Comparison between 2-dimensional echocardiography and myocardial perfusion imaging in the emergency department in patients with possible myocardial ischemia.

BACKGROUND: Accurate identification of patients at high risk for acute coronary syndromes among those seen in the emergency department (ED) with possible myocardial ischemia and nonischemic electrocardiograms is problematic. Both 2-dimensional echocardiography and myocardial perfusion imaging with technetium-99m sestamibi can identify patients at low and high risk; however, comparative studies are lacking. METHODS AND
RESULTS: Patients initially considered at low or moderate risk for myocardial ischemia on the basis of the presenting history, physical examination, and electrocardiogram underwent both echocardiography and myocardial perfusion imaging within 4 hours of ED presentation. Positive echocardiography was defined as the presence of segmental wall motion abnormalities or moderate to severe global systolic dysfunction; positive perfusion imaging was defined as a perfusion defect in association with abnormal wall motion, thickening, or both. End points included MI, percutaneous transluminal coronary angioplasty, and positive stress perfusion imaging. Both imaging procedures were performed in the ED on 185 patients. Six patients had MI, and an additional 4 patients underwent percutaneous transluminal coronary angioplasty. Echocardiography and perfusion imaging were positive in all 10. Overall agreement between the 2 techniques was high (concordance 89%, kappa coefficient 0.74) in the 27 patients who had MI or underwent coronary angiography. For all patients, concordance was 89%, with a kappa coefficient of 0.66.
CONCLUSIONS: Agreement between echocardiography and perfusion imaging with technetium-99m sestamibi is high when used in patients in the ED with possible myocardial ischemia. Both techniques identified patients at high risk who required admission and those who could be safely discharged directly from the ED.