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Diagnosing coronary artery occlusion in NSTEACS with strain echocardiography
  1. Graham Cole,
  2. Jamil Mayet,
  3. Iqbal S Malik
  1. International Centre for Circulatory Health, St Mary's Campus, Cardiovascular Sciences and the Renal Unit, Imperial College Healthcare NHS Trust, London, UK
  1. Correspondence to Dr Iqbal S Malik, Mary Stanford Wing, St Mary's Campus, Imperial College Healthcare NHS Trust, Praed Street, London W2 1NY, UK; Iqbal.malik{at}imperial.nhs.uk

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Introduction

Non-ST elevation acute coronary syndromes (NSTEACS), as defined by acute cardiac chest pain in the absence of ST elevation, is a common condition with an incidence of 3 per 1000 per year.1 Patients with ST elevation myocardial infarction (STEMI) should have immediate reperfusion by either mechanical (PCI) or pharmacological (thrombolysis) means,2 but the role and optimum timing of coronary angiography in NSTEACS (whose incidence is greater than STEMI1) remains less well-defined.

Patients with NSTEACS are a heterogeneous group whose presentations are often less clear-cut and in whom comorbidities are more common.3 Current guidelines suggest urgent angiography is required only in the minority of patients with NSTEACS who have ongoing angina, clinical signs of heart failure, haemodynamic instability or life-threatening arrhythmias.1 The remaining majority can either undergo angiography within 72–96 h1 4 of presentation, or can be managed medically.

STEMI versus NSTEACS

Patients with STEMI usually have an occluded coronary artery.2 Previously, NSTEACS was thought to result from partial or transient occlusion of a coronary artery. However, Wang et al have shown that around one-quarter of patients with NSTEACS have a coronary artery occlusion, particularly in arteries supplying the inferolateral territories.5 The same study showed that patients with NSTEACS with an occluded artery have higher levels of markers of myocardial injury and a higher mortality at 6 months than those patients with NSTEACS but without an occluded artery.5

There is consensus that patients presenting with STEMI should undergo treatment to ensure rapid reperfusion. In contrast, despite appearing to have an identical angiographic problem, patients with an occluded artery who present with NSTEACS may wait much longer before angiography. Delay before angiography …

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