Laboratory parameters	
 Troponin initial (ng/L)	6.0 (6.0–19.0)	6.0 (6.0–15.0)	18.5 (6.0–91.5)	<0.001	
 Troponin hs initial (ng/L)	5.0 (3.0–15.0)	4.0 (3.0–11.0)	18.0 (4.0–306.0)	<0.001	
 CK (U/L)	105.0 (67.0–153.0)	105.0 (67.0–153.0)	96.5 (61.0–154.0)	0.3673	
 CK-MB (U/L)	27.0 (19.0–43.0)	25.0 (18.0–37.0)	46.0 (28.0–128.0)	0.0023	
 Myoglobin (µg/dL)	54.0 (37.0–82.0)	52.0 (36.0–80.0)	65.0 (41.0–106.0)	0.0031	
 Cholesterol (mg/dL)	180.1±51.1	182.9±51.3	168.6±49.5	0.11	
 LDL (mg/dL)	122.5±48.5	124.2±49.0	115.1±46.0	0.29	
 HDL (mg/dL)	48.1±17.0	47.9±15.6	44.7±17.1	0.25	
 Triglycerides (mg/dL)	123.0 (95.0–186.0)	124.0 (96.0–192.0)	118.0 (87.0–161.0)	0.5177	
 Creatinine (mg/dL)	1.0 (0.8–1.1)	0.9 (0.8–1.1)	1.0 (0.9–1.2)	0.0149	
 Haemoglobin (g/L)	135±20	135±20	134±17	0.58	
 NT-proBNP (pg/dL)	147.0 (43.0–790.0)	129.0 (38.0–671.0)	393.0 (95.0–2759.0)	<0.001	
Cardiovascular risk factors	
 Body mass index (kg/m²)	27.3±5.1	27.3±5.2	27.7±4.4	0.56	
 Current smoker	175 (26.6)	155 (26.7)	20 (26.3)	0.89	
 Ex-smoker	186 (28.3)	166 (28.6)	20 (26.3)	0.89	
 Diabetes	102 (15.5)	85 (14.6)	17 (22.4)	0.09	
 Family history of CAD	136 (20.7)	125 (21.5)	11 (14.5)	0.18	
 Hypercholesterolaemia	190 (29.0)	165 (28.5)	25 (32.9)	0.42	
 Systolic blood pressure (mm Hg)	135.6±19.3	135.1±19.2	139.0±19.3	0.04	
 Diastolic blood pressure (mm Hg)	82.3±13.9	80.9±13.7	84.4±15.0	0.038	
Clinical presentation	
 NSTEMI	144 (21.9)	112 (19.3)	32 (42.1)	<0.001	
 Heart rate (bpm)	79.5±17.6	78.8±17.0	85.3±20.9	0.011	
 Killip class I	638 (95.6)	563 (96.9)	65 (85.5)	0.0002	
 Killip class II	29 (4.4)	18 (3.1)	11 (14.5)	0.0002	
 Killip class III	0	0	0	-	
Medication	
 Aspirin	93 (14.2)	77 (13.3)	16 (21.1)	0.079	
 P2Y12 antagonist	13 (2.0)	13 (2.2)	0	0.381	
 Antidiabetic	75 (11.4)	62 (10.7)	13 (17.1)	0.122	
 Antihypertensive	363 (55.3)	315 (54.2)	48 (63.2)	0.177	
 Lipid lowering	117 (17.8)	103 (17.7)	14 (18.4)	0.874	
ECG	
 LBBB	18 (2.7)	12 (2.1)	6 (7.9)	0.0118	
 Cardiac arrest	0	0	0	-	
 ST segment derivation	11 (1.7)	9 (1.6)	2 (2.6)	0.37	
Echocardiography	
 LV-EF≥50	565 (86.0)	529 (91.1)	36 (47.4)	<0.001	
 LV-EF 41–49	73 (11.1)	43 (7.4)	30 (39.5)	<0.001	
 LV-EF≤40	19 (2.9)	9 (1.6)	10 (13.2)	<0.001	
Values are mean±SD, median (interquartile rangeIQR) or n (%).

CAD, coronary artery disease; CK, creatine kinase; CK-MB, creatine kinase MB; HDL-C, high-density lipoprotein cholesterol; LBBB, left bundle branch block; LDL-C, low-density lipoprotein cholesterol; LV-EF, left ventricle ejection fractionNSTEMI, non-ST-elevation myocardial infarctionNT-proBNPN-terminal prohormone of brain natriuretic peptideP2Y12-antagonistadenosine diphosphate-glucose receptor-antagonistRWMAregional wall motion abnormalities

302 patients (46.0%) underwent coronary angiography. Of those, 141 (21.5%) patients received a coronary revascularisation therapy due to the detection of obstructive CAD. RWMA were observed in 26.2% of patients with obstructive CAD as compared with 7.6% of patients not reaching the primary endpoint during follow-up. The study flow chart is displayed in online supplemental figure 1.

Table 2 depicts the association of RWMA with the presence of obstructive CAD. In unadjusted regression analysis, the presence of RWMA was associated with fourfold increased odds for the presence of obstructive CAD (OR (95% CI) 4.35 (2.65 to 7.16), p<0.001). Adjustment for traditional risk factors did not relevantly influence the association of RWMA with the presence of obstructive CAD. Controlling for GRACE score and TIMI-risk score as clinically established scores further did not alter the results. In subgroup analyses of patients with available high-sensitive troponin levels (n=510) as well as analyses of patients receiving coronary angiography (n=312), similar associations of RWMA with the primary endpoint were overserved (online supplemental table 1).

Table 2 Univariate and multivariable logistic regression analysis for the association of RWMA with the presence of obstructive CAD

	OR (95% CI)	P value	
Univariate.	4.35 (2.65 to 7.16)	<0.001	
Adjusted for age, gender, BMI, family history of CAD, smoking, hypercholesterolaemia, diabetes, systolic blood pressure.	3.41 (1.99 to 5.86)	<0.001	
Adjusted for GRACE risk score.	3.16 (1.88 to 5.33)	<0.001	
Adjusted for GRACE risk score, BMI, hypercholesterolaemia, family history of CAD, diabetes, smoking.	3.19 (1.84 to 5.52)	<0.001	
Adjusted for GRACE risk score, BMI, hypercholesterolaemia, family history of CAD, diabetes, smoking, CK, myoglobin.	3.68 (2.09 to 6.51)	<0.001	
BMI, body mass index; CAD, coronary artery disease; CK, creatine kinase; GRACE, Global Registry of Acute Coronary Events; RWMA, regional wall motion abnormalities

The association of traditional cardiovascular risk factors with the presence of RWMA is depicted in online supplemental table 2. Older age as well as higher systolic blood pressure by 1 SD were significantly associated with increased odds for the presence of RWMA. Additionally, in regression analysis, a higher level of troponin per 1 SD was associated with threefold increased odds of RWMA (online supplemental table 2).

Figure 1 displays the improvement of the corresponding AUC for RWMA in addition to a multivariable model including TIMI risk score, cardiac biomarkers and traditional cardiovascular risk factors, demonstrating a relevant improvement in the prediction of obstructive CAD (95% CI 0.777 to 0.804, p=0.0092). Again, a similar improvement of AUC was observed when adding RWMA to a multivariable model including GRACE score instead of the TIMI risk score (95% CI 0.759 to 0.787, p=0.0182, online supplemental figure 2).

Figure 1 Receiver operating characteristics curve, demonstrating an improved prediction of the presence of obstructive CAD by RWMA in addition to a multivariable model containing traditional risk factors, cardiac biomarkers and the TIMI risk score. AUC, area under the curve; BMI, body mass index; CK, creatine kinase; RWMA, regional wall motion abnormalities; TIMI, Thrombolysis in Myocardial Infarction.

Figure 2 illustrates the association of RWMA with the presence of obstructive CAD in different subgroups of interest. Comparable effect sizes were observed for all risk factors groups with the exception of patients with diabetes, where RWMA were not associated with the primary endpoint.

Figure 2 Forrest plot for subgroup analysis for the association of regional wall motion abnormalities with the presence of obstructive CAD. BMI, body mass index; CAD, coronary artery disease.

Figure 3 shows the frequency of patients with obstructive CAD in coronary angiography in subgroups of patients with initial rule-in/out or observe of acute myocardial infarction, depending on the presence of RWMA. Overall, 504 patients in whom a hs-troponin was determined were included in this analysis. Of these, obstructive CAD was detected in 97 patients. Obstructive CAD was significantly more frequent in patients with versus without RWMA, irrespective of categorisation into the rule-in/out and observe subgroups.

Figure 3 Differences in the frequency of obstructive coronary artery disease in patients with versus without RWMA, in subgroups of patients with initial rule-in/out or observe of acute myocardial infarction. RWMA, regional wall motion abnormalities.

Discussion

In the present study, we evaluated the ability of RWMA to predict the presence of obstructive CAD in patients presenting with acute chest pain in the emergency department. Ultimately, the goal of the study was to assess if echocardiography qualifies to improve decision-making in patients with acute chest pain. We found that patients with RWMA had threefold increased odds for the presence of obstructive CAD, independent of traditional cardiovascular risk factors, cardiac biomarkers and established risk scores such as GRACE and TIMI score. Future research on multicentre cohorts is needed to confirm that routine implementation of focused bedside transthoracic echocardiography for assessment of RWMA can improve the diagnostic workup of patients with suspected ACS.

Acute chest pain suggestive of ACS is one of the leading causes for presentations to emergency departments in the industrialised world.1820 However, the initial workup with ECG and cardiac biomarkers is inconclusive in a large proportion of these patients.21 As further evaluation is challenging, many patients receive coronary angiography for the exclusion of obstructive CAD.22 Therefore, an improvement in diagnostic strategies is necessary to enable efficient patient management and to reduce healthcare costs.23

Implementation of imaging modalities of initially inconclusive clinical presentation is the most promising strategy to improve patient workup. Echocardiography provides a non-invasive, easily accessible and time-efficient imaging modality for risk stratification of ACS and screening for alternative pathologies.7 24 Current ESC-guidelines for ACSs suggest performing transthoracic echocardiography only for evaluation of other causes of chest pain when serial biomarker and ECG testing has not led to the final decision of rule-in or rule-out.1 However, the present results demonstrate that transthoracic echocardiography as an initial adjunct in the triage process can provide incremental diagnostic information in patients. Even when an initial workup would have suggested a safe patient’s discharge, echocardiographic screening for RWMA was able to detect patients with increased rate of obstructive coronary lesions.

Prior studies investigated the ability of RWMA, as detected via echocardiography, for the evaluation of CAD provided a considerable variability of results between the studies, in parts explained by differences in patient collectives and endpoints. Studies in high-risk populations described a high sensitivity of echocardiography to detect patients with coronary cause of chest pain.2527 In contrast, Gibler et al found that echocardiography had limited sensitivity, but high specificity in a lower-risk cohort with only 5% of patients reaching the primary endpoint of myocardial infarction.28 Compared with previous studies, our study is the first to review the value of RWMA in patients with acute chest pain from the perspective of the current ESC guidelines by performing a subgroup analysis after initial rule-in/out and observe. Our study shows that performing a transthoracic echocardiography in all patients with acute chest pain in the emergency department can improve diagnostic algorithms.

Different imaging technologies are established for the detection of RWMA.2931 However, the utilisation of complex and time-consuming imaging methods such as cardiac MRI may not be suitable for emergency settings.8 In addition, transthoracic echocardiography can screen for differential diagnosis as a cause of chest pain such as pulmonary embolism, aortic valve stenosis or dissection of the ascending aorta.9 Further studies are needed to confirm our finding that two-dimensional echocardiography with an extended real-time view of the myocardium to evaluate RWMA in an emergency setting allows for risk stratification of ACS patients.

Limitations

Several caveats of the present analysis warrant further consideration. First, this study is limited by the single-centre study design. Multicentre studies are necessary to confirm our results and to demonstrate that the assessment of RWMA improves patient’s management. Furthermore, the study population consisted predominantly of Caucasian patients, hence the generalisation to other ethnic groups remains uncertain. This study relied on a subjective interpretation of echocardiographic images by the evaluating study physician without dedicated evaluation of intraobserver and interobserver variability as part of the present trial. While echocardiography examinations were performed by dedicated personnel, blinded to patient’s laboratory parameters and outcome, we cannot rule out that patients’ clinical expression influenced the evaluation of echocardiographic examinations. Likewise, we did not perform any core-laboratory verification of the presence or absence of RWMA. This, however, will only have biased our results towards the null. Lastly, a coronary angiography for definite inclusion or exclusion of obstructive CAD (via conventional coronary angiography or CT coronary angiography) was not performed in all patients. We extended the follow-up period to 90 days after initial presentation to detect any potential obstructive CAD that becomes overt after initial hospital discharge. However, we cannot exclude that undiagnosed obstructive CAD were also present in patients not undergoing any coronary angiography.

Conclusion

RWMA predict the presence of obstructive CAD in patients presenting with acute chest pain in the emergency room in addition to traditional workup as suggested by current ESC guidelines. Routine bedside echocardiography for the assessment of RWMA in the emergency department can improve diagnostic workup in suspected ACS, especially, when initial biomarkers and electrocardiographic evaluation remain inconclusive.

supplementary material

10.1136/bmjopen-2024-085677 online supplemental table 1

10.1136/bmjopen-2024-085677 online supplemental figure 1

10.1136/bmjopen-2024-085677 online supplemental figure 2

Data availability statement

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.

Review Process File
10 09 2024

Funding: SJ and BB were supported by the Junior Clinician Scientist programme of the University Medicine Essen Academy (UMEA) funded by the Faculty of Medicine, University of Duisburg-Essen. ID was supported by the German Research Foundation (DY149/2).

Prepub: Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2024-085677).

Provenance and peer review: Not commissioned; externally peer reviewed.

Patient consent for publication: Not applicable.

Ethics approval: This study involves human participants and was approved by ethics committee of the Medical Faculty of the University of Duisburg-Essen (18-8198-BO). Participants gave informed consent to participate in the study before taking part.

Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
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